Keywords
Divorce, separation, death, bereavement
The primary responsibility for ensuring the optimal development and well-being of children lies within the family. A variety of different disruptions can interfere with the family’s ability to ensure a child’s physical, emotional, social, and academic needs are met. Significant parental conflict can lead to separation or divorce. Parental illness or injury may create a brief or prolonged period of separation, while the death of a parent results in a permanent separation that may be anticipated or unanticipated. All of these disruptions cause significant stress for the child, with the potential for short- and long-term adverse consequences. The child’s adaptation to these stresses is affected by the child’s developmental stage, temperament, parental behaviors, and the availability of additional support systems.
Divorce
Approximately 50% of first marriages in the United States will end in divorce. About half of these divorces occur in the first 10 years of marriage when couples have added children to their family unit prior to the break-up. At least 25% of children experience the divorce or separation of their parents. Few events in childhood are as dramatic and challenging for the child as divorce. Importantly, parental choices and behaviors around a divorce can help promote a healthy emotional adjustment for the child.
Divorce is likely to be accompanied by changes in behavioral and emotional adjustment. In the immediate post-divorce period, many children exhibit anger, noncompliance, anxiety, and depression. Children from divorced families require psychological help two to three times more frequently than children with married parents. Long-term studies suggest that in the absence of ongoing stressors, most children demonstrate good adjustment a few years after the divorce, but some have enduring difficulties. Easygoing temperament and average to above-average cognitive functioning are child characteristics associated with improved coping skills.
Divorce is not a single event but a process that occurs over time. In most cases, marital conflict begins long before the physical or legal separation, but the divorce brings about permanent changes in the family structure. Multiple potential stressors for the child are associated with divorce, including parental discord before and after the divorce, changes in living arrangements and sometimes location, and changes in the child’s relationship with both parents. The environmental changes that disturb a child’s primary support system as a result of the divorce process further complicate the child’s ability to adapt.
The child’s relationship with each parent can be affected by the divorce. In the short-term, the parent is likely to experience new burdens and feelings of guilt, anger, or sadness that may disrupt parenting skills and family routines. Contact with the noncustodial parent may decline greatly. Parents may be perceived by their children as being unaware of the child’s distress around the time of the divorce. Pediatricians can help parents understand things they can do that will be reassuring to the child. Maintaining contact with both parents, seeing where the noncustodial parent is living, and, in particular, maintaining familiar routines are comforting to the child in the midst of the turmoil of a separation and divorce. The child should attend school and continue to have opportunities to interact with friends. Assistance from extended family can be essential, and so it may be helpful for pediatricians to encourage parents to ask for this support. Pediatricians should look for maladaptive coping responses. Some parents may respond to their increased burdens and distress by treating their children as friends with whom they share their suffering. Alternatively, they may place unnecessary and excessive responsibilities on the child or leave the child unsupervised for longer periods of time. Responses such as these increase the chance that the child will develop behavioral or emotional problems.
Reaction to Divorce at Different Ages
The child’s reaction to the divorce is influenced by the child’s age and cognitive development. Similarly, warning signs of maladjustment may look different at different stages of child development. Although infants do not comprehend the concept of divorce, their need for a stable daily routine and regular contact with a primary caregiver in order to develop secure attachment requires special considerations in relation to custody and visitation. Separations from a primary caregiver should be brief. Increased infant irritability, changes in sleep and appetite patterns, and withdrawal or listlessness may be indicators of distress. In the worst cases of family stress and neglect, the young child may fail to meet developmental milestones as expected. The developmental phase of preschool age children is characterized by magical thinking about cause and effect and an egocentric view of the world. They may believe that something they did caused the divorce, or they may engage in unusual behaviors that they believe will reunite the parents. At this age, parents need to provide a consistent and clear message that the divorce was related to disagreements between the parents, that nothing the child did caused the divorce, and that nothing the child could do would bring the parents back together again. Preschool children may reason that if the parents left each other they also might leave the child. To counteract this fear of abandonment, children may need one-on-one attention and to be reassured that although parents separated, they will not abandon the child and that the child’s relationship with both parents will endure.
School-age children have a more concrete understanding of cause and effect; if something bad happened, they understand that something caused it to happen. However, they are less likely to appreciate the subtleties of parental discord or the idea that multiple factors contribute to a conflict. Children at this age may still worry that something they did caused the divorce. They may express more anger than younger children and often feel rejected. Many young school-age children worry about what will happen to one or both parents. School performance often deteriorates. Older elementary school–age children may believe that one parent was wronged by the other. This belief, in conjunction with their concrete understanding of cause and effect, allows children to be easily co-opted by one parent to take sides against the other. Parents need to understand this vulnerability and resist the temptation to support their child in taking sides, while allowing the child to express their feelings openly.
Adolescents may demonstrate difficulty adjusting to divorce by acting out, becoming depressed, or experiencing somatic symptoms. Adolescents are developing a sense of autonomy, a sense of morality, and the capacity for intimacy. Divorce may lead them to question previously held beliefs. They may be concerned about what the divorce means for their future and whether they, too, will experience marital failure. Questioning of previous beliefs, in conjunction with decreased supervision, may set the stage for risk-taking behaviors, such as truancy, sexual behaviors, and alcohol or drug use. Adolescents with divorced parents, in comparison to those with married parents, are at increased risk for internalizing problems like depression and anxiety in addition to the externalizing problems already mentioned. Parents are encouraged to continue to provide consistent behavioral expectations while encouraging an open forum for discussing the adolescent’s feelings.
Outcome of Divorce
Regardless of the age or developmental level of the child, children that are exposed to hostility and high levels of stress are at increased risk for emotional, behavioral, and academic struggles in the future. One of the best predictors of children’s adaptation to divorce is whether the physical separation is associated with a decrease in the child’s exposure to parental discord. In most cases, divorced parents still must interact with each other around the child’s schedule, child custody and support, and other parenting issues. These types of issues create the potential for the child to have ongoing exposure to significant discord between the parents. For example, if one parent tends to keep the child up much later than the bedtime at the other parent’s house, sleep problems may develop. When children feel caught in the middle of ongoing conflicts between their divorced parents, behavior or emotional problems are much more likely. Regardless of how angry parents are with each other, the parents should be counseled that they must shield their child from this animosity. Clear rules about schedules, discipline, and other parenting roles is ideal, but in cases of conflict, it can also be helpful for the pediatrician to help a parent accept that he or she can only control his or her actions and decisions related to the child. When parents have trouble resolving these issues, mediation may be helpful. Pediatricians need to be wary of parents’ attempts to recruit them into custody battles to substantiate claims of poor parenting unless the pediatrician has first-hand knowledge that the concerns are valid.
Although the primary physical residence for most children is still with the mother, the court’s bias toward preferring mothers in custody decisions has decreased and there is more emphasis on including both parents in the child’s life. In the early 1980s, 50% of children had no contact with their fathers 2 or 3 years after a divorce, whereas today only 20-25% of children have no contact with their father. Most states now allow joint physical or legal custody. In joint physical custody, the child spends a significant amount of time with each parent, and in joint legal custody, parents share authority in decision making. Although joint custody arrangements may promote the involvement of both parents in the child’s life, they also can be a vehicle through which parents continue to express their anger at each other. When parents have substantial difficulty working together, joint custody is an inappropriate arrangement and has been associated with deterioration in the child’s psychological and social adjustment.
Divorce often leads to financial difficulties. Family income usually declines in the first year after the divorce. Only about half of mothers who have child support awards receive the full amount, and one fourth receive no money at all. These financial changes may have multiple adverse effects on the child. A move to a new house may require the child to attend a new school disrupting peer relationships and other potential supports. The child may spend more time in child care if one or both parents have to increase work hours.
Most men and women remarry within 5 years of divorce, with a slightly higher incidence of men who remarry than women (approximately 60% vs. 50%, respectively). Most spouses in remarried couples already have children, such that at least one third of American children become members of stepfamilies. The adjustment to a parent dating and the transition to a blended family pose additional challenges to the child. Parents are encouraged to be sensitive to the child’s reactions and mindful of the importance of maintaining the biological parents as disciplinarians.
Role of the Pediatrician
The pediatrician can be an important voice in helping the parents understand and meet the child’s needs ( Table 26.1 ) before, during, and after the divorce. Children should be told of the parents’ decision before the physical separation. The separation should be presented as a rational step in managing marital conflict and should prepare the child for the changes that will occur. Parents should be prepared to answer children’s questions, and they should expect that the questions will be repeated over the ensuing months. Once parents have told children of the separation, it may be confusing to the child if parents continue to live together and may raise false hopes that the parents will not divorce.
