Divorce: how can you help the family?
Q We find that we can usually tell when a child's parents are going through a divorce. The young child develops a variety of behaviors: He acts out, pesters his younger siblings more, or becomes clingy and regressive. He is overly demanding of his mother or father, or he constantly interrupts adults who are trying to have a conversation. The teen patient often responds to family discord by becoming angry, taking risks with drugs or sex, developing problems at school, or withdrawing from family or friends and exhibiting other signs of depression or distress.
We would like to know what measures we should take to prepare children for potential family realignments and help them weather a divorce. What question(s) should we ask at the well-child exam to discover if a divorce or separation may be coming up? Is it important whether the mother or the father is the first to clue us in? At what age should we begin to ask a child directly about discord at home? Under what circumstances would you refer a child to a specialist without delay? And what kinds of support should the pediatrician provide to families while they are going through divorce?
A The behaviors that you mention are certainly typical of a child going through a divorce as well as one who is apprehensive that his or her parents may be about to separate. It is helpful to look at the situation from the preventive perspective, which follows the pediatric model for ongoing care.
Long ago, I started to ask parents about the health of their marriage as part of every routine well-child visit, and certainly at any visit where I thought symptoms or disease might have a psychosomatic component. As time went on, I started asking the question earlier and earlier. Now I begin asking at the six-week visit and repeat the question at every visit thereafter.
I usually suggest that parents set aside some time every week for themselves, starting by the end of the second month of their child's life. Many people have told me that one of the best things they ever did as parents was to make sure they had a date, for example, every Wednesday night. Several studies in the last few years have noted the spike in marital dissatisfaction that occurs, and often persists, after the birth of a child. Moreover, we know from the work of Cherlin, Belsky, Kelly, and the latest set of national divorce statistics, collected in 1998 by the National Bureau of Health Statistics, that the average age of a child when parents divorce is now under 7 years. That means that most families break up when the children are very young.
Clearly, it is important to find out what is going on in a patient's family, regardless of whether the news comes from the father or the mother. One way to make sure you have a good relationship with both parents is to insist that the father come in for well-child visits. That may mean making time available during evenings or weekends, which is usually possible because extended hours have become fairly common in most practices. We find that fathers welcome this requirement, and it may offer an opportunity to intervene when counseling can still save the marriage. At this point, if both parents are motivated and both agree that there is a problem, I suggest that counseling can often be beneficial to a marriage.
With families struggling to keep up economically these days, you may hear one parent say that the other parent is away much of the time or is always at work. When you hear such a comment, pay close attention to whether the parent seems to sincerely want this situation to change. Lack of desire for change indicates that the money earned by the absent parent is more important to the parents than spending time together, and it is a reliable sign that the relationship needs attention.
Talking with children directly is always helpful. I try to see most patients alone for a few minutes by the time they are 5 to 7 years of age. I do not ask about the parents' marriage, but I do specifically ask how things are at home. If the answer merits it, I ask for detail and then try to talk with the parents if it's apparent that there are problems.
One behavior change that I find to be a potential indicator of trouble in a marriage is a persistent sleep problem in one or more children in a family. Although any sleep disturbance can limit parents' time together and cause adult fatigue (leading to short tempers or feelings of neediness), night waking is especially disruptive and is often a precursor to marital problems. In our New England office, as well as in our national consulting practice, we find that when a child is sleeping in the parents' bed it usually means that the marital relationship is under stress. We are careful, however, to take into account that, in some cultures, there would be nothing unusual about a child sleeping in the parents' bed.
If you try to work in-depth with children going through divorce, remember that the years preceding the divorce often have at least as much to do with their distress as the divorce itself. In fact, many children welcome the divorce, especially if it reduces hostility between parents.
Parents can prevent many problems associated with divorce by adopting a clear-cut parenting plan to minimize friction and ensure that the children maintain a close relationship with each parent. A good plan includes:
• Establishing specific ways of staying in touch when a child and parent are apart. Faxing is very effective because it gives children something tangible and it can be sent any time. E-mail is often the communication mode of choice for children from about age 9 on up because they can access it just about anywhere, anytime. The telephone can be tricky because it usually requires set calling times to avoid interrupting other activities.
• Avoiding parent-to-parent hand overs, which are often the occasion for parental fighting and can make children feel at fault. This can be done by making pickups after school or at day care, with return to the same place. Some families have the children wait at a neighbor's or go to a friend's house to play until pick-up time. Older children often go to the library to do their homework (or, more likely, to use the Internet).
• Working out a liberal visitation schedule that gives each parent time to be a normal parent, not just a visitor in the child's life. If each parent accepts the other parent's time with the children, the schedule will probably work—if not, it bears scrutiny.
When setting up a visitation schedule, I encourage overnight stays with the off-site parent instead of two- to three-hour "Good-time Charlie" visits. Parents should avoid returning children on Sunday night if at all possible. Homework often isn't completed, the child is tired, and the transition is difficult—which can lead to parents becoming angry at each other in front of the child.
It is far better to have the visited parent take the child back to school or day care on Monday morning. The child will likely be better rested, and the parent she spent the weekend with will have to assume responsibility for seeing that homework is done, keeping a reasonable bedtime, and maintaining the child's other routines.
Pediatricians can play a valuable role in the well-being of many families going through a divorce by reviewing normal parenting skills with both parents, especially if one parent does not play a major role in child rearing. Because parents in a troubled relationship are emotionally stressed and often lonely, they are reluctant to make their children unhappy. They let reasonable discipline evaporate and often seek support for themselves by sleeping in the same bed with the children or buying love with a shower of gifts. Such practices can lead to more parental disagreement and "badmouthing," leaving the children trapped in the middle.
If you cannot influence the parenting plan or review good parenting skills with divorcing parents, at least be aware that children of divorce need extra attention. Approximately 50% develop serious problems with risk-taking behaviors. They also may find it hard to establish stable relationships with life partners or other family members. Remember: Intervening sooner rather than later is always better.
Even children in the early elementary grades often have complicated feelings about being at fault for their parents' divorce. Their feelings and perceptions need to be discussed far beyond telling them "it's not your fault," which only says to the child that adults "don't care how I think or feel." Not surprisingly, it's also very common for children of divorce to deeply distrust authority figures and lack confidence in the ability of adults to make good decisions. This is especially true when a child is stuck with a visitation schedule or other arrangements that don't meet his needs.
To make matters worse, many children are parenting a parent, or younger siblings, or both. They lose their own childhood—often opting for whatever benefits they can receive from playing the part of the adult they have been forced to become.
If you have time, children often respond well to an interested adult who is willing to listen to their point of view. Much can be accomplished in a few hours. Moreover, since the pediatrician does not bear the stigma that sometimes attaches to a therapist, the child is less likely to resist. If the child resists talking to the pediatrician, however, and behavior problems are escalating, referral to a specialist with an interest in divorce can be invaluable. The practitioner, however, should follow treatment actively to ensure that progress is made in a short time.
To help pediatricians deal with issues related to divorce, we have developed a series of office handouts. The handouts and other materials are available free of charge at our Web site www. childrenanddivorce .com.
Behavior: Ask the experts.
Contemporary Pediatrics September 2003;20:33.