Mental Health for Children

Promoting mental health for children
of separating parents
Psychosocial Paediatrics Committee, Canadian Paediatric Society (CPS)
Paediatr Child Health 2000;5(4):229-32
Reference No. PP 2000-01
Revision in progress January 2009

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

The objectives of this paper are to describe the effects of parental separation on children who are at different developmental stages and competency levels, and to provide practical advice to physicians about assisting children and families in situations where parental separation is a reality.
Background and Epidemiology
Separation and divorce are increasingly prevalent in North America; between 40% to 70% of children experience the divorce of their parents (1). In Canada in 1997, there were 151,224 marriages and 67,408 divorces. Between 1971 and 1991, marriage rates decreased and divorce rates increased. In 1991, 82% of all lone-parent families were headed by women (2).
Parental separation is not an event frozen in time, rather it is a process. From the child’s perspective, both parents usually remain family members.
To date, an understanding of the epidemiology and effects of divorce has been based on studies of various designs, including case reports, qualitative interview research, prospective cohort follow-up and cross-sectional survey research.
Children who experience their parents’ divorce usually live in households headed by mothers for the first five years after a divorce (3). Because most divorced parents remarry, and the divorce rate is higher for individuals who remarry, children of divorced parents are more likely to experience further relationship disruptions and accompanying new tensions. With the tendency for parents who have separated to become involved in new relationships, it is very likely that children of separated parents will be involved with many parenting figures.
Research is needed on the effects of separation on children in same sex unions and strategies to promote the well-being of children who live in ‘stepfamilies’.
The Canadian government is currently moving toward a more child-centered approach in  legal processes that affect separating parents and their children (4).
Effects of parental separation on children
The end of a marriage can interfere with effective parenting, and deprive children of nurturing from parents who may be temporarily preoccupied with their own personal anguish. Also, divorce is frequently followed by a decline in income for the custodial parent and his or her children. Parental separation, even if it is stressful, may eventually benefit both the child and parents, depending on the family circumstances. The many influences on the child and family include parental stability, social supports, and the child’s age, temperament and resiliency.
Early studies suggested that children from families that experience a divorce and remarriage are more likely to drop out of school, get into trouble with the law, abuse drugs or alcohol, and exhibit emotional distress compared with children who grow up with both biological parents (5). More recent studies find that only a slightly higher proportion of children who are mentally well live in intact families. Some studies suggesting that a high proportion of children are negatively affected by divorce are biased due to clinical samples that were drawn from families who were in therapy rather than from the general population. Wallerstein and Blakeless (6), for example, conducted a long term study of middle class children of divorced parents, and found that almost half of the children expressed long term stress and insecurity that adversely affected their work and social relationships. The study was limited by a relatively small and biased sample of self-selected families, all of whom were referred for therapy (6). Studies based on more representative populations suggest that the risk of dysfunction faced by children of divorced parents is less than that suggested by Wallerstein and Blakeless, with evidence suggesting only a slight increase in behaviour problems in these children compared with children of nondivorced parents (7).
What are the known negative determinants? Chronic stress, associated with a child’s chronic illness, disability or difficult temperament, may contribute to family strain and parental conflict, as well as postseparation stress for parents. Parenting styles, characterized by negative attitude, verbal or physical conflict, and authoritarian behaviour, are recognized as being harmful (8). Research suggests that parental conflict, not parental separation, has the most adverse effect on children (9).
What are the known positive determinants? There is evidence that children with cooperative parents fare best in joint physical residence (1). Children who adjust best have regular contact with a caring, supportive and competent adult, whether it be a parent, relative, teacher or other person.
What is evident in the studies to date is the great diversity in the responses of children and parents to parental separation. Some children are able to cope constructively with the separation process, and emerge competent and psychologically balanced. Other children experience a period of distress, with psychological recovery occurring over a two to three year period. Another group of children experience enduring ill effects.
Developmental issues
A child’s age affects his or her short term reaction to separation and divorce; at each stage, developmental issues are worked through differently. Physicians may be in a position to manage such issues themselves, but should have information about community psychiatric and psychological resources  available to assist with managing more complex situations. Developmental issues include the following:
  • 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.
Minimizing the adverse effects of parental separation
The parental behaviours listed below put children at particular risk for the adverse effects related to a separation; parents who exhibit such behaviours may respond well to intervention.
  • 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).
The most important way to minimize emotional harm to children involved in a separation and divorce is to ensure that children maintain a close and secure relationship with both parents, unless there is spousal or child abuse or neglect, or parental substance abuse.
How can the physician help?
Physicians play a supportive and interpretive role with parents, and advocate for the best interests of  children involved in a separation and divorce (12,13). Physicians can help children and families by doing the following.
  • 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.
Parental separation is now a common event for North American children. Physicians have a key opportunity and responsibility to counsel separating parents on the significant impact of parental separation on their children’s mental health. Physicians can assist families by providing support and advice, and advocating for children within systems that serve separating families. Physicians can advocate by providing information so that individuals who work with such children recognize, and are sensitive to, their individual needs, and provide supportive and nurturing experiences for the children in schools, camps and sporting activities.
These efforts will promote better mental health outcomes for children affected by their parents’ separation. Research is needed to help identify children of separated parents who are at greater risk for enduring ill effects and to determine effective preventive measures for that group.
1. Emery RE, Coiro MJ. Divorce: consequences for children. Pediatr Rev 1995;16:306-10.
2. Hanvey I, Avard D, Graham I, Underwood K, Campbell J, Kelly C. The Health of Canada’s Children: A CICH Profile, 2nd edn. Ottawa: Canadian Institute of Child Health, 1994.
3. Wallerstein J. Separation, Divorce and Remarriage. In Levine M, Carey W, Crocker A, Gross R, eds. Developmental Behavioral Pediatrics, 3rd edn. Philadelphia: WB Saunders, 1999:149-61.
4. Special Joint Committee of the Canadian Senate and House of Commons on Child Custody and Access. For the Sake of Children, 1998. Taken from < Studies/Reports/sjcarp02-e.htm>.
5. Amato PR. Life-span adjustment of children to their parents’ divorce. Future Child 1994;4:143-64.
6. Wallerstein J, Blakeless S. Second Choices – Men, Women and Children a Decade after Divorce. New York: Technor and Fields, 1989.
7. Amato PR, Keigh B. Parental divorce and well-being of children: A meta-analysis. Psychol Bull 1991;110:26-46.
8. Amato PR, Keith B. Parental divorce and the well-being of children: A meta-analysis. Psychol Bull 1991;110:26-46.
9. Hetherington E. Coping with Family Transition: Winners, Losers, and Survivors, Child Dev 1989;60:1-14.
10. Ahrons CR, Miller R. The effect of the post divorce relationship on paternal involvement: a longitudinal analysis. Am J Orthopsychiatry 1993;63:441-50.
11. Bala N, Schuman J. Allegations of sexual abuse when parents have separated. Canadian Family Law Quarterly (in press).
12. Kelly JB. Marital conflict, divorce and children’s adjustment. Child Adol Psychiatr Clin N Am 1998;7:259-71.
13. Shea S. How to help your child adjust to divorce. Contemporary Pediatrics  1991;28-29.
14. Children With School Problems: A Physician’s Manual. Fox A, Mahoney W, eds. Ottawa: Canadian Paediatric Society, 1998.
Psychosocial Paediatrics Committee
Members: Drs Anne C Bernard-Bonnin, Département de pédiatrie, Hôpital Sainte-Justine, Montréal, Québec; T Emmett Francoeur, Westmount, Québec (director responsible); Sally Longstaffe, Child Development Clinic, Children’s Hospital, Winnipeg, Manitoba; William J Mahoney, Children’s Hospital-Hamilton Health Sciences Centre, Hamilton, Ontario (chair); Sarah Emerson Shea, IWK-Grace Health Centre, Halifax, Nova Scotia
Consultants: Drs Katerina Haka-Ikse, Toronto, Ontario; Rose Geist, The Hospital for Sick Children, Toronto, Ontario (representing the Canadian Academy of Child Psychiatry); Peter Nieman, Calgary, Alberta
Liaisons: Drs Mark Wolraich, Vanderbilt Child Development Center, Nashville, Tennessee (American Academy of Pediatrics, Committee on Psychosocial Aspects of Child & Family); Diane Marie Moddemann, Child Development Clinic, Children’s Hospital, Winnipeg, Manitoba (representing the Canadian Paediatric Society Developmental Paediatrics Section)
Principal author: Dr Anne C Bernard-Bonnin, Département de pédiatrie, Hôpital Sainte-Justine, Montréal, Québec