Chronic parental discord and divorce can have profound, long-lasting effects on children. A child’s expectation of being loved, cared for, and a central priority of both parents is often shattered by seeing parents preoccupied by their personal anger, possibly violent to each other, frequently sad or depressed, and unavailable (emotionally and/or physically). If the tension leads to divorce, and especially if the discord continues after divorce, children may feel insecure, suffer diminished self-esteem, and not trust that love and attachment to others is reliable. The severity of long-term consequences may be considerably ameliorated if parents can focus on their love of the child in the midst of their own discord and loss.
The effects of divorce can be divided into three broad areas.1,2 One area is the child’s psychological development. Divorce makes a strong statement that relationships may be unreliable and that even the expectation of a stable family unit can be lost. The second impact relates to parental functioning. Fathers and mothers in the midst of discord and divorce often suffer depression and anger, are preoccupied for months or years with the divorce process, and are no longer spontaneously available in the same home. The third area is financial. The same family resources are now spread over 2 households, and additional, often major, expenses accrue in lawyer fees and other unanticipated costs. Most families cannot sustain such a rapid major increase in monthly expense, and over time, mothers often suffer the more serious financial harm.
Pediatricians should consider divorce as a major risk factor to a child’s development. Although more than 1 million divorces each year involve 1 million children, many pediatricians are not routinely aware of family discord, divorces, or remarriages among families within their practice. Without such awareness, pediatricians cannot provide anticipatory guidance for children in uncomplicated divorces or more comprehensive services, including mental health referral, in virulent divorces.3,4
EXPECTED PSYCHOLOGICAL REACTIONS
Parents may ask whether it is better to stay married “for the sake of the children” than to “put them through a divorce.” The tensions in discordant marriages may result in verbal or physical confrontations, compound other psychological problems such as depression or substance use, and create a bitter emotional tone in the home. Children who live with chronic family discord, tension, and unhappiness become vigilant as to how their parents are feeling and assume responsibility for causing or trying to relieve tension and unhappiness. Many children wonder if they are causing the problems and what they are supposed to do to help. Over time, these children often harbor intense anger at their parents and grow up suspicious of, yet longing for, intimacy. Thus, as young adults, they may feel unable to tolerate intimacy, or they may begin their own marriages dominated by the ghosts of their parents’ discord. If the divorce ends chronic discord, abuse, neglect, and domestic violence (sadly, this is not always the outcome), then the child or adolescent may actually be relieved and benefit from the divorce.5
For parents, divorce represents a loss of both initial marital hopes and the family unit. Dashed hopes, selfish behavior, scorn, substance use, or infidelity may fuel one spouse’s intense anger and disappointment about the other. As a consequence of this rage, some parents become so focused on hurting their spouse that they fail to see the needs of the children. Such parents may become preoccupied and clinically depressed and may turn to substances or use poor judgment. The anger between parents can spill into the pediatrician’s office through requests by one parent to protect the child from the other, which may or may not be appropriate (ie, true risk of danger from parental abuse, neglect, or substance use versus using the pediatrician as a tool to express anger or in a shortsighted, legal strategy). During the divorce, and often for a year or more thereafter, a substantial percentage of mothers suffer clinical depression, while some fathers are dominated by ongoing anger or distance themselves from the parenting role by limiting visits with their children.
For the child, divorce is a loss that is reexperienced at varying intensity throughout childhood. Some children recall feelings of loss when they see well-functioning two-parent families and during events such as birthdays, holidays, graduation, or college visits. While many children experience difficulty adjusting, commonly evidenced by lowered school performance in the first year of divorce, approximately 10% or more, largely those exposed to ongoing discord, experience sustained emotional difficulties and dysfunction through adolescence and young adulthood and commonly require mental health services.6
The causes of the divorce and the child’s perspective of each parent are reframed and possibly grieved again at major development transitions, such as when the young adolescent begins to date, considers moving away from home for college or work, falls “in love” as a young adult, marries, and becomes a parent. As such, the impact of the divorce on children depends in part on their developmental level.
Infants and toddlers are heavily influenced by the emotional state of the caregivers; thus, these children suffer most overtly when their custodial parent (most commonly their mother) is preoccupied, overwhelmed, or clinically depressed. Children under 3 years old require special consideration in terms of visitation, because they have less tolerance for long absences, especially if one parent is the predominant caregiver.
Children 4 and 5 years old have access to more sophisticated language, but they also have important cognitive limitations on their ability to understand concepts, longer time frames, and thus the implications of a divorce. These children have a rich fantasy life, and their developmental stage supports their taking responsibility for most of what happens, including parental discord. Children in this age group may feel guilty about having caused the divorce and parental tension, and any overheard arguments may reinforce their presumption.
School-aged children can begin to understand more realistically and in concrete terms the issues causing and related to the divorce. These children often feel caught in loyalty conflicts, wishing their parents would reunite and wondering about whether the parents would have divorced if they (ie, the children) had been “better.” School-aged children often are moody and preoccupied by the divorce, and boys are commonly more aggressive, especially toward their mother. The sources of this increased aggression may be the inherent propensity for boys to be more aggressive, a sense of security and permission derived from the mother being the custodial parent, or the son possibly eliciting some of the mother’s unresolved anger toward her husband.
FIGURE 21-1. Approach to assessment and management of a family with discord.
Older school-age children and adolescents may react less directly, such as with increasing complaints of psychosomatic disorders, which may be an emotional solution to avoiding angry feelings directed at the parents or reflecting their helplessness during the divorce. A secondary result of both psychosomatic symptoms and oppositional behavior might be to gain the attention of both parents, sometimes jointly, such as during medical visits when worry about a potential illness temporarily replaces parental tensions or when meeting with a school principal focuses the parents’ attention on the child’s behavior.
Although adolescents have the cognitive capacity to understand the divorce process, they are at a particularly vulnerable point in the process of developing their own sense of autonomy, identity, and capacity for intimacy. This process of separation and identity formation starts in early adolescence and lasts into young adulthood. A virulent divorce calls into question the adolescent’s basic assumptions about the meaning of reliable trust and intimacy. Faced with the rapid, real loss of what was their “home,” adolescents may flee into young adult behavior, such as premature sexual activity or substance abuse, or give up their own developmental path to take care of other family members, whether a parent or siblings.7
Remarriage adds complexity and new opportunities. After accepting that the decision to remarry closes any door on reuniting the family, the child or adolescent must negotiate a new relationship with a stepparent and possibly additional siblings. Sometimes remarriage adds to the conflict as angry emotions are rekindled; alternatively, remarriage offers new happiness to the parent and new perspectives that give the child options for supportive relationships with stepparents and siblings.
Divorce has a major impact on the child’s life outside the home. Many activities become complicated by visitation schedules, a decrease in disposable income, or parental discord. Everyday experiences, such as planning a sleepover, team sports, and music lessons, now might have to be approved by two often busy and less than cooperative households. In addition to scheduling problems, the costs of summer camp or school tuition suddenly may be beyond the family’s means or may provoke tense negotiations through lawyers or the courts. If the family’s home is a major asset, it may have to be sold, with the consequence that the child will have to change communities, thereby threatening the social fabric of school, friends, and recreational activities.
Pediatricians should be wary of requests for letters or recommendations unless the issues are clear cut, valid, and known by them firsthand. If the pediatrician has a better preexisting relationship with one parent than the other, it is essential to offer the less-familiar parent an opportunity to be heard. Whenever possible, medical instructions and reports should be given to both parents. If the child has a serious acute or chronic disease, routine scheduling of meetings with both parents should be a high priority.
The goal of custody and visitation decisions should be the child’s long-term optimal development, including having the necessary warm and unencumbered relationship with each parent as needed at each developmental stage. Although the mothers, unless deemed incompetent (eg, because of substance abuse) commonly retain physical custody, especially of young children, agreements for joint parenting are often more effective in supporting the benefits of a strong relationship with the father and the father’s ongoing involvement. Increasingly, courts and legislative statutes encourage parents to negotiate the details of joint physical and legal custody. Joint physical custody implies a close to equal time-sharing arrangement; legal custody relates to shared authority in decision making, which is relevant to such issues as obtaining consent for medical care. If joint physical or legal custody is used to expedite contentious cases, implementation of joint custody often becomes the basis for ongoing discord.8 Under such circumstances, every hour, activity, vacation, and option in the child’s life is a potential vehicle to express anger and initiate another round of poor-faith negotiations. In a positive context, joint custody offers an opportunity for both parents to remain highly involved in their child’s daily life and facilitates appropriate changes in schedule and even physical custody as the child grows older. However, such arrangements require cooperative, flexible parents who are able to focus on the child’s needs and who are willing to live in reasonable proximity (ideally in the same community) of each other for many years.
When either parent begins to “date,” a common concern is how to introduce new men or women into the child’s life. Children often react negatively as they see the new adult as further confirmation that their parents are not reuniting and as a usurper of their priority in the family. It is often wise to limit these introductions to as few as possible and only when the relationship is serious and likely to be long lasting. Asking the child to relate to too many, too brief relationships could ultimately distance the child from both the biological parent and future stepparent.
An approach to management of a family with discord is shown in Figure 21-1. Pediatricians should use questionnaires or ask standardized questions that facilitate recognition of family discord, domestic violence, and psychosocial dysfunction. Larger group practices are likely to have so many families in various stages of divorce that facilitating or leading education or self-help groups, alone or in conjunction with a mental health professional, can be a highly valued clinical service to try to prevent either the divorce itself or the harm of ongoing discord.
Any evidence of significant marital discord, separation, or intention to divorce should initiate a multiyear protocol that assesses the child’s acute reaction, level of parental interpersonal anger, the capacity of the parents to understand the child’s needs distinct from their own feelings of anger and loss, and the screening for symptoms of impaired functioning in any member of the family. Specifically, pediatricians should ask about depression and use of substances, especially alcohol. The best time to initiate help is early in the divorce process. Recommending a mediator to decrease hostility and potential costs might help to focus on the child’s needs and mitigate the damage to a child’s sense of trust and self-esteem. Psychiatric referral for treatment of depression or substance use is a critical priority. Focusing on the needs of the child, the pediatrician can recommend mental health evaluation and counseling for the child or parent as indicated. Evidence of ongoing discord after the separation and divorce is a poor prognostic sign. The pediatrician should recommend that the parents urgently address the tension and, if necessary, consider a court-appointed guardian ad litem, generally a lawyer or mental health specialist with investigatory and arbitration authority to serve on behalf of the child’s best interest. After divorce, pediatric guidance and review should span through adolescence into early young adulthood. A trusted pediatrician may ask at each major developmental stage whether the child’s view of the divorce has changed, whether they might want any information or have new questions, and what they sense are any ongoing effects of the divorce. Providing an opportunity for children to discuss these feelings over time and helping them develop a better understanding and acceptance of the divorce is an invaluable and professionally rewarding service.