More than 800,000 divorces and separations occur annually in the U.S., affecting over 1 million children.
An updated AAP clinical report, Helping Children and Families Deal With Divorce and Separation, outlines the pediatrician’s role in these situations.
Divorce is not an event, but a process, so a child’s response to divorce will advance in stages according to his or her developmental stage, according to the report from the AAP Committee on Psychosocial Aspects of Child and Family Health and Section on Developmental and Behavioral Pediatrics. It is imperative that pediatricians assess a child’s understanding of divorce when counseling families.
The clinical report, available at http://dx.doi.org/10.1542/peds.2016-3020 and slated for the December issue of Pediatrics, includes reading lists about divorce for parents and children of different developmental levels.
Consider child’s best interests
The overriding concerns for pediatricians are to remain neutral, support the parents and keep the best interests of the child at the center of all discussions and decisions.
When serious problems start to occur in children, such as poor school performance, social withdrawal and somatic complaints, the pediatrician can offer to stage a parent conference, either with both parents together or separately. At a conference, the pediatrician needs to establish clear boundaries with parents and should not take sides in the divorce or be a conduit of information between parents. The provider should encourage parents to talk with their children about the divorce in a developmentally appropriate way.
Pediatricians also should encourage the parents to keep the routines of the children as normal as possible and to allow them to express their feelings openly.
Children need to know that they are not responsible for the divorce, and they cannot bring the parents back together again.
“It is important for the kids to know that even though the parents can’t love each other, each parent can love the child,” said George J. Cohen, M.D., FAAP, former member of the AAP Committee on Psychosocial Aspects of Child and Family Health and a lead author of the report.
Pediatricians certainly can counsel families at this traumatic time, but they may need to call on outside help, such as social workers, therapists or psychiatrists, and they shouldn’t wait until problems are severe to do so, said Carol Weitzman, M.D., FAAP, chair of the AAP Section on Developmental and Behavioral Pediatrics Executive Committee and a co-author of the report.
As for the timing of calling in others to help, Dr. Weitzman said, “It has to do with the level of functional impairment. How does (the divorce) affect that child on a day-to-day function? And what is the level of support available to the child to buffer the loss?”
Besides the clinical issues surrounding divorce, the report addresses the legal issues providers face. A pediatrician may be subpoenaed to provide testimony in a child custody hearing. A subpoena deuces tecum requires the submission of medical records, while a subpoena ad testificandum requires testimony in court.
A pediatrician receiving a subpoena for a medical record that he or she did not create should notify the attorney issuing the subpoena of the appropriate custodian of that document instead of disclosing it.
Though uncommon, if asked to testify in court, pediatricians should take care to provide responsible testimony. For example, they should not opine about a matter if they are uncomfortable about the topic or unqualified to render an opinion (e.g., child neglect or abuse). The report urges providers to consult with experts (i.e., child abuse specialists) in this case or inform the court of their discomfort.
If a pediatrician continues to treat the children after divorce, it is critical to clarify who has the legal responsibility for health care decisions and not to exclude the other parent from any ongoing issues about the child.
Pediatricians need to be cognizant of the long-term ramifications of divorce and check in with their patients.
Although many children show behavior changes in the first year of parent separation, most problems resolve in the two to three years after the separation.
“Things can change over time, symptoms can change over time. And pediatricians can find out by having direct conversations with children as they get older,” Dr. Weitzman said, “They can let families know that this will feel better at some point, but they need to let the kids know that we’re going to keep an eye on it, and keep an open door over time.”
- Be alert to warning signs of dysfunctional marriage or co-parenting relationships and impending separation. Consider inquiring orally or by written questionnaire about family changes or problems at each visit.
- Discuss family functioning in anticipatory guidance and offer advice pertinent to divorce, as appropriate. Remind parents that what they do during and after a divorce is important for their child’s adjustment.
- Always be the child’s advocate, offering support and age-appropriate advice to the child and parents regarding reactions to divorce, especially guilt, anger, sadness and perceived loss of love.
- Establish clear boundaries around divorce, and define what role a pediatrician can play.
- If there is concern about abuse or neglect, refer to child protective services. If a pediatrician is uncertain whether his or her statutory obligation to report has been met, discuss the case with a child abuse pediatrician.
- Refer families to mental health and child-oriented resources with expertise in divorce if necessary.