Patient Presentation
A 5-year-old male came to clinic for well-child care. He was excited about starting Kindergarten in the fall. His mother was concerned because his father and her had recently separated and were living apart. Both parents were seeing some behavioral problems around the transitions between the homes. Mainly he would cry when leaving either parent but generally did well after being in the new location for a while. His mother said that he kept making remarks or drawing pictures about his parents reuniting in the future, and she wasn’t sure how to handle that. She had been working more but family members that had provided child care were continuing to provide care. The parents were in counseling but she expected that they would not reunite. She laughed and said, “We just can’t get along as a couple, but we both love [him]. We’re trying to get along about things to do with [him].” The boy said that he didn’t like moving between the houses and that it made him mad and sad. “I’m sad because I don’t want to go (with the other parent). I’m mad because we don’t live together.” The boy reported that he talked with both parents and grandparents about the separation. The pertinent physical exam showed a healthy made with normal vital signs and growth parameters in the 75-90%. His exam was normal.
The diagnosis of a healthy male with recently separated parents was made. The pediatrician encouraged the boy to continue to talk with his parents and grandparents about how he was feeling and also to ask questions when he was confused. The pediatrician encouraged the mother to continue to try to talk with the father and to work from issues where they had common ground such as schedules and routines. He told the mother to be honest about the chances of reconciliation. He said to tell the child that he was loved, and that Mom and Dad are having problems themselves. You have two houses now and it probably will be like that in the future. He offered to meet with the parents and/or provide referrals for mental health counseling if needed.
Discussion
Separation and/or divorce (divorce) is unfortunately a common problem with just less than 50% of first marriages ending in divorce and there is a higher rate for subsequent marriages. It is difficult to separate out the problems that children have specifically with the divorce, and the other issues that are intertwined with it such as transitions between households, decreased parental contact (including non-custodial parent, financially needing to work more outside, increased work inside the home, etc.), economic stress, children’s own and parents’ emotional problems including anxiety and depression, parental dating and remarriage, blending of families, violence victimization, substance abuse, etc.. Children’s responses to these and other multiple stressors depends on the age and developmental level of the children. Boys tend to have more externalizing problems such as behavioral acting out, whereas girls tend to have more internalizing problems. These problems may not be exhibited initially but show up in adolescence. Preschool children tend to show regressive behaviors and physical problems such as bowel or bladder problems and sleep disturbances. Young school age often show sadness, fearfulness and have many hopes for family reconciliation. Older school age show grief, anger, want to clarify the responsibility for the divorce, and do more caretaking of the parent. Adolescents show more anger, acting out and depression, and may have premature emancipation.
Parents can help their children by acknowledging the failure of the marriage, but not failing in the divorce itself. A failed divorce is when the marriage conflicts are never resolved and the ex-spouses’ unmet needs continue to generate hostility and unproductive behaviors. In a successful divorce, ex-spouses proactively work at communication even when it is difficult, behave like an adult themselves and continue to actively parent the children.
Communication issues are key both between the ex-spouses and between the parents and children. One author states, “Parents should be encouraged to view their relationship as a neutral business-like partnership with the children as their joint investment. Divorced parents can benefit from clear rules on visitation, discipline, holidays, finances and other issues. Clear regulations avoid conflict and decrease contact (between ex-spouses). When contact is necessary, it can be civil, polite, and time-limited, much as a business relationship.” “Parents of children of divorce continue to be their parents for life….The parents must see the value in attending to the needs of their children, even when their own adult lives are in turmoil. They must continue to set limits, enforce bedtimes, assign chores. If both parents are to be involved in rearing the children, they must learn to co-parent with some consistency.” Unfortunately the hallmark of many divorces is erratic and inconsistent parenting.
Learning Point
Some guidance for parents who are divorcing includes:
- Tell the children about the divorce
- Explain the reasons for the divorce
- Use neutral terms in a language they will understand
- Both parents should be present
- All children should be told at the same time if at all possible
- Repeat all explanations as many times as necessary for the children to understand. Parents will/may need to do this many times over days/weeks/months/years.
- Tell the children the divorce is not their fault
- Reassure the children that you love them
- Tell the children of the expected family structure after the divorce
- Where will they live
- How will visitation occur
- Tell the children in advance of anyone moving households
- Except if there are concerns about immediate safety concerns or abusive relationships
- Be an adult
- Do not belittle your ex-spouse where your children can hear. Children believe their parents and do not understand when you may say something out of anger, frustration or sarcasm.
- Do not lie or cover up irresponsible behavior by the other parent though. Use a neutral tone to explain the situation. Children quickly figure out when people are lying and parents’ credibility suffers.
- Do not discuss details of financial issues. Children should be told the truth about the financial situation in general terms such as, “Like everyone else, we can’t afford to buy everything and today we are not going to choose to buy XXX.”
- Set clear rules together about schedules, discipline, school, extracurricular and other issues.
- Set up times to discuss issues with your ex-spouse. Don’t spring issues on them.
- E-mail, text or other quick message ahead of time alerts the ex-spouse about an issue to discuss, and makes it easier to discuss the issue calmly.
- Also, an appropriate amount of time can be set. For example, figuring out the carpool arrangements can often be done while dropping/picking up a child, but discussing failing school grades probably needs a separate time set aside.
- Your ex-spouse does not need to know all your personal business, but if it impacts the child’s parenting then it should be discussed honestly.
- For example, new significant other, plans for new marriage, new children entering the family, financial windfall, job loss, increased work travel, death of a friend, etc.
- Realize you and your ex-spouse will not always agree on parenting issues. Try to find areas of agreement and work out a plan from those areas. For example, scheduling time with extended family such as grandparents.
- Support your ex-spouse for their parenting. Don’t allow the children to manipulate one parent against another. For example, “Mom took me to the R rated movie last weekend. How come you won’t take me to this R movie this weekend?”
- Tell the child that there are different rules in different households (supporting the parent who made a decision at that time, and also supporting your own currently) and if you disagree with your ex-spouse’s decision, then make a time to discuss it with the ex-spouse.
- Do not force a child to take sides. Both parents love the child and the child can love both parents.
- Be a parent
- Set rules and be consistent. This is probably the most important issue of all for children.
- Chores, responsibilities, privileges and discipline should be clear and consistently enforced
- Discuss in general terms that there are two households which each will have the same basic rules, but that there will be some different rules in each. For example, at Dad’s house on a Saturday night you might get to stay up a little later because you don’t have school the next day. But at Mom’s house on a school night, you will go to bed on time.
- Support your children
- Support your child’s love for the other parent. For example, “I’m glad you like reading with your Dad” reaffirms the special time they spend together. It also supports the father’s parenting.
- Provide for your child’s physical needs with financial or other support.
- Being physically present as much as you can. When you cannot, find another way to keep in touch. Write a note, instant message, email, call on the phone or video chat.
- Talk with your children. Let them tell you about their world, their concerns, worries, triumphs, and tragedies. Listen.
- Be honest about things you have done right and things you haven’t done right. Don’t unburden yourself but use your own examples to show how you have made good and not so good choices and how you have handled the ups and downs of life.
- Do not make children adults.
- While children may necessarily need to take on certain duties within the household, they should be age appropriate and the amount of time is appropriate.
- Set rules and be consistent. This is probably the most important issue of all for children.
Questions for Further Discussion
1. What other guidance could be offered to parents who are divorced?
2. What resources are available in the local community for parents who are divorced?
3. What is the pediatrician legal responsibilities to the child and each parent after a divorce?
Related Cases
- Disease: Divorce
- Symptom/Presentation: Health Maintenance and Disease Prevention | Behavior Problems
- Specialty: General Pediatrics | Psychiatry and Psychology | Social Services
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Divorce
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Bryner CL Jr. Children of divorce. J Am Board Fam Pract. 2001 May-Jun;14(3):201-10.
Cohen GJ, Committee on Psychosocial Aspects of Child and Family Health. Helping Children and Families Deal With Divorce and Separation. Pediatrics. 2002;110:1019-1023.
Troxel WM, Matthews KA. What are the costs of marital conflict and dissolution to children’s physical health? Clin Child Fam Psychol Rev. 2004 Mar;7(1):29-57.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 