CHAPTER 149

Divorce

Carol D. Berkowitz, MD, FAAP

Divorce is a legal term meaning the legal conclusion or dissolution of a marriage. Divorce has been equated to the “death” of a marriage and in some ways may be more devastating for children than the death of a parent. When a parent dies, that parent becomes idealized in the mind of the child, but when parents divorce, the noncustodial parent is often devalued. Even with a joint custody arrangement, each parent is frequently criticized by the other. For the child, the parents are no longer the ideal figures they once were. The challenge for the pediatrician is to maintain a neutral position, be supportive, and serve as a source of advice and guidance. Remaining neutral may be challenging because much of the contact may have been with 1 parent—usually the mother.

The pediatrician plays a specific and potentially unique role in caring for children experiencing parental divorce because other resources may be few and other agencies or individuals may lack an antecedent relationship with the family. Extended families are often geographically distant and less available to provide help. Religious institutions have often failed to assume a counseling role in this area; some religions view divorce unfavorably. Most families do not routinely seek out mental health services unless problems are more apparent. Therefore, it is critical for the pediatrician to become involved in anticipatory guidance of families considering and undergoing divorce. It is important to recognize that divorce is not a single event; rather, it is a process that occurs over time, and parental separation may antedate the actual divorce by months or even years. Anticipatory guidance focuses on preparing children and families for times ahead. Additionally, the pediatrician serves as a child advocate. The parents themselves are often so consumed by their own emotional turmoil that they may not be available or are not even aware of the stress and trauma their children are experiencing. The pediatrician should be knowledgeable about the effect of divorce on children and their subsequent psychological development. Additionally, the pediatrician can help as new families form, assisting the transition of caregivers into the role of stepparents and children into becoming stepsiblings.

Epidemiology

Divorce affects nearly 50% of marriages, although the rate recently has decreased to closer to 40%, attributed in part to the decrease in the marriage rate. In fact, separation of unmarried heterosexual partners is far more common than divorce between married individuals. Approximately 40% of all births are to unmarried women. Socioeconomic differences exist, with 11% of higher income parents divorcing as opposed to 17% of lower income couples. Divorce is more common among those who have served in the military. Couples are less likely to divorce while they remain with the military, instead divorcing after they leave the service. Veterans are 3 times as likely to be divorced as those who have never served.

The median length for a marriage in the United States is 11 years. On average, there are 800,000 divorces a year, and 90% of divorces occur outside of court. A divorce may be collaborative (ie, uncontested), in which the parents negotiate an agreement with the advice of a separate attorney for each parent. Mediated divorce involves a mediator but no attorneys, to reach an agreement. Children do not routinely have legal representation in the process. Mediators may assist in establishing visitation schedules and in general, children do not participate in these meetings either.

The legal profession has been endorsing greater focus on and participation of children in divorce disputes. Approximately 1.5 million children per year are affected by divorce. Nearly one-third of all children live in households in which parents are divorced or remarried. Children between age 3 and 8 years are the major age group affected. Children involved with parental divorce require at least 2½ to 3 years to regain their equilibrium and master a sense of control, although developmental challenges may continue to emerge at different times after the divorce.

Divorce usually results in reduced economic resources to mothers and children. In the first year after divorce, the mother’s income is reduced to 58% of the predivorce level. Even after 5 years, income for mothers and children is only 94% of the predivorce amount; for intact couples, income has risen to 130% during that period. Decreased income is often associated with multiple moves to more affordable housing, along with change in schools and loss of friends. More affordable neighborhoods may not provide the same resources and environment to which the children were previously accustomed.

Types of custody include sole, joint, legal, and physical. The types of custody define the legal responsibilities of each parent as well as the time spent between parent and children. Bird’s nest custody is a unique form of joint custody in which children remain in the home and the parents take turns moving in and out. This is less common than other arrangements. Many states now promote joint custody, which is associated with higher levels of involvement by the biological father, increased child support payments, and greater paternal satisfaction. Issues of remarriage and stepsiblings are also important. Eighty percent of divorced men and 75% of divorced women remarry, and 40% of these remarriages end in divorce. As a result of the high rate of remarriage, 1 in 3 children in the United States has a stepparent. Eighty-six percent of stepfamilies include the biological mother and a stepfather. Children in stepfamilies often must readjust to differing roles in differing households and differing relationships between their biological parents, stepparents, biological siblings, and stepsiblings.

Psychophysiology

The experience that children have following parental divorce is influenced by many factors. When a divorce is contentious and children are exposed to hostility between their parents, high levels of stress can result in physiologic changes, including elevated levels of cortisol, which can be associated with sleep disturbances, anxiety, irritability, and weight change.

The individual child’s temperament and personality also affect the child’s adjustment to parental divorce. An easygoing child with strong self-esteem and a positive outlook fares better than a less easily adaptive child with a less optimistic personality. The reaction to divorce also depends, to a large extent, on the age of the child (Table 149.1). Generally, children do not have the cognitive ability to understand the meaning of divorce until they reach 9 or 10 years of age. The experience is also different for children without siblings, that is, “onlies.” Not only do they lack brothers or sisters with whom to commiserate, they may also experience parental overconcern, manifested by being asked repeatedly how they are feeling and how they are doing. Studies have demonstrated that the negative effect of parental divorce on adolescent academic performance is mitigated by increased sibship size.

Infants and toddlers (up to age 2 years) react to changes in routine and may experience sleeping and feeding disturbances, as well as increased spitting up and clinginess. Between 2½ and 4 years of age, a child may exhibit increased separation anxiety and regressive behavior. The child becomes needy and dependent, with behavior characterized by irritability, whining, crying, fearfulness, and sleep problems. Aggression and regression, particularly in the area of toilet training, may manifest. One-third of children in this age group continue to exhibit regressive behavior 1 year after divorce.

Children between 3½ and 5 years of age often show more aggressive patterns of behavior with hitting, biting, and temper tantrums. Regressive behavior may also be seen. Young children feel particularly responsible for their parents’ divorce (ie, the parents are divorcing the child). At this point in development, children experience what Piaget has referred to as an egocentric way of thinking. Self-blame, decreased self-esteem, and a high level of fantasy, particularly about parental reunion, are apparent. Approximately 1 year after divorce, 65% of these children still show decreased levels of functioning. Preschool-age children may repeatedly ask the same questions as a means of processing and assimilating the information. Such questioning should be met with patience and reassurance.

Children 5 to 6 years of age are often depressed and may exhibit behavior that is less mature or age appropriate. Girls in this age group seem to react more poorly than boys to divorce. Two-thirds of girls are less well-adjusted 1 year after the divorce, as opposed to only approximately one-fourth of boys. Children of this age may seem moody and daydream, whine, or have temper tantrums.

Children between 6 years of age and adolescence seem to experience profound disequilibrium, with feelings of shame, anger, and loneliness. This anger may manifest as antisocial behavior. Older children also talk about an overwhelming feeling of sadness and grief. Their somatic reports include headache, abdominal pain, and an increase in symptoms of preexisting medical conditions (eg, asthma). Sometimes the somatic symptoms of children, particularly those in the school-age group, are attributed by 1 parent to the poor living conditions at the other parent’s household. It is important for the physician to anticipate that 50% of children involved in parental divorce show a deterioration in their school performance. Therefore, the school should be notified about the pending divorce and changes in family structure. Decreased school performance is attributed to decreased ability to concentrate, sadness, and depression or decreased conduciveness to do homework in 1 household over the other.

Parental divorce is particularly difficult for adolescents, who describe it as “extraordinarily painful.” Problems may emerge during adolescence, and adolescents may exhibit externalizing behavior (eg, delinquency, risk taking, alcohol use) and internalizing behavior (eg, anxiety, depression). The experience is worse for younger adolescents. During the first stages of divorce, they feel a personal sense of abandonment and a loss of parental love. Older adolescents are concerned about their future potential as marital partners. They also feel anxious about financial security, especially money for college. De-idealization of both parents is precipitous. Adolescent girls do better than boys early on, but this reverses with time. This pattern is referred to as a “sleeper effect” or “delayed effect,” with girls subsequently feeling rejected and unattractive as they reinterpret their parents’ divorce with their additional maturation. Divorce during adolescence sometimes results in precocious sexual activity or risk- or thrill-seeking behavior. Studies suggest that paternal involvement after the divorce reduces the risk of alcohol abuse. Adolescents from divorced families are more likely to experience teenage parenthood. Adolescent girls from divorced families are less likely to succeed academically than girls from families in which divorce has not occurred. Additionally, adolescents may turn to alcohol or drug use to help cope with the stress of parental divorce. Boys may engage in illegal activities, such as burglary. Suicidal ideation is noted in teenage boys and suicide attempts more often in teenage girls, although this is influenced by whether the teenager is residing with the mother or the father.

Differential Diagnosis

Children who present with reports such as headache, abdominal pain, enuresis, and poor school performance should always be assessed for environmental factors that may be contributing to their symptomatology. When evaluating a child with suspected somatic concerns, it is always appropriate to consider organic etiologies.

Many parents who are undergoing a divorce do not appreciate the effect the divorce is having on their children. They are often caught up in their own personal feelings and are not aware of their children’s symptomatology. Additionally, divorcing parents experience a deterioration in their physical and mental well-being, and divorced mothers have an increased rate of illness.

Parents engaged in custody disputes may express concerns that their child is maltreated by the other parent. These concerns may include allegations of sexual abuse, which may require a referral to a physician who specializes in child abuse pediatrics or a child advocacy center (see Chapter 145).

Questions about the family and family resources should be part of any health maintenance visit. A parent may not mention marital discord unless asked specifically. It is important to remember that parental divorce has a significant effect on family resources (see Chapter 141).

Evaluation

Regardless of a child’s presenting concern, the focus of the evaluation should be on the interview. Determination of the full extent of the effect of home factors on children’s symptomatology may take several visits. It is not appropriate to pursue extensive laboratory tests in search of an organic etiology without first adequately determining what changes are occurring within the household.

History

The medical evaluation of the child experiencing a parental divorce should include a review of the medical history and a discussion with the child of factors of change (Box 149.1). This may help open up a discussion that reveals that the parents are in the process of divorce or that 1 parent has moved out of the household. Specific parental concerns about child maltreatment should be noted in detail and consideration given to consultation with a physician certified in child abuse pediatrics.

Physical Examination

Any symptom or specific report, such as abdominal pain or headache, should also be addressed (see Chapters 125 and 129, respectively). Depression and the risk for suicide should also be evaluated (see Chapter 66). A complete physical examination is usually warranted because the child who is experiencing stress may also develop stress-related medical problems. If concerns exist about sexual abuse, a careful anogenital examination by an experienced examiner is indicated.

Laboratory Tests

Some simple baseline laboratory studies may be warranted, particularly in the child with reports such as abdominal pain or enuresis. These tests may include a complete blood cell count or urinalysis.

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