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Divorce:
Changing the Lives of Fifteen Million Children
In the 1990s

During the 1990s, almost fifteen million children1,2, the majority of whom were under eight years of age3,4, faced a life altering crisis: divorce. Divorce has a dramatic effect on children, their peers, their schools, and the social/legal fabric of our culture. Despite the increasing evidence that the effects of divorce on children can be devastating4-12, society in general and pediatricians in particular have not mobilized resources to help these children in the same way that support groups have been formed to help victims of physical or substance abuse.

There is clearly an opportunity for pediatricians to play a role in helping divorcing families, with a view to improving the lives of their children. Divorce, unlike crises such as illness, death, or natural disaster, is a family crisis where parents often put their own needs before those of their children, and in which there is a pervasive loss of support systems12. Moreover, children dont even benefit from their parents learning from the experience. Although more than 80% of divorced parents do remarry7,8, the divorce rate in second and third marriages is upwards of 60%. It is projected that by 2010 more than half of school age children will have spent a substantial time living with a single parent or in a step-family15.


In this article we will present an overview of the current research findings that reveal the extent and the seriousness of this problem. Our emphasis will be primarily on helping pediatricians identify the major underlying needs of children (regardless of age). Meeting the needs of children with divorced parents requires an office structure which welcomes both parents and provides the resources necessary to keep both of them involved in the childs life. Drawing on our suggestions for office policy, a second article will define advice that can be given about general issues that are likely to be pertinent during the separation, negotiation of the divorce settlement, or in the years following the granting of the divorce decree.

An overview of the research

Studies have documented both immediate and long-term effects of divorce on children. Two conclusions stand out from the data: First, the economic and emotional security of children is better maintained when both parents continue to play an active role in the childs life16-20. Second, divorce is a continuum of experiences which affect many children into adulthood5,12,21-22. Problems range from poor peer relationships, psychosomatic illness, lack of emotional commitment to personal relationships, and academic failure to suicide, drug dependence and criminal activity5,12,21-32.

Pediatricians need to carefully evaluate the research in order to assess its relevance to their own patient population. Wallerstein11,12 has followed sixty families in California for more than a decade. Her general conclusions are shown in Table 1. She has been perhaps the most effective advocate drawing attention to the plight of these children, but the focus of her research has been divided between the outcome for the adults and the children. Others5,8, including her original partner17, have questioned the validity of the findings of this much quoted study because there is no control group and the families involved were recruited from members of a group therapy session. While most of the adult literature has focused on the process of adult recovery generally taking 2-3 years5,7,33, Wallerstein has indicated that many of the children who initially, and at five years, seemed to be adapting successfully were having more difficulty at the ten year assessment11. This finding deserves to be more widely recognized and highlights the potential importance of the continuity of care pediatricians provide. We believe attention to the issues identified in the second article could substantially change the outcome for many children.

Heatherington10,26.27, Furstenberg4,8, and Ahrons5 have studied other populations ranging from 48 to 96 couples, but the follow-up duration has been shorter than Wallersteins, and equally reliant on retrospective information. Unfortunately none of these studies has an adequate control group. In a culture which has absorbed many significant changes in gender stereotype, family demographics, and media content/exposure, it is difficult to determine what is the effect of the divorce per se and what is the effect of other societal forces. The conclusions of these studies have been somewhat more optimistic than the findings of Wallerstein. The Ahrons study highlights the resilience of children, but all show increased emotional distress, inability to commit to relationships, and increased adolescent acting out in the children of divorced parents.

If there is a consensus among the studies, it is the following: all have emphasized the importance of strong parent-child relationships as a critical determinant of childrens mental and emotional health following divorce.

Social History
Until the beginning of the twentieth century, children generally stayed with their fathers following a divorce35. Over the last sixty years, influenced by a doctrine based on attachment theory called the tender years36, children typically ended up living with their mother (physical custody) while the father was granted visitation rights. Even though they may have shared legal custody, this often left fathers in a secondary role and mothers unintentionally cast as single parents. The acceptance of the notion that women have a natural capacity to parent that men lack has now been questioned. There is a large body of research which documents the contribution fathers make to the development of their children. The work of Parke37 and Lamb38 have pointed to specific attributes of children that seem to be augmented by the father-child relationship and others have identified the importance of the father relationship for both sons and daughters in the development of ethical decision making39,40, empathy34,41-42, and critical thinking34.

Fortunately for children, the research data is not convincing that either fathers or mothers should be the prime parent11,20,4344. While it has been reported that boys fare less well post-divorce than girls, newer data suggests that girls are just as vulnerable to emotional sequelae and that boys are equally likely to adjust successfully in the post-divorce years5,45,46. Some of the earlier studies were done in step-families which complicates the interpretation. Others did not look thoroughly at the differences in children who had adequate time (at least 1/3) with each parent. Other scholars6,47 report data which indicates that ongoing parental hostility, regardless of the gender or age of the child, is the prime determinant of outcome4,8. Current statistics suggest that fathers are much more likely to stay in contact long term with their children if they are granted joint physical custody.

Establishing the pediatric office as a resource
for families of divorce

Since divorced parents are understandably and undeniably stressed, feeling judged, and treated unfairly, the pediatrician can serve the useful function of being the childrens advocate. By helping parents understand their childrens actions and point of view, pediatricians can be an invaluable resource to these families over the years. In order to establish and successfully fulfill this role pediatricians and their office staff should consider these guidelines:


Choose language carefully
Society has come to accept much of the current legal terminology without questioning the impact on families of divorce. No pediatrician should ignore the stigma of the words we use, e.g. custody implies children can be treated like property and visiting parent is an oxymoron20,34. Even terms like non-residential parent are pejorative.

Respond to the news professionally not personally
The subject of divorce often arrives without warning and out of context. Typically, while walking down the hall to have the child weighed, the parent casually remarks, Oh, and by the way, Johnnys father and I separated six months ago. It is easy to hear this type of statement as though it is purely social information and respond with an Oh, Im sorry to hear that. But it should also be received and responded to as medical information which is as important as if the parent had said, Oh, and Johnny passed out at school last week, or Hes been urinating more recently.

Maintain an advocacy role
Establishing the office as a sympathetic, nonjudgmental resource that will help both mother and father provide for the welfare of their children is an essential task. At times this is tough since it is often necessary to offer parents advice that they may not want to hear, especially when their childrens needs are at variance with their own48. For instance, the traditional advice to adults has been that they need a few years to recover from the divorce and should attend to their own social, emotional and economic needs. Yet parents need to be reminded that they do not have the luxury of being able to put their childrens needs aside or on hold while they recover.

If the parent is feeling angry and resentful, or depressed and hopeless, it is tempting to respond by merely listening to all the details/justification of the break-up and trying to be supportive of the adults plight. If the adult is calm and matter-of-fact, perhaps relieved that their spouse is out of the house, then the temptation for the listener may be to let well enough alone. But divorce, although common, is a significant red flag. While not ignoring the immediate emotional status of the parent, those who care about children have to bring the divorcing parents back to reality and use the visit as a time to offer to work together in the childrens best interests.

Dont over-identify with one parent
It is a mistake to jump to conclusions based on only one persons story. No matter how sympathetic or empathetic the approach, taking sides with one parent makes the health care professional ineffective as the childrens advocate. To best serve the children the pediatrician needs to be an unbiased listener to all concerned and, unless there is a real risk of child abuse, maintain the position that both parents should remain actively involved in the childrens lives.

Involve the children
People tend to think about divorce as an event that takes place at one point in time, but childrens feelings and behavior are affected by the family interaction leading up to the separation, during the divorce process, and for years thereafter. Parents may tell you their children are doing fine and need not talk to you, but they may not have noted changes in behavior that reflect emotions children are looking to be able to express to someone as long as the environment is safe. The pediatricians office should be presented to the children as such a safe environment. Even if things seem fine, and the children state they are relieved that the hostility and the fighting have come to an end, in a few months time they may be thinking, acting, and feeling differently.

Giving the children an opportunity to express their point of view is important. Not only will a whole new perspective come to light but this models to parents that their childrens point of view is important. If possible talk to the children without their parents present, so they are less inhibited by fears they are being disloyal or fears they will provoke an angry backlash when they get home.

Assess the quality of parenting
It is not unusual for the parents own emotional needs to compromise their ability to function well as parents5,12,48. A clinically depressed or chronically angry parent cannot respond to his/her childrens needs. Asking parents about discipline problems and changes in sleep behavior will usually provide sufficient insight into their current parenting style and how recent events have altered their own and their childrens behavior. Whether acting out of guilt or an effort to be the nicer parent, adults often let discipline become lax, which can lead to increasing parent-child friction at home, or provocative behavior in school or with peers. Parents need the assurance from professionals that rules and limits that they felt were beneficial to their children before the separation are just as valuable after.

Maintain the childs support network
Children cope better with divorce when they have a broad support network5,12,48. Encourage parents to maintain their childrens valuable friendships and extracurricular activities, like sports teams, music, ballet, Girl Scouts etc., even if that means some financial compromises, and limits parent-child time together--it will pay big dividends in the long run. Find out whether there are coaches, or other non-family adults, who could be recruited to offer valuable stability to the children, especially if their parents are consumed with financial and emotional adjustments.

Encourage parents to tell the school
No one likes to disclose personal difficulties, but finding the right person at the school (and depending on the institution it may the teacher, the principal or a guidance counselor) may reveal valuable resources for the children, e.g. special lunch groups that discuss a wide range of problems, but undoubtedly include other kids of divorce. A timely parent-teacher conference can prevent a misinterpretation of the reasons for the childs deterioration in academic performance or behavior. Also remind the parent to begin having the school send out a copy of all report cards, announcements, etc. to each parent, so they both stay informed of progress and activities.

Contact the other parent
As child advocate the pediatrician needs to foster the continued involvement of both parents since that is a crucial factor which in determining a healthy outcome for the children following a divorce. If the parent in the office objects to you contacting the other parent, get an explanation. Abuse may have played a part in the separation, but reluctance to involve the other parent is more likely to be a reflection of general parental hostility. When faced with comments like, He doesnt care about them or he wouldnt have done what he did, do not take that statement at face value. The one constant in divorce is that parents do care about their children even if they no longer care about each other, so the estranged parent will likely appreciate your outreach. If the parent being contacted does not know or have prior connections with the pediatric office he or she may feel defensive at being called. Make sure the call establishes a positive supportive link and is not an interrogation. Both parents need to see the nurse, the pediatrician, and the medical office staff as a resource.

Having established the pediatric office as a resource for families of divorce and the pediatrician as the childrens advocate, the pediatrician is potentially faced with trying to discriminate between the children who are doing well and those who are not, and the children who are doing well now but are at higher risk of problems over the coming years. The problem is that there are few markers which allow specific identification of high and low risk children.

Childrens emotional and behavioral responses to divorce

Children express many emotions in response to the dissolution of their parents marriage and manifest a broad range of behaviors (Table 2). Their emotions vary from day-to-day depending on the circumstances. Their behaviors can be equally difficult to predict or understand. Often the behaviors in any given child seem contradictory. The adolescent who has voluntarily taken on new household responsibilities may also show separation anxiety. The five-year-old who develops tantrums and sibling aggression reminiscent of his behavior at age two, may present with the abdominal pain or headaches more typically seen in the ten or twelve-year-old. Even infants, while growing and developing normally may show sleep disturbances, increased spitting of feedings, and more irritability in response to family tension. Although these behaviors might also arise in the course of normal development or in reaction to other life stresses like a move or the transition to a new school, divorce, is a unique developmental challenge for the child. The sometimes erratic behavior is a reflection of the alternating feelings of being powerless and powerful, being blameworthy and being victimized, being treated like a kid and being expected to be grown-up.

How a child copes with divorce is not how a child copes with bereavement even though both involve profound loss. Nor do children try to recover from divorce in the same way as their parents. Over a few years most adults successfully grieve the loss of the marriage and rebuild their lives; but for children it is an ongoing process that may last a lifetime, or at least through the lifetime of their parents. In childhood the experience is shaped less by the grieving over the loss of a relationship than by the desperate struggle to continue a parent-child relationship with both their mother and father. This is not just a logistic struggle. In the childs mind there is always the risk of alienating one parent by continuing to love the other.

The pediatrician needs to be able to assess whether the behaviors described in the children are part of the natural process of divorce. Many of the behaviors seen following a separation or divorce commonly occur when children are under stress for any reason and as in other circumstances require careful monitoring and/or referral if they:

a) Are causing other problems which will lead the child into a downward spiral e.g., persistent academic failure, destructive peer group associations, etc.

b) Are fixed patterns which arent modified in response to the changing circumstances of the divorce.

c) Are putting the child at immediate risk: severe depression, suicidal thoughts, drug/alcohol abuse etc.

On the other hand many of the new behavioral manifestations a child may exhibit can be very adaptive to the childs immediate circumstances. For example:

a) Regression or a decrease in academic performance will usually serve to elicit attention and help at a time when the child is feeling needy.

b)Refusal to go on play dates ensures more time at home. Requests to spend more time with peers gets a child away from a home with bad vibes. Both may be constructive behaviors to be supported rather than discouraged.

c) Refusals to sleep alone may be less a reflection of the childs need for comfort than covert encouragement by his/her newly singled parent who may also seek affection and reassurance.

d) Somatic complaints may allow a child who has little permission or ability to express his thoughts and feelings to at least communicate his distress through his body and get attention that way.


Parent behaviors which put their children at higher risk

Assessment of the childrens behaviors will be aided by understanding the impact of parental actions, especially those which violate what we have termed The Rights of Children (table 3)

Hostility and aggression (verbal or physical) in front of the children
Even behind closed doors arguments upset children. Watching parents fight is frightening and traumatic even to the most resilient children.

Criticizing or badmouthing the other parent in front of the children
Most children love both parents and want to continue to do so. Hearing one put down threatens their freedom to express the love of the vilified parent to the other and can feel to the child like a personal assault on their self-worth.

Preventing the children from visiting with the other parent
Even when one parent believes the other parent is a bad influence, short of a significant risk of child abuse, children should be encouraged to regularly stay with the absent parent.

Limiting the ability of the children to contact the other parent
Restricting phone access, email or fax contact, either overtly with restrictions or covertly with negative comments, is harmful to the maintenance of a long term relationship.

Falsely reassuring or lying to the children
The greatest casualty of divorce is often the childs trust in the believability of what his parents say. Offering explanations of the reasons for divorce that are untrue, or reassuring with promises which get broken, breaks the essential belief the children need that their parents are trustworthy.

Using the children as messengers to the other parent
Although children may at first be willing to carry messages about support checks due and visitation arrangements needing change, they often end up in the middle of parental struggles.

Asking children to keep secrets from the other parent
Expecting children to not tell about what they did or who they met when at their other home unfairly compromises the communication with the parent to whom they are returning.

Using the children as spies
Asking children to tell tales on the other parent puts children into a loyalty bind which leads them to be unsure who they can trust with what information.

Leaning too heavily on the children for support
When a parent says their child is their best buddy, or their rock, it is likely the child feels overburdened and inadequate.

Adding excessive adult responsibilities to the childrens lives
Although children may need to increase their participation in chores in a single parent household they still need time for age appropriate activities.

Ignoring their childrens point of view about visitation
Listening to what children would like is not the same as letting them make the decisions. But if they feel their wishes go unheard they will never accept the difficulties split households involve.

Inability to tolerate their childrens criticism and anger
Parents who cannot tolerate or take too personally their childrens sense of outrage and anger silence their kids and put in jeopardy their relationship with their children.

Unwillingness to accept that their best interest and their childrens will often differ
Establishing a social life, , getting a higher paying job, and going back to school are all routes to adult recovery from divorce. However, especially in the first few years, how and when these are done significantly detracts from parents physical and emotional availability to their children when they need them most.


Summary

Divorce directly affects the families of more than a million children every year and indirectly impacts their peers and the families of their peers. Little active support or child-centered guidance is available, offering pediatricians an opportunity to take steps to lessen many of the negative outcomes documented in the research.




Table 1

Conclusions from Wallerstein study

Unlike the adults, children and adolescents did not, as a group, show an improvement in their psychological health during the years following the separation.

Even children who seemed to be doing well at five and ten years had the sense of having sustained a difficult and unhappy time in their lives which cast a shadow over their childhood and adolescence.

The relationship between the child and both original parents did not diminish in emotional importance to the child over the five years, even though the fathers role in the day-to-day life of the children was lessened (note: they were all families in which the mother had physical custody).

Findings point to the undesirability of courts routinely designating one parent as the psychological parent (primary parent with sole physical and legal custody) in custody arrangements.

Table 2

Childrens emotions in
response to divorce

Anger
Elation
Relief
Anxiety
Confusion
Fear
Loneliness
Distrust
Disbelief
Misery
Anticipation
Fatigue



Table 3

The Rights of Children of Divorce

A lasting relationship with both parents
Truthful answers to their questions
Relief from feelings of guilt and blame
Freedom from inter-parental hostility
Attention to their thoughts and feelings
Input into the visitation schedule
Privacy in communication with family and friends
Recognition of displacement by competing relationships
No requirement to parent their parents
Freedom from the role of messenger
No coercion to keep secrets
An understanding of the divorce agreement

Acceptance of legal precedents like the tender years and the assignment of one parent, usually the mother, with the majority of the child rearing time, has blurred the distinctions between the self-interest of the child and that of the parent. This rarely serves the childrens interests. Pediatricians have the health and welfare of children as their number one professional responsibility. Their role as advocates for childrens needs starts with their patients parents but can reach beyond the family into the community. There are not only personal consequences to the families involved when children of divorce are allowed to grow up without the supports they need, but there are also societal consequences. Pediatricians can play a vital role in keeping the childrens perspective in focus and promote the concept of the rights of children of divorce when communicating with parents, schools, attorneys, legislators and public policy makers.

Many would prefer to keep this a list of needs, or see certain items as impossible ideals, but our work with hundreds of families has confirmed our belief that the Rights of Children of Divorce1 should be a charter adopted by all who hold the future of these children in their hands. Since we wrote our book we have become aware of similar lists have devised by the American Association of Matrimonial Lawyers and the Childrens Rights Council.

CONTEMPORARY PEDIATRICS ARTICLE PART 11

In Part I of this article we established that a startling number of children are affected by divorce each year and discussed the societal and developmental issues which should encourage pediatricians to become more effective advocates for these children. Divorce is a serious red flag, since it puts children at risk for numerous social/emotional/behavioral consequences. Once they know of marital difficulties, we would urge pediatricians to take an active role in ensuring that the interests of the children involved are not eclipsed in the legal and emotional turmoil that characterizes the divorce/separation procedure. The pediatric office should be a place parents can turn to for unbiased opinions when friends, family members, and the legal profession are bombarding them with advice which may support them in their feelings of anger and loss, but do not focus on the needs of their children.

As practitioners, however, we know that time and energy are limited, so in Part 2 we will concentrate on specific advice which is valuable to families of divorce. Much of this material is drawn from our experience working with divorced families over the last two decades. Our book, Dont Divorce Your Children: Children and Their Parents Talk About Divorce (Contemporary Books 1999), provides an in depth discussion of the day to day issues and concerns every divorcing family faces.

GUIDANCE ON SPECIFIC ISSUES

The following is a list of the every day problems that parents or their children might raise in the office. Being prepared to offer brief guidance can be of benefit in helping them work out their own problems.

The adjustment to divorce
It is important to clarify for parents that children adapt to divorce over time, but their adaptation may not mirror that of their parents. Most parents think that the real effects of the divorce commence at the time they tell the children that theyve made the decision. That is far from reality. The children have often been making adjustments to the unraveling of the marriage for months or years. Even in marriages ostensibly suddenly torn asunder by infidelity the children have been coping for some time with the parental coldness and disharmony that leads to, or is the consequence of, an extra-marital affair. As they get older, even though parents may think they, and their children are beyond the divorce, children revisit issues with each stage of social, cognitive, and sexual development.

Setting a schedule
One of the greatest burdens for parents when they separate is negotiating and agreeing on an acceptable schedule of parent time with the children. In all too many families, this arrangement, developed in the midst of considerable personal and economic chaos, becomes the permanent schedule. Unfortunately at the outset no-one, parent, child, or professional advisor, can predict how life will evolve in the ensuing months. Based on the experience of dozens of families we advise that pediatricians encourage parents to agree on a period of a year in which they can alter the patterns of visitation without being fearful they are setting a precedent for the final visitation schedule (see Chart 6).

Maintaining contact with both parents
Helping parents set a schedule for when and how they can contact their children, avoiding emotionally charged times like bedtime or dinner time, is important. Determine whether children can initiate the contact by asking them, right there from the office, to get hold of the parent who is not present. If they know how to do that then one can assume that there is adequate access and that the exact mechanisms of contact have been appropriately worked out (see Chart 7).

Transitions & Handovers
The fundamental problem for children is that divorce makes it risky to display, or admit to one parent, that they are thinking about, or missing, the other. As a result they are often anticipating the emotional turmoil of the handover back to the other parent instead of enjoying the last hours or minutes before the transfer actually happens. The pediatrician can counsel parents to minimize the number of transitions per week from one household to the other and avoid parent-to-parent handovers by picking the children up a neutral location, e.g. school or day care. When possible, returning them to the same place after an overnight or weekend stay, prevents additional acting out by the child or parent. The pediatrician can also mention that setting a schedule for telephone calls to the parent the children are not with, and making use of other contact mechanisms such as e-mail, will ease everyones adjustment.

Ensuring truthful answers to questions
Pediatricians need to stress to parents that at all times they need to tell the truth especially when asked a direct question about the past, present or future--even when the answer may be I dont know or lead to personal embarrassment. Pediatricians can counsel parents to give their children responses which are truthful and can stand the test of time. The parents may add more information as the child gets older, or their own understanding of what happened becomes clearer, but they never want to have to retract a statement as a lie. The erosion of trust and security caused by such behavior may be as harmful as the negative effects of a divorce itself, especially if the pretending drags on for years1,2,4.

The mention of telling the truth immediately raises concern about sharing information about affairs, or substance abuse, or physical abuse. Pediatricians should remind parents that children almost always know, especially those above the age of five, and the alternative risk of lying, causing a serious breech in the relationship with the child, is significant.

How children can understand the divorce agreement
In their attempt to come to terms with their parents divorce many children
ask what the divorce agreement actually says. They know that this piece of paper restricts their freedom, limits their financial resources, stifles flexibility, and causes friction between their parents. Yet parents will rarely discuss the details, although they intimate that each provision is cast in stone. Following all the turmoil during the separation, this hardly makes children optimistic or more trusting of their parents. More than one child has remarked that this may be a settlement, but it rarely ever sounds like an agreement. To be told that they cant see this document, read it, or be privy to its contents--when its quite plain even to a five-year-old that this will be the Bible of life--generates a broad range of reactions. Rarely are any positive. Withdrawal, anger, confusion, hostility are typical and expectable.

The best way to answer childrens questions about the future is for parents to read the document with them. Thats easiest if the divorce agreement is written in plain English, so it is comprehensible without an interpreter. Some people opt for a short version which explains the allotment of time with each parent, holidays/vacations, financial arrangements, and provisions for future considerations like college.

Why it is essential to avoid false reassurance
During times of stress and turmoil parents want to be able to say something to make children feel safe and secure5. However blanket reassurance never works. Being told not to worry or someone will always take care of you can stifle childrens willingness to share their viewpoint, leaving them feeling vulnerable, rather than seeing they have any control over their lives. The pediatrician can counsel parents to limit reassurance to words which can match their actions and their ability to carry through with promises. During an office visit signs that a child is feeling the emptiness of apparently reassuring words are inappropriate facial expressions or withdrawal when the parents use words/phrases like always, love, Im doing it for you, I want them to know Ill never leave. After all, children know their parents made such promises to each other, so these words may no longer be as comforting for the children as the parent wishes they were.

Listening to the children verbalize their feelings of fault
People of all ages seek to make sense out of events they do not understand. Ascribing blame or fault to someone is one way of doing this. No one likes to feel at fault for breaking up a marriage, so many children develop somatic complaints, become unusually compliant, act out by throwing tantrums, threaten to run away, or show major changes in behavior style, e.g. become unusually apathetic or aggressive (See Table 8). Guilt commonly leads to feelings of not being good enough, especially when one parent takes on a much less involved role in the childs life. The child is left wondering What did I do that caused Mom/Dad not to want to spend time with me? Parents do best by their children when they enable them to talk out the inevitable conflicts and confusion. (See Chart 9)

Money Issues
The pediatrician can help reduce conflicts by encouraging parents to reach an initial settlement only after examining the real costs of what they spent on children in the last few years and by pointing out expenditures which need to be anticipated. If parents ensure that a rise in income of either benefits everyone, then hostility is minimized. This may sound over egalitarian to some, and offensive to those who honestly feel theyre paying sufficient support, or that the other parent squanders those funds on him/herself rather than use them responsibly for the children. There may seem no reason to give more money to the other parent if it wont immediately benefit the children, but there are creative ways around that dilemma.

Planning for future responsibilities
Parents overwhelmed with their own issues may need prompting to remember that the arguments about support checks, visitation and long term responsibilities are not about winning and losing and retribution but about their childrens future. Theres more involved here than money, and addressing this topic allows the pediatrician to bring many issues to the parents attention (see Chart 10).

Integrating dating & sexuality into single parent lives
Studies have shown that casual sexual relationships are frequently part of the personal divorce recovery process of both parents2,4,7. Many men and women, whether the person leaving the marriage, or the one being left, feel an overwhelming need to engage in a series of sexual conquests to off-set the distressing sense of failure, humiliation, and personal rejection which is universal when a marriage dissolves. Parents and therapists often defend these casual liaisons as part of the adult recovery process, but what is OK for the childless thirty-year-old is not permissible for the parent of an impressionable adolescent/child1,2. No matter how necessary such relationships may be, they should not be part of the childrens experience. Pediatricians can remind parents to confine social/sexual explorations to the nights and weekends when they are not responsible for the care of the children. Pediatricians may also mention that if, as a result of the divorce, a parent is suddenly more socially active, sexually liberated, or produces a new persona with a change of wardrobe, new hair cut, etc., then their children will implicitly feel they have the right to make similar decisions.

In their efforts to stay close to a parent, younger children may engage in very inappropriate behavior, e.g. the nine-year-old daughter may become seductive with males of all ages, or the five-year-old son wants to be in control of everything and everyone. Parents, unfortunately, often see this as flattery or signs of maturity. The pediatrician should explain what is really going on.

If a child is acting out socially or sexually because of the divorce, they likely will verbally blame one or both parents as a justification for their actions. Contrition, or self-defense, on the parents part will rarely make any headway, but focusing on the childs self-interest may initiate a dialogue. If the behaviors are self-destructive, and talking with the child doesnt produce an immediate and dramatic change in behavior, outside advice should be sought.

Refusal to spend time with a parent
Refusals happen for a variety of reasons other than a dislike, or fear of, the non-residential parent. At times they occur because the child may feel its a way to get the parent who is rebuffed to come back home to live, or to pay more support. Older children may want to establish some independence, especially if they had no say in making the schedule and it has been rigidly enforced. While not only wanting to have more freedom, adolescents find ways to spend less and less time at home regardless of whether their parents are married or divorced. Hence, as they get older, even a schedule which worked before simply doesnt fit into the logistics of their lives or their peer relationships.

Given all the possible reasons, there is no one right response to a refusal to spend time with a parent. If it is clear that resistance to visitation is increasing, arranging the handovers in a neutral location, without a parent-to-parent hand-off, minimizes the temptation for the child to act out and the parent to give in. If the child acts out at the neutral location, it forces the parent with whom they need to talk to address the issue and does not leave the other parent as mediator. If refusal to see a parent continues beyond a few dates, then both parents should look carefully at their own behavior and whether they are giving out subtle or overt signals that visiting the absent parent is not important or will be hurtful to the one left.

Home responsibilities
Many children voluntarily assume, or are asked to assume, various household responsibilities, especially when the residential parent has to work full-time. There is a difference, however, between playing a role which is appreciated and one where the family is over-dependent on the child. The adolescent should not be made to feel responsible for caring for the parent even though they may be willing to do so out of feelings of guilt. Parents often offer praise to the child when this has happened by saying I dont know how Id make it without .... Other important indicators of the child being placed in an inappropriate parent role are the child becoming the primary disciplinarian and caretaker of younger children, often further enabling the parent to spend less time at home (see Chart 11).


SUMMARY

Divorce happens in the family of one million children every year. Pediatricians are obligated to help such a large group of children who currently have no effective advocates. Though pressed for time and burdened with other demands, we hope that the advice in these articles will enable pediatricians to serve the families of divorce and the millions of children who will benefit from that effort.



Chart 5


Issues to be addressed at any time
Maintaining contact with both parents
Truthful answers to questions
An understanding of the agreement
Adult dating
False reassurance
Verbalizing fault
Refusal to see a parent
Child assuming parent role
Planning for future obligations


Chart 6

Devising A Schedule
Initial considerations Parents self-interest, and the best interests of their children, will not always be in synch, especially in the coming months.

Agree on duration of period (preferably a year) to try different arrangements to see what really works with no legal prejudice to either parent.

Avoid short visits--less than overnight on weekdays and 48 hours on weekends.

Avoid parent-to-parent handovers. Minimize transition difficulty by transferring children at a neutral location.

Three months Parents should have a mechanism to change arrangements that is not producing conflict.

Look at transitions/handovers when going from one parent to the other, including day after, and day before, behavior.

Each parent should feel the schedule is fair, providing enough time with each child to maintain a strong relationship.

Give children a chance to say what about the schedule works for them.

Six months Concentrate on the individual needs of each child. No one wants to always be a part of the generic unit known as the children.

Determine whether each parent gets time alone with each child-this minimizes loyalty conflicts.

Talk about cancellations or last minute changes. Does the responsible parent tell the child, or is the residential parent blamed by the child?

Consider whether a child serves as messenger or time with the children is being used for inappropriate emotional or financial leverage.

Does a child feel unduly powerless, out of control in reaction to moving, changing school, taking a back seat to parental adjustment/recovery?

Nine months Talk about each childs plans for the next year and anticipate adjustments that need to be made.

Make sure residential parent has sufficient private time without the children to rest and meet their own needs.

Ask the children what they want to change.

Adopt a readable agreement


Chart 7

STAYING IN CONTACT
Mechanism Pros/Cons

Telephone Offers access at only one location
Regular calls have to be scheduled or
else they are intrusive and resented
People are not as accessible by phone
A live voice has a special appeal
Answering machines have to be capable of taking long messages

Beeper Offers ready access
Can provide a brief message
Expectation of a quick response

E-mail Children have access at many locations including school
It can be used at any time which is vital if one parent obstructs communication
Messages are fairly complete and multiple exchanges can take place
Messages can be printed so instructions are easily followed
Affect/emotions can be misread easily

Fax Widely available, including schools Printed message avoids confusion
Traveling may be better than phone
Children can send/receive drawings/
messages in their/parents writing

Table 8


Important Considerations About Fault
Children need the opportunity to talk about why they feel at fault and how they think they caused the divorce. These conversations wont create a problem since the guilt is already there. Parents should help their children understand that adults are responsible for their own actions and decisions.

Encourage each child to be very specific about what I (the child) did to cause the divorce and what I (the child) might do to fix it or stop it from happening. Hearing her describe it in her own words, and then responding, is more constructive than blanket reassurance.

The child who feels at fault will also feel responsible for righting the wrong. Just as they didnt cause the divorce, children need a clear statement from each parent that they cant prevent it or reverse it.

Seeking to make Mom or Dad happy helps give the child a sense of control and purpose. Schedules which severely restrict time with one parent limit the childrens ability to play a positive role with both parents and may feel like a punishment.

Telling children its too complex to explain or you would never understand the reasons for the divorce may be transiently reassuring, but still leaves them wondering whether they have the power to change their parents plans and whether things were worse than they could imagine.

Children feel better when theyve developed an explanation that makes sense to them. Rather than preclude that, parents can offer the whole picture, e.g. Yes we argue about you, but you didnt cause the breakup....

Chart 9


Talk It Out
The following are some exchanges which demonstrate how to stay focused on making sure a child doesnt trap himself in this circle of blame while trying to discover who is the bad guy: me, Dad, or Mom? A shut-down response will rapidly terminate the conversation, but not be reassuring to a child. The talk it out response leaves room for the child to better understand the situation and return to the subject at a later date.

Child: I always make Daddy angry.... Isnt that why he left?
Parent: (shut-down response): Thats not why Daddy left.
Parent: (talk it out response): Yeah, sometimes you did make Daddy angry. And we made you angry. But that is part of living with someone. You also made us each very happy, and you still do. What happened was that Dad and I never got beyond being angry with each other. We were never able to resolve things between ourselves. You did a lot better than we did. When we told you we were angry because you got home late, you actually started to get home on time. So you didnt make Dad leave. Dad was angry about many things, and that was part of why he left. Im not sure he or I understand it all, but well keep trying to explain it to you because neither one of us believes that you caused this.

Child: I feel like I caused you and Mom to split up.
Parent: (shut-down response): Thats just not true. You shouldnt feel like its your fault.
Parent: (talk it out response): I understand you do feel guilty. But I know you arent. I dont blame you and neither does your Mom. Is there something we said or either of us did that makes you think, or feel, you caused our problem?

Child: I think I caused the divorce because you and Dad never have any time together. When Dad wasnt traveling, and he was home, you spent all your time with me.
Parent: (shut-down response): Thats not true.
Parent: (talk it out response): We did spend a lot of time with you. But thats because your Dad and I both wanted to do that. We could have, we should have, made other decisions, so we had more time together. But there was no way for you to know that, or to help us see we should have been behaving differently. Im sure if we had it to do over again wed still spend just as much time with you. Im not sure I understand everything that happened between your Dad and me, but Ill explain what I can. Hopefully it will help you see that you didnt cause us to separate, although I can see how you might think that.


Chart 10


Future Responsibilities
Extracurricular activities plan for anticipated costs
parent schedule allows time for transportation
participation by both parents at games, etc. will infringe on the sanctity of schedule time with either parent
anticipate that the activities chose as the get older will consume more parental time and money
College costs many states now have tax sheltered plans
define obligations of each parent
Medical insurance define scope and ongoing cost obligations
Major items parents budget for clothes, but often forget costly necessities like new computers or birthday presents for friends


Chart 11


Signs of Too Much Responsibility
Spends more time with siblings than parent
Serves as primary disciplinarian
Forms an alliance of equals with parent
Forced to repeatedly restrict other interests to
create more free time for parent
Becomes parents confidant