More than 1 million children each year experience their parents’ divorce. For these children and their parents, this process can be emotionally traumatic from the beginning of parental disagreement and rancor, through the divorce, and often for many years thereafter. Pediatricians are encouraged to be aware of behavioral changes in their patients that might be signals of family dysfunction so they can help parents and children understand and deal more positively with the issue. Age-appropriate explanation and counseling is important so children realize that they are not the cause of, and cannot be the cure for, the divorce. Pediatricians can offer families guidance in dealing with their children through the troubled time as well as appropriate lists of reading material and, if indicated, can refer them to professionals with expertise in the emotional, social, and legal aspects of divorce and its aftermath.
Each year, more than 1 million children experience the divorce of their parents. In 1995, less than 60% of US children were living with both biologic parents, almost 25% were living with their mother only, approximately 4% were living with their father only, and the rest were living with stepfamilies, adoptive families, or foster families (including other relatives). It is estimated that there are 500 000 new divorced fathers each year. Divorce rates peaked in 1979–1981 at 5.3 per 1000 persons and decreased by 1995 to 4.4 per 1000 persons. Approximately 50% of first marriages and 60% of second marriages end in divorce.1,2
Divorce and separation may be solutions to a discordant marriage, and any decrease in intrafamily hostility may be constructive; however, for many children and their parents, tensions continue and the entire divorce process is a long, searing experience. Divorce is the termination of the family unit, and thus, it is often characterized by painful losses.3 Approximately half of all children do not see their fathers after divorce, and relatively few have spent a night in their fathers’ homes in the past month.4
The divorce itself is usually not the first major change in the affected child’s life. Parental conflict before the separation often leads to internalizing and externalizing behavior problems, even in preschoolers.5 Children’s sense of loss is ongoing and may increase, especially on holidays, birthdays, and special school events and when trying to integrate new family relationships. Other losses for the child or adolescent relate to changes in home, extended family, school, playmates, financial status, and parental work schedules.6,7
Up to half of children show a symptomatic response during the first year after their parents divorce. Risk factors for continuing childhood difficulty include ongoing parental discord, maternal depression, psychiatric disorders in either parent, and poverty.5,7–10 Long-term follow-up studies indicate that divorce may limit or delay children’s capacity for intimacy and commitment as young adults.11–13
The clinical manifestations of divorce in children depend on many variables, including the child’s age; the predivorce level of the family’s psychosocial functioning; the parents’ ability in the midst of their own anger, loss, and discomfort to focus on their child’s feelings and needs; and the child’s temperament and temperamental fit of parents with their children.5,10,14,15
Infants and children younger than 3 years may reflect their caregivers’ distress, grief, and preoccupation; they often show irritability, increased crying, fearfulness, separation anxiety, sleep and gastrointestinal problems, aggression, and developmental regression.8,14,16
At 4 to 5 years of age, children often blame themselves for the breakup and parental unhappiness, become more clingy, show externalizing behavior (acting out), misperceive the events of the divorce situation, fear that they will be abandoned, and have more nightmares and fantasies.10,17
School-aged children may be moody or preoccupied; show more aggression, temper, and acting-out behavior; seem uncomfortable with gender identity; and feel rejected and deceived by the absent parent. School performance may decrease, and they may agonize about their divided loyalties and feel that they should be punished.9,10,14,16
Adolescents may feel decreased self-esteem and may develop premature emotional autonomy to deal with negative feelings about the divorce and their deidealization of each parent. Their anger and confusion often lead to relationship problems, substance abuse, decreased school performance, inappropriate sexual behavior, depression, and aggressive and delinquent behavior.18–20
At all ages, children frequently have psychosomatic symptoms as a response to anger, loss, grief, feeling unloved, and other stressors. They may try to play 1 parent against the other because they need to feel in control and test rules and limits. However, they are likely to feel guilty and responsible for the separation and feel that they should try to restore the marriage.
Parents also suffer detrimental effects from divorce and manifest a variety of negative and uncomfortable reactions. Mothers are likely to react to daily stressors as well as untoward major events; to consume more alcohol; to use more mental health services for depression, anxiety, or feelings of humiliation; and to feel overwhelmed and less capable as parents. Fathers often feel pushed away, are likely to seem less accepting of their children, and also may develop depression, anxiety, and substance abuse. Grandparents as well often perceive a decreased quality of relationship with their grandchildren, with custody arrangements being more influential in determining visiting schedules than is geographic distance.10,18,21–25
Although divorce may be associated with a variety of negative reactions in all members of the family, protective and risk factors have been identified. Predivorce parental rancor, along with children’s misunderstanding of the significant changes in their lives and their feelings of guilt for the separation, are likely to lead to greater emotional difficulties. Poor education, poverty, and parents’ mental health problems may be more important negative factors than the separation itself. Inconsistent discipline, the child’s sense of vulnerability, and rejection by a parent are likely to cause adjustment problems, particularly in children with difficult temperament traits, such as low emotionality or high impulsivity. Factors that lead to better outcomes include positive child temperament and an optimistic view of the future, consistent parental discipline, parental acceptance and warmth, and maintenance of as normal a routine as possible.5,8,10,17,18,24,26–29
THE PEDIATRICIAN′S ROLE
Pediatricians may only be able to learn about divorce or separation from the children’s behavioral changes, family moves, and changes in family financial responsibility. Inquiring about family stressors, including marital difficulties, can be a routine part of the pediatric health supervision visit. When pediatricians counsel the family regarding issues of child development and behavior, areas of marital discord or stress are often uncovered. Addressing these stressors directly or referring for marital counseling is appropriate and may preserve the marital relationship. Pediatricians must consider their own attitudes and ethical positions concerning divorce, especially if they have experienced divorce in their own families, and they must be as objective as possible in counseling children and parents. If the marriage is to end, early interventions can aim to decrease parental hostility and assist the child and parents in coping with family disruptions to come.
In cases of marital discord, the potential role of pediatricians in the area of prevention cannot be underestimated. The pediatrician faces 2 preventive tasks: preserving the intact family when appropriate or decreasing morbidity related to separations that occur.
The pediatrician can assess the child’s reactions, the parents’ reactions and levels of hostility, their abilities to meet the child’s physical and emotional needs, their support systems, and any indication of parental mental illness.30,31
Understanding the child’s experience of divorce is essential if the pediatrician is to advise the family. The works of several authors can be particularly helpful.17,20,32–35 Wallerstein36 correctly notes that the family divorce is a process, not simply a single event. Consequently, a child’s adjustment occurs in stages.
The event of acute parental separation, which precedes the legal divorce by months or years, is typically the time of highest vulnerability for the child. Parental distress is high. One parent is absent and often temporarily lost to the child. The custodial parent may find parenting responsibilities more difficult because of his or her own distress. At a time when children’s needs are increased, parents are at an emotional disadvantage and are often less able to address the needs of their children.
Decreasing school performance, behavioral difficulties, social withdrawal, and somatic complaints are common reactions of children and accompaniments of divorce that require intervention. Profound sadness is typical, and depression is not uncommon.
A parent conference at this stage might be scheduled. The pediatrician can meet with the parents together ideally, or separately if necessary, to assess the current situation, assist in future planning for the children’s needs, and reestablish an ongoing, working doctor-patient relationship with each parent. If one parent is not able or willing to confer with the pediatrician, the conference must be with the custodial parent. The pediatrician may offer the noncustodial parent an opportunity to discuss the separation as it affects the child. It is important that the pediatrician understand and respect possible individual parent preferences for a man or woman as the counselor, whether the counselor is the pediatrician or an expert to whom the pediatrician refers the family.
The discussion can begin by inquiring how each member of the family is doing at this time of family stress. Do both parents have adequate support systems, such as extended family, clergy, or a personal physician to help meet their own physical and emotional needs? Are there supports that can help parents in their parenting roles? What is the apparent emotional reaction of the children? It may be helpful to interpret these reactions to the parents on the basis of the child’s developmental level and perspective.
Pediatricians can help parents understand their children’s reactions and encourage them to discuss the divorce process with their children. Parents can be helped to answer the children’s questions honestly at their level of understanding. The children’s routines of school, extracurricular activities, contact with family and friends, discipline, and responsibilities should remain as normal as possible. Children should be given permission for their feelings and opportunities to express them. They must understand that they did not cause the divorce and cannot bring the parents back together. Hopefully, they can be told that each parent will continue to love and care for them. The pediatrician can offer families pertinent written material on divorce directed at parents and children (see reading lists at the end of this report).
Custody options can be discussed, and the parents’ plan may be explored. It is often helpful to remind parents that they together know better than anyone else their children’s needs after divorce and that their knowledge of their own children makes them remarkably more qualified than outsiders, including those in the legal system, to develop a good plan. When consensus cannot be reached or disagreement exists, methods of conflict resolution can be discussed. The pediatrician must insist on being the child’s advocate and not take the side of either parent. However, if living with either parent seems to present a risk of abuse or neglect for the child, the pediatrician must contact child protective services and possibly seek advice from his or her own attorney. Seductive behavior by a parent toward the pediatrician can be rebuffed politely but firmly. Custody arrangements should be planned always with the children’s best interests in mind. Legal custody and parental rights and responsibilities can vary in their physical and legal arrangements from sole 1-parent custody, to various forms of shared arrangements, to equal or joint custody.35 Varying statutory requirements exist to protect the interests of children. The reader is referred to the American Academy of Pediatrics statement “The Child in Court.”37
More important for the child’s mental health than the type of custody is the quality of parenting that the child receives through the divorce and postdivorce periods as well as the child’s own resilience. Regardless of the type of custody arrangement, it is important that the pediatrician be given a copy of the divorce decree or be informed in writing by both parents of who is responsible for informed consent, who is to pay for the child’s health care, and with whom the pediatrician may discuss health information about the child. If the noncustodial parent has visiting rights, it is important that immunization and other pertinent health records be given to both parents in case of an emergency or urgent situation. Parents should inform the child’s school of the change in the family structure, request that report cards be sent to both parents, and identify which parent has authority to grant permission for the child’s school-related activities.
Although many children have long-lasting emotional and adjustment problems associated with their parents’ divorce, most adjust and function well over time, particularly those who have supportive relationships and a positive temperament and receive professional counseling.2,20,32–34 Pediatricians must recognize that a divorce is a process and not an event; substantive periods of change during the process can demand new adjustments on the part of children. Although the legal divorce is an important event for parents, it may be an insignificant event to a younger child who knows little of the legal process or a very significant event for the older child who experiences further proof that his parents will not reconcile. Among troublesome issues for children may be the parents’ dating and sexual activities. Parental discretion and truthfulness are important for the maintenance of respect for the parents. Stepfamilies introduce another adjustment challenge for children and their parents.
As children develop and mature, their emotions, behaviors and needs with regard to the divorce are likely to change. A custody arrangement that made sense for a younger child may need adjustment for a preadolescent or adolescent. In addition, Wallerstein36 describes the “sleeper effect” on some early adolescents. With their advancing maturity, awakening sexuality, and important steps toward their own adulthood, their parents’ divorce is reinterpreted and requires rediscussion and readjustment. Many behavioral and emotional reactions from the separation can be reawakened at times of subsequent loss, at anniversaries, with the child’s advancing maturity, and with the need to adjust to new and different family structures.36 Ideally, the pediatrician will be able to maintain a professional relationship with both parents so as to continue to help them care for their children in a comfortable and positive manner.
ADVICE FOR ASSISTING CHILDREN AND FAMILIES
Be alert to warning signs of dysfunctional marriage and impending separation.
Discuss family functioning in anticipatory guidance and offer advice pertinent to divorce as appropriate.
Always be the child’s advocate, offering support and age-appropriate advice to the child and parents regarding reactions to divorce, especially guilt, anger, sadness, and perceived loss of love.
Try to maintain positive relationships with both parents rather than taking sides. If there is evidence of an abusive situation, referral to child protective services is indicated.
Encourage open discussion about separation and divorce with and between parents, emphasizing ways to deal with children’s reactions and identifying appropriate reading materials.
Refer families to mental health resources with expertise in divorce if necessary.
Become familiar with the Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version38 and review the diagnostic criteria carefully so that a specific and appropriate diagnosis is used when helping children and families deal with separation and divorce (Appendix 1).
Committee on Psychosocial Aspects of Child and Family Health, 2002–2003
Joseph F. Hagan, Jr, MD, Chairperson
William L. Coleman, MD
Jane M. Foy, MD
Edward Goldson, MD
Ana Navarro, MD
Thomas J. Sullivan, MD
J. Lane Tanner, MD
F. Daniel Armstrong, PhD
Society of Pediatric Psychology
Peggy Gilbertson, RN, MPH, CPNP
National Association of Pediatric Nurse Practitioners
Sally E. A. Longstaffe, MD
Canadian Paediatric Society
Frances J. Wren, MD
American Academy of Child and Adolescent Psychiatry
George J. Cohen, MD
National Consortium for Child and Adolescent Mental Health Services
READINGS FOR PARENTS
American Academy of Child and Adolescent Psychiatry. Children and Divorce. Washington, DC: American Academy of Child and Adolescent Psychiatry; 1998
American Academy of Pediatrics. Divorce and Children. Elk Grove Village, IL: American Academy of Pediatrics; 1999
Barnes RG. You’re Not My Daddy. Winning the Heart of Your Stepchild. Grand Rapids, MI: Zondervan Publishing House; 1997
Condrell KN, Small LL. Be a Great Divorced Dad. New York, NY: St Martin’s Griffin; 1998
Davis RF, Borns NF. Solo Dad Survival Guide: Raising Your Kids on Your Own. Chicago, IL: Contemporary Books; 1999
DeBord K. Focus on Kids: The Effects of Divorce on Children. Raleigh, NC: National Network for Child Care, North Carolina Cooperative Extension Service, North Carolina State University; 1997
Engber A, Klungness L. The Complete Single Mother: Reassuring Answers to Your Most Challenging Concerns. Holbrook, MA: Adams Media; 2000
Kennedy MM, King JS. The Single-Parent Family: Living Happily in a Changing World. New York, NY: Crown Trade Paperbacks; 1994
Lansky V. Vicki Lansky’s Divorce Book for Parents: Helping Your Children Cope With Divorce and its Aftermath. 3rd ed. Deephaven, MN: Book Peddlers; 1996
Noel B, Klein AC. The Single Parent Resource. Beverly Hills, CA: Champion Press; 1998
Ricci I. Mom’s House, Dad’s House: A Complete Guide for Parents Who Are Separated, Divorced, or Remarried. New York, NY: Simon & Schuster; 1997
Seymour T, Francis C, Steffens P. Supporting Stepfamilies: What Do the Children Feel? Lincoln, NE: Nebraska Cooperative Extension; 1995
READINGS FOR CHILDREN
Blume J. It’s Not the End of the World. Scarsdale, NY: Bradbury Press; 1972
Danziger P. The Divorce Express. New York, NY: Delacorte Press; 1982
Holyoke N, Nash S. Help! A Girl’s Guide to Divorce and Stepfamilies. Middleton, WI: Pleasant Company Publications; 1999
Johnson J, O’Neill C. How Do I Feel About My Stepfamily? Brookfield, CT: Copper Beech Books; 1998
Kimball G. How to Survive Your Parents’ Divorce: Kids’ Advice to Kids. Chico, CA: Equality Press; 1994
Rogers F, Judkis J Let’s Talk About It: Divorce. Pittsburgh, PA: Family Communications Inc; 1996
Appendix 1. Reimbursement and DSM-PC Diagnoses Related to Family Divorce
The Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version38 provides diagnoses appropriate to the management of family divorce in pediatric practice. The DSM-PC defines diagnoses regarding specific problems of the child as well as situations that impact the child’s health and well-being. The DSM-PC diagnostic codes are consistent with codes found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). All DSM-PC codes conform to the coding of the International Classification of Diseases, Ninth Revision (ICD-9).
The situational diagnosis code for family divorce is v61.0. Additional situations may also be managed within the context of the pediatric encounter with the child and can be specifically coded, such as marital discord (v61.1) or domestic violence (v62.8).
Multiple diagnoses for children impacted by family divorce can be found in DSM-PC. Clinicians are encouraged to review the diagnostic criteria carefully so that a specific and appropriate diagnosis is used.
If the child’s difficulty appears to be acutely related to issues of adjustment and the adjustment to stress is marked by specific symptoms, various adjustment disorders might be considered appropriate diagnoses, including the following:
Adjustment disorder with depressed mood (309.0);
Adjustment disorder with anxiety (309.24);
Adjustment disorder with mixed anxiety and depressed mood (309.28); and
Adjustment disorder with disturbance of conduct (309.3).
Newly occurring symptoms suggestive of attention-deficit/hyperactivity disorder at the time of parental separation might, with time and further evaluation, more properly be diagnosed as adjustment disorder with anxiety.
Many children will endure their family change with varying levels of sadness. Some will meet the diagnostic criteria for depression, depressive disorder (NOS 311.0), or major depressive disorder (296.12 × or 293.3 ×). The DSM-PC also defines a “sadness variation” (v65.45) or “sadness problem” (v40.3).
Appropriate current procedural terminology codes to bill for work performed with children with these diagnoses might be 99213–5 (expanded, detailed, or complex problem). These codes are time sensitive. Note that these codes may be used whether or not the patient is present; thus, they can be used for time spent speaking with parents alone. Telephone case management codes (99371–3) and preventive counseling codes (99401–4) may also be appropriate procedure codes, although many primary care practitioners report difficulty in obtaining reimbursement for these services from third-party payers.
Appropriate diagnostic and procedure coding as well as documentation are essential to reimbursement for the important additional services that primary care and specialty pediatricians provide to children and families in the context of family divorce.
- ↵Emery RE. Marriage, Divorce, and Children’s Adjustment. Thousand Oaks, CA: Sage Publications; 1999
- ↵Sammons WA, Lewis J. Helping children survive divorce. Contemp Pediatr.2001;18 :103– 114
- ↵Healey JM Jr, Malley JE, Stewart AJ. Children and their fathers after parental separation. Am J Orthopsychiatry.1990;604 :531– 543
- ↵Wallerstein JS. The long-term effects of divorce on children: a review. J Am Acad Child Adolesc Psychiatry.1991;303 :349– 360
- Cherlin AJ, Furstenberg FF Jr, Chase-Lansdale L, et al. Longitudinal studies of effects of divorce on children in Great Britain and the United States. Science.1991;252 :1386– 1389
- ↵Clark JA, Schneider A. Focus on Kids: The Effects of Divorce on Children. Raleigh, NC: North Carolina Cooperative Extension Service; 1997
- ↵Jaskowski SK, Dellasega C. Effects of divorce on the grandparent-grandchild relationship. Issues Comp Pediatr Nurs.1993;16 :125– 133
- ↵Wallerstein JS, Johnston JR. Children of divorce: recent findings regarding long-term effects and recent studies of joint and sole custody. Pediatr Rev.1990;11 :197– 204
- ↵Ricci I. Mom’s House, Dad’s House: A Complete Guide for Parents Who Are Separated, Divorced, or Remarried. New York, NY: Simon & Schuster; 1997
- ↵Wallerstein JS. Children of divorce: the psychological tasks of the child. Am J Orthopsychiatry.1983;53 :230– 243
- ↵American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. The child in court: a subject review. Pediatrics.1999;104 :1145– 1148
- ↵American Academy of Pediatrics. The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Wolraich ML, Felice ME, Drotar D, eds. Elk Grove Village, IL: American Academy of Pediatrics; 1996
- Copyright © 2002 by the American Academy of Pediatrics