Mental Health for Children

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Contents

Background and Epidemiology
Effects of parental separation on children
Developmental issues
Minimizing the adverse effects of parental separation
How can the physician help?
Conclusion
References

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• Infants are somewhat protected from the immediate consequences of separation and divorce, but the importance of maintaining a stable and secure attachment relationship with at least one parent complicates housing arrangements.
• Preschool age children may attribute parental separation to something that they have done.
• Early school age children (five to seven years of age) may understand issues related to separation and divorce in concrete terms, and attempt to maintain ties with both parents, while late school age children (nine years of age and older) may be more inclined to be angry with one parent and choose sides. Children in this age group may play one parent against the other or idealize an absent parent.
• Adolescents are in the process of becoming independent, dealing with their sexuality and establishing career goals. When a teenager’s family is in conflict, routine adolescent tasks are more difficult, and reactions may be repressed or deferred with maladaptive behaviours or an attempt to mask feelings. Teenagers may tend to take on inappropriate responsibility for their parents’ well-being.

• After a separation, about 25% of custodial mothers become compromised by depression and emotional distancing from their children.
• After a divorce, parental conflict over child care issues places children at particular risk for behavioural and emotional problems.
• Substance abuse by either parent may be a factor in parenting inadequacy.
• Paternal lack of interest is associated with poor self-esteem in adolescents (10).
• Parents play a key role in protecting and supporting their children in situations where there is a risk of, or actual physical, sexual or emotional abuse. Substantiating abuse allegations is a particular challenge in custody access in situations where there is a high rate of false allegations (11).

• Because the underlying harmful effects of parental conflict begin long before the divorce, it is important to provide all families with anticipatory guidance about the effects of conflict on children and how to facilitate a child’s emotional well-being.
• Physicians should incorporate into well child care inquiries about family functioning that might identify families at particular risk for conflict and children showing early signs of strain.
• Before a separation occurs, parents whose marriages are in difficulty should be made aware of community resources available for conflict resolution. Physicians should have a list of available community resources, which could include resources for substance abuse or anger management counselling, or psychiatric resources for the assessment of parental depression. A template for such a list is available in Children with School Problems, published by the Canadian Paediatric Society (14).
• Physicians should be cautious about making statements that appear to take the side of one parent. Physicians can help educate parents to understand that false accusations of child abuse harm children and ex-spouses, and that each parent should focus on parenting as a responsibility rather than a right. If feasible, both parents should hear the advice provided.
• When parental break-up appears inevitable, physicians can offer both counselling and referral to appropriate resources to initiate early intervention before maladaptive patterns become entrenched. In the early stages of parental conflict, physicians can help diffuse an emotionally charged milieu and help parents communicate. In the later stages of conflict, physicians can discuss parenting strategies and help to ensure a meaningful role for each parent.
• Parents can be encouraged to think of themselves as a binuclear family and to separate ongoing parenting commitments from leftover marital disagreements. Physicians can provide anticipatory guidance about the importance of sharing health and other child care information with the other parent.
• In a practical sense, physicians can help parents develop clear rules about issues such as determining weekly schedules, sharing medical information, making holiday arrangements (including support and supervision for children travelling alone) and visiting arrangements that are developmentally appropriate for each child.
• Physicians can advise parents about strategies for effective communication with children, including techniques such as listening without interrupting, empathizing with a child’s feelings, offering physical affection and respecting a child’s timing about the need to communicate.
• Parents can be made aware of how important it is to reassure a child that both parents love him or her, that he or she is not expected to take sides, that he or she is not the cause of the divorce, and that he or she will visit with the noncustodial parent, or if this is not possible, with a substitute supportive adult.
• Parents can be given strategies to help children express their feelings and to maintain normal discipline at both households. Physicians should also advise parents against demeaning or arguing with an ex-spouse in front of a child.
• Appropriate anger management by parents who are separating is a crucial skill for effective coparenting. Parents can be encouraged to share angry feelings with another supportive adult rather than a child.
• Physicians can help noncustodial fathers parent more effectively after a separation. Current research suggests that when a mother is the custodial parent after a separation, a close relationship to the father is strongly associated with the improved well-being of a child. Noncustodial fathers can best assist their children by continuing with parenting tasks, such as homework and behavioural guidance, rather than involving themselves in recreational activities only.
• In situations where there are allegations of child abuse by either parent, the physician should gather historical information carefully and, if there are grounds to suspect abuse, report it to the appropriate child protection agency. Physicians should be prepared to document a child’s injuries, and report any findings to child protection authorities. In the case of alleged sexual abuse in a prepubertal child, if the responding physician is inexperienced, it is helpful to consult with a physician who is an expert in child abuse about the timing and nature of an examination.