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"Since 1970, at least a million children have seen their parents divorce--building a generation of Americans that has come of age. It bears repeating that a quarter of adults in this country under the age of 44 had their parents divorce during childhood. Demographers also report that 40% of all married adults in the 1990s have already been divorced."^1:xxvi To put it another way, we in the United States live in a divorce culture. The question is, how does divorce affect people's mental, emotional, and physical health? How do the effects of divorce show up in doctors' offices?

To focus on the impact of divorce on children as they grow up, Judith Wallerstein's book The Unexpected Legacy of Divorce compares children of divorced parents with a matched control group of childhood friends whose parents often had substantial marital problems but who decided not to divorce. For more than a quarter century, the author has examined the subsequent life experiences of these two carefully studied groups. Personal, in-depth interviews with study participants and controls were administered during childhood, teenage years, and young adulthood. Wallerstein reported that the effects of divorce on children are more far-reaching than we ever imagined, and she described in careful detail how children and their parents differ in their view of divorce.

For parents, divorce is a way to escape a bad relationship and is a solution that promises hope for a better future. For children, however, divorce is a tragic ending of the secure, predictable family structure they've known. For children, divorce represents an abrupt, forced end to childhood. Wallerstein points out that even though most adults insist to children that their lives will be better as a result of the divorce, children cannot accept the adult rationale.

At every developmental stage, children seem to experience their parents' divorce anew. The book features five young adults with compelling stories about how divorce affected the way they grew up. Divorce of their parents caused the children to feel afraid, to assume adult responsibilities at an early age, and to feel abandoned by the parent who "moved away" from the family. Other experiences included living with a mother who was "emotionally unavailable" while she struggled to cope with the massive changes of divorce and was often depressed. Divorce also left the children without key role models or models for being in relationships. These grown children of divorce described themselves as adults who lack critical life skills, are unable to cope with change, are unable to build long-term relationships, and are unable to identify and communicate their desires, feelings, and needs.

Wallerstein points out that children who grow up in families where parents have troubled relationships (without violence toward the mother or children) fare better than children of divorce, because they feel secure, feel wanted, and have appropriate role models.

What does all this mean to Kaiser Permanente? As children of divorce move into adulthood, we can expect to see increasing numbers of patients with coping behaviors like smoking, drug use, alcohol use, and overeating. Less obvious coping behaviors include promiscuity, "workaholic" behavior, abnormal sleep patterns, chronic overspending, unrestrained compulsive gambling, and mild chronic depression.

The Adverse Childhood Experiences (ACE) Study² found strong, irrefutable correlations between family dysfunction during childhood and both high-risk health behavior and chronic disease during adulthood. Overeating, smoking, and drinking alcohol are coping behaviors people use to ease feelings of pain, fear, anger, frustration.² Foege³ reminded us that 40% of deaths in the United States result from three factors alone: tobacco use, poor dietary habits, and alcohol abuse.

Taking a detailed psychosocial and medical history of the patient and family is key to identifying patients who are at risk. This type of examination means asking questions that may have deeply disquieting answers. Such questions include several that appear in the Southern California Permanente Medical Group's Health Assessment Questionnaire used in San Diego:⁴

1. I often feel hopeless or down in the dumps	Y	N
2. I often feel suicidal	Y	N
3. I am having serious problems with my marriage	Y	N
4. I have been physically abused as a child	Y	N
5. I have been sexually molested as a child or adolescent	Y	N
6. I have been raped	Y	N
7. Has your partner ever threatened, pushed, or shoved you?	Y	N
8. Was there ever a time when you had five or more drinks a day of any kind of alcoholic beverage?	Y	N

By asking tough questions and by listening carefully to patients' responses, we gain valuable insight about why they need to smoke, drink too much, or eat enough to become chronically obese. We can refer them to community groups designed to help them understand and cope with the real problem. Indeed, helping patients to connect with appropriate risk abatement programs can substantially improve quality of life and can save millions of dollars in health care costs long into the future.

If Judith Wallerstein is correct, by asking patients and their children "personal" questions about divorce, we can invite discussion about critical emotional support that the entire family needs if they are to avoid spending long, painful years moving from one destructive coping behavior to another and from the doctor's office to another.

References

1. Wallerstein JS, Lewis JM, Blakeslee S. The unexpected legacy of divorce: a twenty-five year landmark study. New York: Hyperion; 2000.
2. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998 May;14(4):245-58.
3. Foege WH. Adverse childhood experiences. A public health perspective. Am J Prev Med 1998 May;14(4):354-5.
4. Southern California Permanente Medical Group. Health appraisal questionnaire. San Diego (CA): The Southern California Permanente Medical Group; [no date]. p 2, 5, 6.

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