When Parents Split Up, What’s a Pediatrician to Do?

For the child there is no “Ex,” stresses developmental pediatrician Barbara Howard, and the emotional fallout can be significant.

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Barbara Howard, M.D.

When parents divorce, what can pediatricians do? Plenty, according to Assistant Professor of Pediatrics Barbara Howard, who presented on the topic at Hopkins Children’s annual Pediatrics for the Practitioner Update in September. The pediatrician’s primary concern, of course, is the well-being of the patient, the child. And considering all the potential pain that can come his or her way through marital discord and divorce, says Howard, it’s a concern that shouldn’t be taken lightly.

“In a way, divorce is similar to a diagnosis of cancer in that you know there’re going to be years of struggle ahead of you,” Howard said. “And there’s plenty of pain to go around – for parents, the child, and the clinician.”

The child’s reaction to divorce varies by age, Howard explained. Preschoolers’ reactions are marked by regression, sleep disturbances and a yearning for the non-custodial parent. The child in early latency may openly express grief and hold fantasies of parents reuniting; in late latency anger and powerlessness are most prominent, though the child may feel inclined to take care of the parents, too. Reactions characteristic of adolescents include acute depression, promiscuity, suicidal ideation and violent acting out.

“Adolescents may also judge their parents morally,” Howard said, “while fearing for their own future love and marital relationships.”

Howard stressed that the impact on kids comes more from the marital discord than the divorce itself – and often the discord diminishes dramatically with the parents parting – though divorce translates for the child into multiple losses – the loss of parental love, support, structure, a home, and friends. These children may also suffer a loss of self esteem, and even learning problems and reduced school performance. So, what can pediatricians do?

Being aware of the marital relationship is a good start. Parents are reluctant to tell their physicians about marital problems because they perceive it as embarrassing, Howard said, so pediatricians need to watch out for any red flags. They also need to keep their own reactions and biases in check, as parents’ marital troubles can stir up the personal divorce experiences of pediatricians, 29 percent of whom have gone through divorce.

“The hardest part may be controlling the anger we as pediatricians might feel,” said Howard. “We feel like saying, ‘Why can’t you guys just work it out. Can’t you see what this is doing to your child?’”

Howard stressed that it’s important for pediatricians to help relieve the child’s guilt and pain with a clear message. “This may be so painful for the child that he or she may not be able to speak,” says Howard. “It’s important to say, ‘It’s not your fault.’”

Pediatricians can also help the child by counseling parents on what emotions to expect from their separating spouse and child during the divorce process, and that they need to minimize their anger. Howard recommends that pediatricians advise parents to show strength, avoid speaking negatively about the other parent, avoid being a Santa Claus parent, and re-establish routines and discipline at home.

“Trying to keep the house in order conveys to the child that things are going to be okay after all,” said Howard. “They want to know everything is going to be okay.”

Myriad other issues may surface in a divorce, including financial difficulties, charges of abuse or neglect, shifting family roles, grand-parenting and step parenting issues, new romantic relationships for the divorced parents, and uncertain living and sleeping arrangements for the child.

“Middle school children, particularly,” said Howard, “are eager to know they have a place to stay and eat.”

Legal issues, of course, also come with divorce, and may involve the community pediatrician, too. Howard advised pediatricians to keep careful notes as issues like abuse are invisible but toxic, and let the parties know early on whether they’re willing to testify. An option, she noted, is to provide written testimony rather than appear in court. She added, “You can bill for your time.”

Risk factors for poor outcomes for the child of divorced parents, she concluded, include persistent guilt, lack of social support, and other mental health conditions in the child and/or the parents.

“Track this as a chronic condition, monitor depression in all parties and be prepared to refer to mediation and counseling,” Howard said. “Avoid taking sides and keep your focus as an advocate for the child.”