PEDIATRICS Vol. 110 No. 5 November 2002, pp. 1007-1009
COMMENTARY |
Parental Separation and Divorce: Can We Provide an Ounce of Prevention?
This month’s American Academy of Pediatrics clinical report on "Helping Children and Families Deal with Divorce and Separation" highlights the continued high incidence of parental separation and divorce in the United States and describes the disturbances of child development, behavior, and health—short- and long-term—that accompany parental conflict and separation. With
40% of children experiencing the divorce of their parents before their 16th birthday, parental separation and divorce stands as one of the most common and significant risks to the healthy development of children today. The Committee on Psychosocial Aspects of Child and Family Health prepared this report to assist and encourage pediatricians in recognizing early signs of parental conflict, monitoring the well-being of the affected children, advocating for the child’s needs, and striving to maintain a supportive relationship with each parent. However, the Committee also believes that pediatricians have an opportunity to positively influence parental relationships in advance of marital disruption. Pediatricians are often participants in family events that are known stressors to marital relationships. Not only is it important for the clinician to understand how parental conflict may impact the child, we contend that parents and families may gain needed support when pediatricians attend to the ways in which the child may stress the marriage.
Even with the most wanted pregnancy, the arrival of the first infant redefines life for the new parents in practically every detail. From changes in daily routines to basic alterations in role and identity, first-time parents enter a new, and often uncharted, phase of life. With the child come incursions on time for the partner, for friends, for work and career goals, for sexual relations, and for leisure activities. Time available for each parent to focus on themselves and on each other usually drops precipitously in the first months of parenthood. Although for many couples this is a period of extraordinary excitement and mutual satisfaction—a time of coming together in the formation of their family—for most it is also a time of increased intensity requiring very substantial personal adaptations and adjustments in their relationship with each other. With subsequent children, parents have the advantage of "knowing the territory." However, with each new child, demands multiply and parents are called on to create a balance that will best meet the needs of all family members.
In an already stressed marriage, a new infant may help the parents refocus and reset priorities that effectively bring them together in important new ways. On the other hand, a new infant may exaggerate conflicts around issues such as financial priorities, job choices, division of labor and unreconciled issues of control and autonomy within the relationship. New parents who look to the infant for qualities of relationship that are missing in the marriage may in the process move toward more disengagement with their partner. The regular strains of parenting a young child—including, for example, the everyday management of crying and colic, sleep disruptions, childhood illnesses, behavior management, and the other myriad tasks of everyday childcare—may exacerbate old differences and resentments between parents, and raise new ones.
Nor is parental adaptation demanded only during the first years of the child’s life. Each developmental transition for the child brings new challenges for the parents to cope with individually and as a couple. For instance, the child’s entry into school forces parents to evaluate their child and themselves in relationship to the broader cultural norms and belief systems represented in the school and the community. Adolescent strivings for independence and identity routinely require parents to reevaluate their relationship with their teen and with each other.
When a child has an increased risk to health or development, parents must reckon with very personal feelings of anxiety, and in some cases of grief and loss, while simultaneously attending to the special needs of the child. Mutual support by the parents for each other—and other family members—not uncommonly takes a back seat. A familiar pattern in these circumstances is for one parent to become fully dedicated to the ill or disabled child while the partner, often the father, takes a more distant and peripheral position. When this pattern persists and becomes more entrenched, feelings of neglect and lack of support may be experienced by one or both parents. Feelings of resentment toward the child may emerge. It is not uncommon for pediatricians to hear from the main caretaking parent after the breakup with the spouse that taking care of the child is "simply easier this way."
Childhood behavior problems and adolescent rebellion, in particular, are often linked to family distress, both as a source of stress for the parents and/or reflective of conflict between the parents. The clinician’s inquiry into how the child’s behavior is affecting the family—including what each parent believes is driving the behavior, how they are responding to it, and whether they feel they are working together or at odds with each other—will usually illuminate the degree to which marital stress is involved.
Other special risks to the marriage accompany the birth and development of the child when one parent has a disability or illness, or when crisis or change is impacting the family. Maternal postpartum depression occurs in 10% to 20% of all pregnancies, and at this frequency ought to be the subject of routine pediatric well-child screening.2,3 Job loss, poverty, family mobility, or the serious illness or death of one parent’s parent are examples of important life changes that may exacerbate the stresses attached to new parenting.4
Given the major impact that the infant and child has on the family and the parental relationship, we contend that inquiring into the health of the marriage ought to be a regular component of longitudinal pediatric care and a routine aspect of charting the child’s health and well-being. Experienced practitioners know how often the parent provides abundant cues that she is experiencing difficulties. Simple questions such as, "who helps you with the infant?" and "how are things at home?" are open invitations to bring these concerns into the clinical encounter. More direct questions, eg, "how are you and your spouse weathering all the changes with this new child?" or "how is your marriage faring with all that you have to do (eg, for the new infant, or, a sick or disabled child, or, an older child with special needs, etc)?" will not be regarded as inappropriate or intrusive when asked in the context of these significant family experiences. The support that parents receive or do not receive from their own parents is important in comprehending the degree to which a parent may feel connected with or cut off from their primary teachers about parenting.
This kind of inquiry can also extend to adolescents. Teenagers often need to be guided into discussing the family context for their concerns. Questions such as: "Do you feel comfortable talking with both your parents about this?" or "Do your parents agree on what to do about your concern?" or "How do you think this problem is affecting other members of your family?" will invite the teen to discuss aspects of family life that may be critical to understanding the problem, and at the same time provide the clinician with a window into the parental reaction and adjustment.
None of the above is "urgent care" talk. That is, it can only take meaning and importance within the context of a longitudinal relationship of interest and trust between the family and clinician. The routine inquiry into the well-being of the parent, of the couple, and of the family is an important early step in encouraging this relationship to grow.
Can we prevent divorce? As such, this is an overlarge expectation given the limited contact and context of the pediatric encounter. But, can we assist in supporting parents and their relationships during their transition to parenthood and during stressful periods of parenting? Surely, the answer must be "yes."
This is a task that is not new to primary care pediatricians—indeed, it is difficult to imagine a pediatrics that does not encompass parental support. However, practice conditions of managed care have made clinicians leery about becoming "entangled" in the psychosocial concerns of their families, as opposed to regarding this role as a rewarding and central aspect of their practice. Problems with professional reimbursement have led to efforts by our primary professional organizations, most especially the American Academy of Pediatrics, to support, legitimize, and advocate for the retention of parent and family support as an intrinsic component of primary pediatric care. The publication, for example, of The Classification of Child and Adolescent Mental Diagnoses in Primary Care5 and the newly released Bright Futures in Practice: Mental Health Practice Guide6 provide guidance and tools for working effectively with stressed families, as well as specific billing codes to appropriately represent the time and effort involved. However, there is a "use it or lose it" principal involved with this. To regain recognition and reimbursement for time spent, pediatricians must bill for this time, advocate within their own physician groups, and, where needed, recruit parents to lobby with insurance companies regarding the core importance of this function to the mission of pediatric care.7
In the service of support for parents and for the parental relationship within the context of primary pediatric care, the Committee has the following specific practice recommendations:
- Openly recognize to parents our understanding as clinicians of the major changes and challenges that accompany the transition to parenthood.
- Familiarize ourselves with the particular family and social circumstances of each of our patients, eg, who is in the family and lives at home with the child? Which adults are the primary caretakers? Was the infant planned? Are there significant differences between parents regarding childcare/child rearing practices?
- Provide support through understanding of the impact of the child and the child’s needs on the individual parents and their relationship.
- Be alert to risk factors of marital strain, such as those described above.
- Be prepared to encourage and facilitate referral for appropriate marital support, whether in the form of support groups with other parents who share similar stresses (eg, a disabled child), or more directly in marital therapy.
At the level of systems of care, these considerations for family health in pediatrics would suggest the following regular components:
- Continuity of care should be a first priority within the design of the medical home.
- Prenatal pediatric visits with both parents in attendance should be routinely offered.
- Requests to meet each parent during one of the early well-child visits should be an expectation of the health maintenance program.
- Clinicians should request follow-up visits to include both parents whenever danger signals of parental conflict or significant marital stress are discovered, and third party payors should reimburse such time appropriately.
- The medical home concept should encompass other mechanisms for parental support, for instance, parent groups and affiliated counselors/mental health specialists.
As the Committee Report stresses, "divorce is a process and not an event." Pediatricians have a unique role to play at the very beginning of the process of family formation, and in support of parents caring for their children in times of well-being and in times of need. Given the high prevalence and enormous impact on children of parental separation and divorce, we are obligated to contribute what we can.
Division of Developmental and Behavioral Pediatrics, Children’s Hospital of Oakland, Oakland, CA 94609
FOOTNOTES
Received for publication Aug 1, 2002; Accepted Aug 1, 2002.
Address correspondence to J. Lane Tanner, MD, Division of Developmental and Behavioral Pediatrics, Children’s Hospital of Oakland, 747 52nd St, Oakland, CA 94609
REFERENCES
1. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. Clinical report: helping children and families deal with divorce and separation.
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2. Dixon SD, Stein MT. Encounters with Children: Pediatric Behavior and Development. 3rd ed. St Louis, MO: Mosby Co; 2000:135–150
3. Seidman D. Postpartum psychiatric illness: the role of the pediatrician.
Pediatr Rev.1998; 19
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4. Tanner JL. Crisis and change in the family: divorce, remarriage, death, and mobility. In: Green M, Haggerty RJ, Weitzman ML, eds. Ambulatory Pediatrics. 4th ed. Philadelphia, PA: WB Saunders Company; 1999:12–16
5. Wolraich ML, Felice ME, Drotar D, eds. The Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Elk Grove Village, IL: American Academy of Pediatrics; 1996
6. Jellinek M, Patel BP, Froehle MC, eds. Bright Futures in Practice: Mental Health Practice Guide. Vol 1, 2. Washington, DC: National Center for Education in Maternal and Child Health, Georgetown University; 2002. Available at: www.ncemch.org
7. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. The new morbidity revisited: a renewed commitment to the psychosocial aspects of pediatric care.
Pediatrics.2001; 108
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PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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