CHAPTER 26 Divorce, Separation, and Bereavement
The family is the child’s principal resource for meeting his or her needs for protection, emotional support, education, and socialization. A variety of different events can result in disruptions that cause the child to be separated from his or her parents. At times, these separations may be relatively brief but unexpected (e.g., a parent’s acute illness or injury). The separation may occur in the context of significant parental discord, as often occurs with a divorce. The death of a parent results in a permanent separation that may be anticipated or unanticipated. All of these disruptions cause significant stress for the child, with the potential for long-term adverse consequences. The child’s adaptation to these stresses is affected by the reasons for the separation and the child’s age, temperament, and available support systems.
DIVORCE
Approximately 40% of first marriages end in divorce. About half of these divorces occur in the first 10 years of marriage, so there are often young children in the family when the parents divorce. At least 25% of children experience the divorce or separation of their parents. Few events in childhood are as dramatic and challenging for the child as divorce.
Divorce is likely to be accompanied by changes in behavioral and emotional adjustment. In the immediate postdivorce period, many children exhibit anger, noncompliance, anxiety, and depression. Children from divorced families require psychological help two to three times more frequently than children with married parents. Long-term studies suggest that in the absence of ongoing stressors, most children demonstrate good adjustment a few years after the divorce, but some have enduring difficulties. Overall, when groups of children from divorced families are compared with groups of children from married families on standardized measures of psychological adjustment, the children from divorced families have only a relatively small increase in problems.
Divorce is not a single event, but a process that occurs over time. In most cases, marital conflict begins long before the physical or legal separation, and the divorce brings about permanent changes in the family structure. Multiple potential stressors for the child are associated with divorce, including parental discord before and after the divorce, changes in living arrangements and sometimes location, and changes in the child’s relationship with both parents.
The child’s relationship with each parent is changed by the divorce. In the short-term, the parent is likely to experience new burdens and feelings of guilt, anger, or disappointment that may disrupt parenting skills and family routines. Contact with the noncustodial parent may decline greatly. Parents may be perceived by their children as being unaware of the child’s distress around the time of the divorce. Pediatricians can help parents understand things they can do that will be reassuring to the child. Maintaining contact with both parents, seeing where the noncustodial parent is living, and in particular, maintaining familiar routines are comforting to the child in the midst of the turmoil of a separation and divorce. The child should attend school and continue to have opportunities to interact with friends. Given the parents’ distress, assistance from the extended family can be helpful, but these family members may not offer to help for fear of “interfering.” It may be helpful for pediatricians to encourage parents to ask for this assistance. Pediatricians should look for maladaptive coping responses. Some parents may respond to their increased burdens and distress by treating their children as friends with whom they share their distress. Alternatively, they may place excessive responsibilities on the child or leave the child unsupervised for longer periods of time. Responses such as these increase the burdens on the child and increase the chance that the child will develop behavioral or emotional problems.
Reaction to Divorce at Different Ages
The child’s reaction to the divorce is influenced by the child’s age and developmental level. Infants do not react directly to the divorce, but if the divorce results in prolonged or more frequent separations from a primary caregiver, developing a secure relationship with this individual may be more difficult. Infants require special consideration in relation to custody and visitation. Separations from a primary caregiver should be brief. Preschool children are characterized by having magical beliefs about cause and effects and an egocentric view of the world. They may believe that something they did caused the divorce, leading them to be particularly upset. They may engage in unusual behaviors that they believe will bring the parents back together again. At this age, parents need to deliver a clear message that the divorce was related to disagreements between the parents, that nothing the child did caused the divorce, and that nothing the child could do would bring the parents back together again. Preschool children may reason that if the parents left each other they also might leave the child. To counteract this fear of abandonment, children may need to be reassured that although parents separated, they will not abandon the child and that the child’s relationship with both parents will endure.
School-age children have a concrete understanding of cause and effect; if something bad happened, they understand that something caused it to happen. However, they are not likely to understand fully the subtleties of parental conflict or the idea that multiple factors contribute to a conflict. Children at this age may express more anger than younger children and often feel rejected. Many young school-age children worry about what will happen to one or both parents. School performance often deteriorates. Older elementary school–age children may believe that one parent was wronged by the other, further contributing to their anger. This belief, in conjunction with their concrete understanding of cause and effect, allows children to be easily co-opted by one parent to take sides against the other. Parents need to understand this vulnerability and resist the temptation to support their child in taking sides.
Adolescents may respond to the divorce by acting out, becoming depressed, or experiencing somatic symptoms. Adolescents are developing a sense of autonomy, a sense of morality, and the capacity for intimacy, and divorce may lead them to question previously held beliefs. They may be concerned about what the divorce means for their future and whether they, too, will experience marital failure. Questioning of previous beliefs in conjunction with decreased supervision may set the stage for risk-taking behaviors, such as truancy, sexual behaviors, and alcohol or drug use.
Outcome of Divorce
One of the best predictors of children’s adaptation to divorce is whether the physical separation is associated with a decrease in the child’s exposure to parental discord. In most cases, divorced parents still must interact with each other around the child’s schedule, child custody and support, and other parenting issues. These types of issues create the potential for the child to have ongoing exposure to significant discord between the parents. For example, if one parent tends to keep the child up much later than the bedtime at the other parent’s house, sleep problems may develop. When children feel caught in the middle of ongoing conflicts between their divorced parents, behavior or emotional problems are much more likely. Regardless of how angry parents are with each other, the parents should be counseled that they must shield their child from this animosity. Clear rules about schedules, discipline, and other parenting roles often are helpful in minimizing conflicts. When parents have trouble resolving these issues, mediation may be helpful. Pediatricians need to be wary of parents’ attempts to recruit them into custody battles to substantiate claims of poor parenting, unless the pediatrician has first-hand knowledge that the concerns are valid.
Although the primary physical residence for most children is still with the mother, the court’s bias toward preferring mothers in custody decisions has decreased, and there is more emphasis on including both parents in the child’s life. In the early 1980s, 50% of children had no contact with their fathers 2 or 3 years after a divorce, whereas today only 20% to 25% of children have no contact with their father. Most states now allow joint physical or legal custody. In joint physical custody, the child spends an approximately equal amount of time with both parents, and in joint legal custody, parents share authority in decision making. Although joint custody arrangements may promote the involvement of both parents in the child’s life, they also can be a vehicle through which parents continue to express their anger at each other. When parents have severe difficulty working together, joint custody is an inappropriate arrangement and has been associated with deterioration in the child’s psychological and social adjustment.
Divorce often creates financial difficulties for the mother and child. The mother’s family income often declines by 30% or more in the first year after the divorce. Only about half of mothers who have child support awards receive the full amount, and one fourth receive no money at all. These financial changes may have multiple adverse affects on the child. The family may have to move to a new house and the child may have to attend a new school, disrupting peer and family relationships. The child may spend more time in child care if the mother has to return to work or increase her work hours.
Role of the Pediatrician
Pediatricians may be confronted with issues related to marital discord before the divorce, may be consulted around the time of the divorce, or may be involved in helping the family to manage issues in the years after the divorce. The pediatrician can be an important voice in helping the parents understand and meet the child’s needs (Table 26-1). Before the divorce, parents may wonder what they should tell their children. Children should be told of the parents’ decision before the physical separation. The separation should be presented as a rational step in managing marital conflict and should prepare the child for the changes that will occur. Parents should be prepared to answer children’s questions, and they should expect that the questions will be repeated over the next months. Once parents have told children of the separation, it may be confusing to the child if the parents continue to appear to live together and may raise false hopes that the parents will not divorce.
TABLE 26-1 General Recommendations for Pediatricians to Help Children During Separation, Divorce, or Death of a Close Relative
| Acknowledge and provide support for grief the parent/caregiver is experiencing |
| Help parent/caregiver to consider child’s needs |
| Encourage parent/caregiver to maintain routines familiar to the child |
| Encourage continued contact between child and his or her friends |
| If primary residence changes, the child should take transitional objects, familiar toys, and other important objects to the new residence |
| Minimize frequent changes in caregivers, and for infants keep times away from primary caregiver brief |
| Have parent/caregiver reassure the child that he or she will continue to be cared for |
| Have parent/caregiver reassure the child that he or she did not cause the separation, divorce, or death (especially important in preschool children) |
| Encourage parent/caregiver to create times or rituals that allow the child to discuss questions and feelings if the child wishes |
Many parents report not feeling like their life had stabilized until 2 to 3 years or more after the divorce, and for some the divorce remains a painful issue 10 years later. Children’s understanding of the divorce changes at different developmental stages, and their questions may change as they try to understand their family’s history. Although most children ultimately show good adjustment to the divorce, some have significant acting-out behaviors or depression that requires referral to a mental health professional. Some parents need the assistance of a mediator or family therapist to help them stay focused on their child’s needs. In the most contentious situations, a guardian ad litem may need to be appointed by the court. This individual is usually a lawyer or mental health professional with the power to investigate the child and family’s background and relationships to make a recommendation to the court as to what would be in the best interests of the child.
SEPARATIONS FROM PARENTS
Children experience separations from their primary caregiver for a variety of reasons. Brief separations, such as those to attend school, camp, or other activities, are nearly a universal experience. Many children experience longer separations for a variety of reasons, including parental business trips, military service, or hospitalization. Child adjustment to separation is affected by child factors, such as the age of the child and the child’s temperament; factors related to the separation, such as the length of and reason for the separation, whether the separation was planned or unplanned, and factors related to the caregiving environment during the separation, such as how familiar the child is with the caregiver and whether the child has access to friends and familiar toys and routines.
Children between 6 months and 3 to 4 years of age often have the most difficulty adjusting to a separation from their primary caregiver. Older children have cognitive and emotional skills that help them adjust. They may be better able to understand the reason for the separation, communicate their feelings, and comprehend the passage of time, allowing them to anticipate the parent’s return. For older children, the period immediately before a planned separation may be particularly difficult if the reason for the separation causes significant family tension, as it may in the case of hospitalization or military service.
If parents anticipate a separation, they should explain the reason for the separation and, to the extent possible, give concrete information about when they will be in contact with the child and when they will return home. If the child can remain at home with a familiar and responsive caregiver, this is likely to help adjustment. If children cannot remain at home, they should be encouraged to take with them transitional objects, such as a favorite pillow, blanket, or stuffed animal. Familiar toys and important objects such as a picture of the parent should be taken to the new environment. Maintenance of familiar family routines and relationships with friends should be encouraged.
DEATH OF A PARENT OR FAMILY MEMBER AND BEREAVEMENT
Death of a close family member is a sad and difficult experience. When a child loses a parent, it is a devastating experience. This experience is not rare. By 15 years of age, 4% of children in the United States experience the death of a parent. This experience is likely to alter forever the child’s view of the world as a secure and safe place. Similar to the other separations, a child’s cognitive development and temperament along with the available support systems affect the child’s adjustment after the death of a parent. Many of the recommendations in Table 26-1 are helpful. The death of a parent or close family member also brings up some unique issues.
Explaining Death to a Child
Children’s understanding of death changes with their cognitive development and experiences (see Chapter 4). Preschool children often do not view death as permanent and may have magical beliefs about what caused death. As children become older, they understand death as permanent and inevitable, but the concept that death represents the cessation of all bodily functions and has a biologic cause may not be fully appreciated until adolescence.
Death should not be hidden from the child. It should be explained in simple and honest terms that are consistent with the family’s beliefs. The explanation should help the child to understand that the dead person’s body stopped functioning and that the dead person will not return. Preschool children should be reassured that nothing they did caused the individual to die. One should be prepared to answer questions about where the body is and let the child’s questions help determine what information the child is prepared to hear. False or misleading information should be avoided. Comparisons of death to sleep may contribute to sleep problems in the child.
There are many possible reactions of children to the death of a parent or close relative. Sadness and a yearning to be with the dead relative are common. Sometimes a child might express a wish to die so that he or she can visit the dead relative, but a plan or desire to commit suicide is uncommon and would need immediate evaluation. A decrease in academic functioning, lack of enjoyment with activities, and changes in appetite and sleep can occur. About half of children have their most severe symptoms about 1 month after the death, but for many the most severe symptoms in reaction to the death do not occur until 6 to 12 months after the death.
Should the Child Attend the Funeral?
Children often find it helpful to attend the funeral. It may help the child to understand that the death occurred and provide an opportunity to say good-bye. Seeing others express their grief and sadness may help the child to express these feelings. Going to the funeral helps prevent the child from having fears or fantasies about what happened at the funeral. If the child is going to attend the funeral, he or she should be informed of what will happen. If a preschool-age child expresses a desire not to attend the funeral, he or she should not be encouraged to attend. For older children, it may be appropriate to encourage attendance, but a child who feels strongly about not wanting to go to the funeral should not be required to attend.
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