Studies have shown that children of divorced parents may suffer more mental health problems, particularly conduct disorders. What programs might be effective in helping these children deal with the stress of their parents' divorce? Are there effective programs to teach parents better coping skills?
Over 1 million children in the United States experience parental divorce annually (Clarke, 1995). Although most children adapt well to this transition, approximately 20% to 25% develop mental health or adjustment problems twice the rate experienced by children from continuously married families (Hetherington et al., 1998). Meta-analyses of studies conducted between 1950 and 1999 indicated that children from divorced homes function more poorly than children from continuously married parents across a variety of domains, including academic achievement, social relations and conduct problems (Amato, 2001). They continue to be at risk for clinically significant mental health difficulties into adulthood (Chase-Lansdale et al., 1995; Zill et al., 1993), are more likely to receive mental health services (Zill et al., 1993), and have a shorter life expectancy (Tucker et al., 1997) than those who grew up in two-parent families.
Risk for mental health problems appears to result from disruptions in the family's social and physical environment that often precede, coincide with or follow divorce. Such disruptions may include interparental conflict, parental maladjustment, reduced contact with the noncustodial parent, decreases in parent-child relationship quality, school and housing changes, and declines in economic resources (Amato, 2000). Conversely, warm parent-child relationships, effective parental discipline and high child-coping efficacy are associated with positive postdivorce functioning (Sandler et al., 2000; Wolchik et al., 2000b).
Given the high prevalence of divorce and the concomitant risks for children's adjustment, a variety of preventive interventions have been developed to improve children's adaptation (e.g., court-mandated parent education, divorce mediation) (Dawson-McClure et al., 2003). The present review focuses on preventive interventions with evidence from experimental or quasi-experimental studies demonstrating improvements in child adjustment following program participation: multi-session child coping and parenting skills interventions.
School-Based Child Interventions
Beneficial effects have been reported for two preventive interventions provided directly to children of divorce: Stolberg and colleagues' Children's Support Group and Pedro-Carroll and colleagues' Children of Divorce Intervention Project.
Children's Support Group. The Children's Support Group is a 14-session, school-based group program designed to give children emotional support, encourage parent-child communication and teach cognitive-behavioral skills, including anger management; self-control; problem-solving; and identification of divorce-related thoughts, feelings and behaviors (Stolberg and Mahler, 1994). In an experimental trial with children ages 8 to 12, Stolberg and Mahler (1994) demonstrated reductions in internalizing and externalizing behaviors, total pathology, and clinical symptomatology at posttest and one-year follow-up, compared to randomized, no-treatment controls.
Children of Divorce Intervention Project. The Children of Divorce Intervention Project is a 12-session, school-based group intervention designed to give school-age children emotional support, help them identify and appropriately express feelings, correct divorce-related misconceptions, improve coping, and promote positive perceptions of themselves and their families (Pedro-Carroll, 1997; Pedro-Carroll and Cowen, 1985). It has been adapted for kindergarten to 8th grade children from diverse sociocultural backgrounds. Through a series of evaluations, Pedro-Carroll and colleagues (1997) have found short-term reductions in internalizing and externalizing behaviors, increases in competence, and improvements in coping and problem-solving abilities, compared to no-treatment controls. In one quasi-experimental trial, intervention gains were maintained at two-year follow-up for both internalizing and externalizing problems (Pedro-Carroll et al., 1999).
Multi-Session Parenting Skills Programs
In addition to school-based programs, child-adjustment benefits have been demonstrated for two parenting-focused preventive interventions. Both programs are for mothers whose children reside with them following divorce.
Parenting Through Change. Parenting Through Change (PTC) is a 14-session group intervention designed to teach parenting skills, including noncoercive discipline, appropriatepositive reinforcement, monitoring andproblem-solving. It also teaches techniques to help mothers control negative emotions and handle interpersonal conflicts (Forgatch and DeGarmo, 1999). The intervention also included mid-week phone calls to encourage use of parenting skills and individual sessions as needed.
In an experimental trial with mothers of boys ages 6 to 10 whose parents had separated, boys whose mothers participated in the PTC program exhibited lower noncompliance at 30-months follow-up, compared to randomized, no-treatment controls (Martinez and Forgatch, 2001). Participating in PTC was associated with reductions inmothers' coercive discipline and maintenance of positive parenting practices (Forgatch and DeGarmo, 1999), which accounted for the intervention effect on noncompliance at the 30-month follow-up (Martinez and Forgatch, 2001).
New Beginnings Program. The New Beginnings Program (NBP) is the first preventive intervention for children of divorce that was subjected to methodologically rigorous evaluation with evidence of long-term effects on a wide range of mental health, substance use and academic outcomes in adolescence (Wolchik et al., 2002). The 11-session intervention is designed to improve mother-child relationships, increase effective discipline, promote father-child contact, and decrease children's exposure to interparental conflict and negative divorce events. In addition, two individual sessions are included to tailor parenting skills to each family's needs (Wolchik et al., 2000a, 1993).
Two experimental trials have been conducted on NBP. In the first trial of mothers with children ages 8 to 15, NBP participation resulted in lower child-reported aggression and mother-reported behavior problems at posttest, as compared to randomized, no-treatment controls (Wolchik et al., 1993). Positive program effects were also demonstrated for mother-child relationship quality, effective discipline, exposure to negative events and willingness to change visitation.
A second experimental trial including 240 families with children ages 9 to 12 resulted in similar short-term program effects, as well as a wide array of program benefits six years later, when children were ages 15 to 18 (Wolchik et al., 2000a). Compared to a randomized, self-study control group, children whose mothers participated in NBP demonstrated lower internalizing and externalizing problems at posttest and fewer externalizing behaviors at six-month follow-up. Most important, six years after intervention, the NBP group had lower adolescent externalizing problems, mental disorder symptoms and substance use, as well as higher grade point averages compared to the control group (Plummer et al., unpublished data; Wolchik et al., 2002).
Mediational analyses have suggested that program effects on improvements in maternal discipline and mother-child relationships at posttest accounted for the positive short-term program effects on child adjustment at six-month follow-up (Tein et al., in press). Currently, analyses are being conducted to identify mechanisms that might mediate long-term program effects at the six-year follow-up.
Because NBP is a prevention program, children in the study were not diagnosed patients and diagnostic interviews were not conducted before the intervention began. However, 36% of children scored in the clinical range on one or more pretest questionnaire measures of symptomatology: 25% on mother-reported internalizing, 12% on child-reported anxiety and 16% on mother-reported externalizing. All children who were currently receiving mental health services were deemed ineligible. Due to ethical concerns and the preventive nature of the intervention, families were further screened out and referred to treatment if children scored above the clinical cutoff on self-reported depressive symptoms or endorsed an item about suicidal ideation, or if mothers reported severe levels of externalizing problems (in order to screen out children who might not be able to tolerate the group-learning environment).
Given that diagnostic interviews were not conducted at pretest, no information is available regarding differences in response for children with and without comorbid psychiatric diagnoses when the intervention began. However, analyses of program moderators have revealed several baseline-by-treatment effects, indicating that families who entered NBP with higher child-externalizing problems, lower parenting quality and higher overall risk for subsequent child mental health problems (based on a risk index of externalizing behaviors and family environmental stressors) benefited most from the program (Dawson-McClure et al., submitted; Wolchik et al., 2002, 1993). Among families at high risk for child mental health problems at program entry, 46% of adolescents from the control group qualified for a mental health disorder diagnosis at six-year follow-up, compared to 25% of those at high risk whose mothers participated in NBP. Among those children initially at low risk, no significant differences were found between control and intervention groups (14% versus 10% received a mental health disorder diagnosis, respectively) (Dawson-McClure et al., unpublished work).
Results from experimental and quasi-experimental studies provide support for the efficacy of child coping programs and parenting skills interventions in the prevention of mental health problems for children of divorce. These findings have important public health implications. Meaningful reductions in mental health problems for a significant subgroup of today's youth could be achieved if such programs were widely available. The widespread implementation of efficacious programs introduces new challenges regarding maintaining the fidelity of intervention implementation, adapting programs to be both acceptable and effective across diverse cultural groups, and identifying and recruiting families most likely to benefit. After addressing these issues, large-scale effectiveness trials can be conducted to evaluate the success of these prevention programs when delivered in public service settings with access to the divorced family population (e.g., courts).
Because the interventions described in this review were developed to prevent mental health problems and did not include patients in treatment, it is not clear how effective the programs would be for psychiatric populations. The more direct implications are that prevention strategies can be quite effective to prevent the incidence of diagnosis in nonclinical samples of children who experience parental divorce. However, given that the children who received the most benefit from NBP were those who entered the program with externalizing problems, skill-based interventions might be helpful for children of divorce who have psychiatric disorders, as an adjunct to treatment received in the care of psychiatrists.
Programs proven to be effective for children of divorce have yet to be widely disseminated; therefore, psychiatrists and families interested in skill-based interventions would need to seek out and evaluate the appropriateness of the various mental health services available locally. Table 1 lists resources for finding local parenting and child coping interventions that might be appropriate for children of divorce and their families. Ideally, interventions should include multiple sessions to allow families to learn, practice at home, and receive feedback on specific skills pertaining to parenting (e.g., consistent discipline) and/or child coping (e.g., anger management). Table 2 includes self-help resources. Although the efficacy of self-help books to prevent or ameliorate child-adjustment problems following divorce has not been established, some parents might benefit from reading books that provide parenting tips for divorced families.
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