During the 1990's more than ten million families, including almost twenty million children, the vast majority of whom are under eight years of age (Monthly Vital Statistics, 1994), have faced a life altering crisis: Divorce. Yet despite the studies documenting the dire outcomes for a substantial percentage of these children (Wallerstein & Kelly, 1979; Ahrons, 1981; Heatherington & Furstenberg, 1989), the medical system has done little to help their families. There is nothing comparable to the support groups and resources provided for families of alcoholics, compulsive gamblers, drug addicts, premature infants, and others.
Tragically the immediate future shows few signs of positive change. Advocacy groups such as Parents Without Partners and the Children's Rights Council have begun to have some effect on policy, but at the direct care level little has been altered. The cost-effective model of medical care which dictates ten minute well child visits, as well as the lack of priority in pediatric training given to psychosocial problems (Jellinek, 1982), means pediatricians are not addressing the situation despite parental expectations that primary caregivers will be able to manage psychosocial crises (Bellet & Maloney, 1991). On the other hand, while many divorcing parents are looking for anticipatory guidance, they resist referral to a psychiatrist since they don't believe they have a "severe" problem that merits the stigma (Fritz, 1986) of "seeing a shrink." In parallel to the unavailability of pediatric attention, parents face a similar problem in that most psychiatrists do not have specific training to deal with divorce and their availability is also severely limited.
CLOSING A GAP IN THE MEDICAL SYSTEM
As developmental pediatricians we have been asked by hundreds of parents across the country from a wide range of backgrounds what to do and what to say to their children when they find themselves caught in this gap in the medical system. We see this as an opportunity for pediatricians and child psychiatrists to work more closely to help these families with a view to improving the lives of their children--a special task since 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-family. These children of divorce are our future entrepreneurs, political leaders, physicians, teachers--and the parents of our grandchildren.
The caregiver faces a difficult challenge when asked to help a divorcing family. While the pain for children caused by the death of their parents' marriage may not be quite as intense as that which occurs consequent to a bereavement, it continues indefinitely, since, as both parents can and should remain part of their lives, there is no closure for the children. Meanwhile as long as both parents remain involved, it is clear that the models for single parenting shed little light on the divorcing adult's dilemmas and concerns. Therefore, whilst there are no set guidelines to follow, the clinician faces immense pressure to both "fix" immediate problems, relieve current emotional tensions, and prevent other crises from occurring. These are ambitious goals when faced with parents caught up in their own life adjustments and concerned about their ability to provide needed emotional support to their children.
Intuitive parenting doesn't function well at this time and parental feelings of competence have generally been undermined. Parents are seeking help to re-establish their role as the "good-enough parent" (Winnicott, 1971). As a result, while wanting insights into their own and their children?s behavior and emotions (often unavailable in the pediatric office), parents also want quick, practical advice and may therefore resist what they see as the "intrusive" and lengthy model of classical psychiatric intervention.
ESTABLSHING A ROLE AS CHILD ADVOCATE
Clinicians are most likely to succeed at helping families by establishing themselves in the role of child advocate. Too often, especially early in the process when the most preventive work could be done, the child, the real object of concern, gets lost in an effort to help the adults help themselves. While that is a laudable goal it has been shown (Wallerstein, 1997) that what is in the best interest of the adults is not necessarily in the best interests of their children.
A child advocate needs to help parents understand how the family interaction leading up to the divorce affected the child and help the parents conclude a settlement agreement and manage the post-divorce years in ways that give the children the best opportunity to realize happy, productive lives. This does not require coparenting in which both parents participate actively on a daily/weekly basis in decisions relating to the children (Furstenberg & Nord, 1985), though encouraging parents to talk with each other about their children, perhaps with the clinician as mediator, does enhance the likelihood of success. More often, parents barely talk at all, about anything. Though parents may loathe each other, what the caregiver can rely on, however, is the parents' continuing love for the children, which serves as the base for the acceptance of what we have termed the rights of children (Lewis&Sammons, 1999):
CHILDREN HAVE A RIGHT TO:
--Be the first priority in their parents' lives
--An attentive relationship with both parents
--Truthful answers to their questions
--Relief from feelings of guilt
--Attention to their thoughts and feelings
--Private communication with family and friends
--Sensitivity to "displacement" by competing relationships
--Freedom from hostility between parents
--A childhood unburdened by "parenting" their parent
--Freedom from the role of "messenger" between parents
--No obligation to keep "secrets"
--Knowledge of the terms of the divorce agreement
If both parents ensure that their children have these rights, then our experience is that the whole family will thrive despite the divorce. Playing the role of child advocate often involves telling both mothers and fathers things that they don't want to hear, but once the caregiver establishes that the child's best interests are the defining criteria for the advice offered, it is easy to form a working alliance.
ASSESSMENT PHASE: The skilled clinician has the interviewing skills and the evaluative ability to gain an understanding of the structures of family function. Pediatricians often are aware of previous coping strategies that served individuals or the whole group well, and their previous experience of the ways a given family functions can be valuable information to the child psychiatrist. Establishing this knowledge base lets subsequent advice and guidance be tailored to fit each family's needs.
PARENTING ASSESSMENT: Asking parents about discipline problems and sleep disturbances will quickly provide provisional insight into their current parenting style and how recent events have altered their own and their children?s behavior. Whether acting out of guilt or an effort to be the "nicer" parent, adults often let discipline become lax, which then 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 were beneficial to their children before the separation, are just as valuable after. Similarly if children had been sleeping independently and are now co-sleeping with their parent, the question should be raised as to whose need for emotional support and physical closeness is really being met with the new arrangement. Maintaining the normal sleeping arrangements and re-establishing rules and discipline help parents focus on more constructive coping strategies for themselves and their children.
Children cope better with divorce when they have a broad support network. Encourage parents to maintain 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 if their parents are consumed with their own problems.
It is not unusual for the parent's own emotional needs to compromise their ability to function well as parents. Clinically depressed or chronically angry parents cannot respond to their children?s needs. A parent's reluctance to support the social network of the child can mark over-involvement with the parent-child relationship in order to compensate for feelings of guilt and failure, or underinvolvement in the child's life leading to ignorance of the child's activities outside of the parent's sphere of control. Such findings are opportunities to clarify parental perspectives, support parents and normalize their distress while offering practical suggestions.
CHILD ASSESSMENT: One key to obtaining the most information in the least amount of time is to make sure the parents call each child by name--too often they protect themselves by referring to "my children" as if they are unit, or avoid salient idiosyncrasies of the relationship(s) by talking about "my son" or "my daughter." Descriptions of emotional and behavioral problems prior to the separation can provide valuable information not only about the child but the parenting style as well. By having the parent, and the child independently where possible, describe the parent-child relationship and how it has changed, the clinician can make appropriate judgments about what may require immediate advice/intervention or merits further evaluation.
It is critical to learn what the child has been told and what the child has heard. Since the strength of the two parent-child relationships is the single most important determinant of the child's future, the clinician gains the most from evaluating affection/attachment behaviors (Cassidy, 1994) and appropriate compliance responses, remembering that even toddlers seek to gain more control in response to separation/divorce (Lewis&Sammons, 1999). Since divorce often makes life seem like an endless series of good-byes, close attention to reunion behavior is often more revealing than assessing the child's degree of protest or apparent anguish at separation(Rutter, 1995). Pairing this information with the emotional tone of the parent's description of the child's behavior provides an excellent working picture of the child's status which can be augmented by quick checks with teachers, coaches, or other important adults if that is appropriate.
Because the breakdown, and then the break-up, of the marriage has changed parents in ways they may not appreciate, children often feel lonely and shut out. Our experience has been that from five or six-years on they welcome the opportunity to talk with an empathetic adult. We have found that children possess more information about what went "wrong" than their parents think possible, and that they have made a more accurate assessment of their parents? strengths and weaknesses than their parents have made of their children's.
GUIDANCE AND INTERVENTION PHASE: While many married adults think of divorce as an "event" they hope never happens to them, children and families experience it as an evolving series of events. The prime role of the child advocate should be to anticipate problems in such a way that parents can function proactively and not merely reactively. Child advocates function most effectively when they remain in the background and their visibility is minimal or non-existent. Children are reassured by seeing their parents act competently without the involvement of a third person.
We would suggest always advising parents to:
TELL THE TRUTH: In an effort to spare their children, parents may not tell them about the impending separation until the last minute, or alternatively offer them an untrue version of the story. By doing this, not only do they fail to make sense of the often aberrant behavior that the children have been living with, but when the parent is "discovered" the already injured level of trust, that is the backbone of the parent-child relationship, can be permanently damaged. When they are not told the truth, or more often told little or nothing at all, children attempt to put things they have seen and overheard into a coherent story. They frequently develop their own interpretation of events which are riddled with misunderstandings, guilt, shame, and anger. This understandably leads to feelings of fault and elaborate plans to reverse the tide they feel overpowering them: "Tuesday I created a big row by refusing to stop playing my video games and Wednesday Dad said he and Mom were getting a divorce. I tried telling them I'd never play Doom again if they would just not split up but..." or "If I could get Mom to come to soccer practice on Saturday, when I know Dad will be there, and then pretend to twist my ankle, they'll both take me to the hospital and maybe..." Parents who "protect" their children from the truth may be isolating them from other sources of support while leaving them feeling misunderstood and confused.
OFFER AGE-APPROPRIATE INFORMATION: Part of telling the truth is to explain it in a way that children can understand. "Age appropriate information" as a criterion always sounds good, but in the case of children of divorce is not so easy to determine. Many grade schoolers know, despite their parent?s best efforts, about parental affairs, drug/physical abuse, etc. Even for five-year-olds this knowledge makes a simplistic explanation like "Mommy and Daddy don't love each other any more and need to live apart" raise more questions than it answers. Younger children may not reveal their knowledge and prefer to cling to magical thinking in hopes of reversing their parents' decision. Seven or eight-year-olds focus more on the issues of fairness and fault, but not just in ways that reflect egocentric thinking (Lewis&Sammons, 1999). They may also apportion blame to one or other parent as in "If it's not my fault it must be Mom's or Dad's." The ten-year-old possesses more ability to use abstract thinking and ponder the future, and this increases resistance to simple reassurance responses which most parents rely on (Koocher, 1986; DeMaso, 1997).
AVOID REASSURANCE AS A FIRST RESPONSE: Children are worried, they feel isolated for good reasons. Encourage parents to let their children talk about their concerns and only then, if at all, tell the child "Don't worry" or "I'll always be here for you." In the process of separation/divorce parents become more fallible and children get more realistic about the frailty of human relationships, so such responses often get dismissed as untrue or heard by them as the parent actually saying "I don't want to hear what you think/feel about ...." thus closing down further communication. Parents need to keep in mind that children have a valid, but very different perspective on events, and that they may be worried about something entirely different from that which the adult anticipated or associates with the previous topic of conversation or the immediate interaction.
BE PREPARED FOR DIFFICULT QUESTIONS: Telling the truth and avoiding reassurance will drastically limit incidents of being caught off guard, but doing a little play acting with parents will often minimize their emotional reactions to questions like "Why are you so selfish Daddy?" or "Why don't you love me any more?" Parents can be helped to hear these critical comments as representing the child's search for an understanding of what they have seen and heard so far, and be encouraged to ask their children "What did I do or say to make you ask that question?" rather than dismissing the concern or being angry as in "You're too young to understand," or "Of course I still love you."
SHARE FEELINGS AND EMOTIONS WITH THEIR CHILDREN: Since parents are often confused, and their feelings are constantly changing over the course of weeks and months, they are reluctant to reveal too much to their kids. Parents say they are afraid to share how they feel while their feelings are in flux for fear of misleading the children, or worse, scaring them. Clinicians can allay the adult fears that expressing sad feelings will scare the kids and they can help the parents distinguish between talking about feelings and "losing it/breaking down."(Brent, 1983) By helping parents find ways to voice their own feelings, the clinician makes it safer for the children, who consequently feel safer expressing their own "scary" thoughts and feelings. Conversely four or five-year-olds tell us that the non-communicative parent leaves them worrying just how much "love" or being married really meant to their parents "Mommy never talks about it..." or "Mommy's not sad, so how can I be?" If one parent seems unconcerned about the separation from the other it raises doubts in the child's mind whether they could be abandoned by that parent too.
EXPECT CHANGES IN BEHAVIOR: Everyone acknowledges that parental behavior will change (Wallerstein & Kelly 1979), and it is not surprising that children's behavior also changes as they adapt to their new life circumstances. Such changes are often perceived by parents as indicating that the child needs mental health intervention and a sign that the process has gone awry, an understanding of normal grief reactions (Kubler Ross, 1970) and how they effect the behavior and functioning of adults and children can be offered. Reassurance that anger, sadness, and denial are all to be expected, and will give way to a brighter outlook on life over time, is reassuring. An assessment needs to be made of whether the children's behavior is trying to signal that they do not have enough time with each parent, or do not have adequate contact mechanisms . Acknowledging that their own parental mood can fluctuate wildly, parents can be advised to devise a signaling system their children will understand (e.g. red, yellow, or green flag on the refrigerator door handle) to tell the kids when it is a tough day.
DEVELOP A VISITATION SCHEDULE WHICH CAN BE CHANGED AS CHILDREN'S NEEDS CHANGE: One of the most unrealistic expectations parents have is that in the midst of the emotional turmoil of separating and concluding an agreement they will hit upon the "right" visitation schedule at the first attempt. An effective intervention is to help parents agree on the necessity of a trial period in which they can experiment with different options. This forces them to occasionally have a civil conversation and gives them the time to determine the requirements of the children by talking with them and observing the glitches that are bound to occur, rather than guessing what will work and feeling permanently committed to a less than workable arrangement.
MAKE THE CHILDREN PART OF THE SOLUTION: Many serious family problems would be solved quickly and without hostility if children were included in the discussions as competent family members. If told the truth and listened to respectfully, children will often pitch in to take on new responsibilities and devise the solutions to difficult problems such as schedule changes or preventing arguments at the ends/beginnings of time with the other parent.
EXPAND THE CHILDREN'S SOCIAL NETWORK: Parents are reluctant to encourage more social or extra-curricular events time because it cuts into their time with the kids, which has already been limited by splitting time with the other parent. Discussions focused on whose needs are being addressed by spending all the available allocated time together are likely to reveal who is emotionally supporting whom in the relationship. Facilitating an expansion of peer activities is not only important to meet the children?s need to individuate, but also gives parents more freedom, allaying some of their guilt, helplessness, and frustration as they take the time to work out a new life role, a new social identity, and make career adjustments.
ENCOURAGE THE AVAILABILITY OF A READABLE SETTLEMENT DOCUMENT: Children are mystified by parents who tell them they can or can't do certain things because of the divorce "Agreement", especially when they disagree about what it proscribes. The children often feel trapped in a loyalty bind as they need to take one side or the other in the disagreement. For many it is also unsettling to be told that there is a higher force controlling not only what they can do but also what their parents can do. They need to see the "locus of control" reside in their parents to prevent them spinning out of control themselves. Although many parents resist showing their children the actual divorce/separation agreement, children feel much better when they understand that "The Agreement" is a compromise both parents signed and when they are allowed to read it. If necessary they can be shown a simplified document which at least spells out the schedule and how it can be changed, the basic financial arrangements, ways/times the children can contact the other parent, and looks ahead to major issues, such as funding for college.
SUMMARY
-- Child Advocate or Therapist--which role to take:
Divorce may end the marriage but it does not end the significant role parents need to play in their children?s lives--extending over months and years. The skilled clinician can be a valuable ally to both parents by initially serving as the children's advocate. Some pediatricians will grasp this role, but most regrettably lack the training and are limited by inadequate compensation under most managed care plans. Therefore, to meet the needs of these families, they often refer to a psychiatrist, hoping that person will do the screening to determine what is appropriate. Unfortunately there are no guidelines for dealing with the family of divorce. Most people are stressed, pathology which could respond to therapy is evident.
Many of these families, however, will recover without therapy, and many are not ready for that but are available for help. We maintain the recovery will proceed more quickly if the therapist explores all the options to let the parents/family work it out. As a child advocate your clinical skills will be well used, letting the vast majority of parents who need practical advice and insights into the behavior of different family members fulfill their role and be able to support their children. Reaffirming their parenting activity is of prime importance to the children. A minor percentage will need to establish a therapeutic relationship and the information obtained as a child advocate will be a valuable foundation. The vast majority, however, will applaud your efforts and their successful coping will validate the therapist's work in this nontraditional role.
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