December 2013

Vol. 29, No. 12 ISSN 1058-1073

Online ISSN 1556-7575
Highlights
In this month's top story, Dr. McConville
discusses the importance of counseling
and therapy for the whole family after a
divorce.

Keep Your Eye On See page 2
The effects of parental support among
transgender adolescents
Cyberbullying and problematic internet
use in teens
Predictors of first-onset substance use
in adolescents with bipolar disorders
Whats New in Research See page 3
Offending behaviors of child
and adolescent firesetters
Editors Commentary
Treating maternal depression to promote
child development: A two-fer
By Gregory K. Fritz, M.D.
See page 8

Free Parent Handout
Co-Parenting:
A Guide for Parents
Children of Divorce
Treating Children in Families of Divorce
By David McConville, Ph.D.
Various studies on marriage and divorce
in the United States report findings that
4150% of first marriages end in divorce.
How spouses navigate this transition has
significant impact for children. These rela-
tionships, vital to childrens development,
can fail to evolve and shift, stay rooted in
anger and mistrust, and therefore cut off
from possibilities of growth and transforma-
tion. Family therapy, while not able to heal
all ruptured relationships, can help bridge
the gap for many postdivorce families and
foster healthy cooperative networks across
households that facilitate healthy develop-
ment for children and adolescents.
Widening the lens beyond the child
Ahrons & Rogers (1987) coined the
term binuclear family to describe the shift
many families make after the breakup of
the nuclear family. In many cases, chil-
dren split time between two households
that invariably develop new and differ-
ent rhythms, routines, and family cultures.
They frequently add members gradually
through remarriage and new siblings, or
abruptly by blending with new families
going through their own changes. Often, it
is the children that emerge as the symptom
bearers when this complex developmental
task breaks down. Healthy families that
successfully navigate divorce and remar-
riage are often cognizant of the many con-
nections that exist between households,
while also effectively establishing and
maintaining healthy boundaries around
and within households.
Teens and Self-Injury
Understanding and helping adolescents
with nonsuicidal self-injurious behavior
By Karyn Horowitz, M.D., and Jennifer Kittler, Ph.D.
Definition
When people hurt themselves on pur-
pose it is called self-injurious behavior (SIB).
This behavior can be considered in two dif-
ferent ways. One way is called nonsuicidal
self-injury (NSSI). This means that some-
one causes destruction to his/her own body
but without the intent to die. A second way to
consider this behavior is suicide attempts.
This means that someone hurts him/herself
with the intention to end his/her life.
NSSI comes in many forms, most com-
monly cutting or burning oneself. How-
ever, some adolescents may also hit,
pinch, bang or punch walls/objects in
order to feel pain or break bones, and
some may interfere with wounds heal-
ing. Teens who engage in these behav-
iors are often impulsive and utilize these
behaviors to cope with emotional and/or
cognitive distress. Many teens report that
hurting themselves distracts them from
their psychic pain and for some it even
prevents them from acting on suicidal
thoughts. However, approximately 70% of
Monthly reports on the problems of children and adolescents growing up
See Teens and Self-Injury, page 5
Published in cooperation with Bradley Hospital
See Treating Children of Divorce, page 4
View this newsletter online at wileyonlinelibrary.com DOI: 10.1002/cbl.20201
The Brown University Child and Adolescent Behavior Letter December 2013
4
Navigating these, at times, contrasting
treatment goals may be considered the
developmental achievement for families
transitioning postdivorce, and a sign of a
successful systemic treatment.
Such cases often present in the clinical
setting as disruptive behavior problems
where the presenting parent holds out little
hope or even interest in involving the non-
custodial parent team.
When clinically indicated, clinicians
may consider contacting the entire co-par-
enting team at intake or shortly thereafter.
Working systemically requires a flexible
approach for clinicians who may need to
vacillate between and among a rotating
cast of characters across multiple house-
holds. Over time this might include joint
meetings with both houses all together to
foster healthy communication throughout
the new suprasystem. Much of the work
initially is often with individual family sub-
systems, dyads within houses, as well as
individual treatment concerns.
Even when the noncustodial parent or
parent team are not active participants in
regular sessions, establishing their inclu-
sion at the outset of treatment allows for
therapy to revisit their role in fostering
healthy family relationships as issues
emerge over time.
Psychoeducation
In the initial stages of therapy with com-
plex systems, psychoeducation about the
effects of divorce on children can be a safe
place to start. While 80% of children in
remarried families function within the aver-
age range, informing families of typical and
potentially problematic emotional behav-
ioral reactions can focus parents on foster-
ing healthy coping and development. For
example, parents should know about the
loyalty dilemmas children face to prevent
splitting (as when parents ply their children
for information about an ex-spouse), and to
prevent resentment (many children sens-
ing lingering conflict offer little information
about visits). Conversely, some children
may provocatively over inform at other
times to instigate a well-rehearsed family
pattern. Just as children can be coached
to say Im uncomfortable being put in the
middle when parents inquire about other
parents activities, parents need to main-
tain the other end of that boundary by not
getting pulled into childrens oversharing
about their ex-spouse. Educating families
about the fluid nature of family structures
in binuclear families can also have a paci-
fying effect. An 8-year-old male who stays
close to the mothers home shortly after
the divorce may gravitate more and more
to the fathers home later in adolescence.
Contextualizing these behaviors can help
depersonalize such slights for parents in an
emotionally trying time.
Structural interventions
Structural interventions help to build
fences as well as bridges. Family therapy in
general often includes in its treatment tar-
gets the establishment of clear boundaries
in family relationships.
Boundaries that reflect the ages of the
children, developmental concerns, life-
cycle issues, and level of support and agree-
ment between households frequently need
to be adjusted and monitored throughout
the treatment. Establishing how informa-
tion gets conveyed, how consequences do
or dont get transferred between house-
holds, and how and when contact between
children and noncustodial parents occurs
are common sticky issues. Such fences
should flexibly adjust based on the ages of
the children and the lifecycle of the family
itself; a newly remarried family may need
to raise fences initially, gradually lower-
ing them as the family consolidates.
In addition to crisp boundaries between
households, supportive bridges need also
be a target in family therapy interventions.
In most cases that present for treatment,
such connections often seem unlikely, if
not impossible. All too often, noncusto-
dial parents play a starring role in the
consulting room without ever being physi-
cally present. Instead, they are referenced
weekly and show up via complaints and
blame from parents struggling with the
aftermath of unresolved conflict. These
characters are common and familiar
to many of us: the mother who doesnt
believe in therapy; the goodtime weekend
Dad who eschews limits, making life more
difficult for custodial parents; an ex who
insists on casting the other in a negative
light to the kids during visits. While fami-
lies of all constellations show up for treat-
ment, it is often single mothers showing up
in our offices complaining of disengaged
fathers. To that end, William Pinsof, the
President of the Family Institute at North-
western University has a clear agenda. He
has said that he works like crazy to keep
fathers involved in treatment, and when
supervising trainees, insists they do the
same to get noncustodial parents into ther-
apy. Maintaining a therapeutic alliance
with otherwise distant fathers allows for
the possibility of subsystem change, if not
better collaboration between households.
Often, the most critical bridge building
needs to occur between ex-spouses. Some
may never be ready or able, and in cases
where violence was common in relation-
ships, it may be contraindicated. However,
in many cases with ex-spouses in conflict,
family therapy can be an effective and
necessary intervention. Though difficult,
the clinical research in this area supports
the effort and persistence often needed.
In a longitudinal study of families up to 20
years postdivorce, the variable that con-
tributed most to self-reports of well-being
was the nature of the continuing relation-
ship between the parents. Those subjects
whose parents were able to establish a
supportive, low-conflict parental unit after
divorcing reported better relationships
with their parents, grandparents, steppar-
ents, and siblings. Thus, even 20 years after
the divorce, the parent relationship contin-
ues to have a cascading effect on the qual-
ity of relationships throughout families.
The development of new narratives
Systemic interventions with children
who live in binuclear families offer the pos-
sibility of the development of a new family
narrative. Conflict, blame, rejection, and
emotional impasses leap out at intake ses-
sions. Family therapy offers the possibility of
helping new family stories take root; stories
that reflect a shift from a family broken apart
to one that heals and builds anew. Initially,
Trevors family fit this mold. He was 10 when
referred by his father, Jerry, for individual
Treating Children of Divorce
From page 1
Often, the most critical bridge
building needs to occur between
ex-spouses. Some may never be
ready or able, and in cases where
violence was common in relation-
ships, it may be contraindicated.
The Brown University Child and Adolescent Behavior Letter December 2013
5
therapy due to disruptive behavior that was
tearing the family apart. When a family
intervention was recommended the father
agreed since everyone was tired of his
behavior. This included Jerry and his new
wife Gina, Ginas daughter from a previous
marriage and Trevors sister. This subsys-
tem was struggling to blend their families
and establish agreed-upon routines, and
to parent three children with varying needs
and talents. The other parental subsystem
was comprised of Trevors mother Tori and
her new husband Sal.
Despite Jerrys prediction that his ex-
wife would have no interest in attend-
ing, she was contacted and participated
in family therapy readily. Toris co-par-
enting team was characterized by Sals
old school approach to discipline, which
mirrored the views of the mothers parents,
who were also active caregivers for Trevor
and his sister.
In this family, both strong fences and
sturdy bridges needed constructing. Toris
father, for example, resented Jerry, and
believed he mistreated Tori during their
marriage. Tori had accused Gina of being a
know-it-all, and made accusations as well
that she drank too much. Repair between
Tori and Gina was integral to helping the
family move on and remove Jerry from
arbitrating disputes that inevitably put him
at odds with one or both women. Over
time, Toris acknowledgement that she
might be able to learn to trust Ginas inten-
tions and back her up when needed, but
Ill never be friends with her, may be the
very definition of the good enough coordi-
nation espoused by Jay Lebow in his work
with high conflict divorce cases.
Both step-parents were coached to
work in support of the biological parents
and to work to actively monitor childrens
behavior, coaching and encouraging posi-
tive behavior, rather than acting as first-
line disciplinarians. For stepfather Sal,
this involved moving away from a role of
reactive protector and champion of Tori
against her Jerry and Gina. Connecting
with his love for Tori, he gradually moved
toward a role as solid supporter, stand-
ing firmly behind her when differences
emerged, rather than preemptively in front
of her as the first responder to conflict. For
stepmother Gina, this meant saying less
in the moment and more behind closed
doors to Jerry. Feeling less undermined by
his wife paved the way for more dynamic
dyadic work between them around a cen-
tral theme: it was very difficult for Gina to
support Jerry in arguments with the chil-
dren due to her first husbands volatility
and physical abuse toward her daughter. A
maladaptive solution to this dilemma was
her tendency to scapegoat Trevor, which
was one way to engender connection with
Jerry. Therapy focused on helping them
draw up new dance steps for high-affect
situations in their household.
This work was done in fits and starts
and multiple constellations came in for
therapy at different times. Maternal grand-
parents joined Tori and Sal for sessions via
telephone. Jerry and his family were often
the focus of weekly sessions. After progress
was felt, the four adults came into session
with a focus of elevating the biological par-
ents and validating the step-parents con-
tributions. Trevors biological parents were
seen together both with and without him
present when specific concerns emerged
over the mechanics of a behavior plan. The
time-intensive nature of the work far out-
weighs the frustration and dead ends that
often come with dealing with ex-spouses
in absentia. And while this level of col-
laboration is not always possible or even
indicated in some systems, when possible
the extra effort is often worth it.
Divorce work at its core is often about
the pain, loss and resentment that gets
stirred. The adjustment to divorce pres-
ents a considerable challenge to families
with children and initiates a developmen-
tal shift felt throughout the family system.
This structural shift in the family creates
challenges both pragmatic (role adapta-
tion, underdeveloped parenting skills) and
emotional (grief and loss issues, childrens
fantasies about reunification, blame and
recrimination). Working at multiple lev-
els at once is often necessary in helping
families navigate these complex interrela-
tionships and progress toward honoring
the connections among members old and
new, while supporting effective boundar-
ies around new family structures.

David McConville, Ph.D., is an outpatient clinical
child and family psychologist at E.P. Bradley Hospital.
He is Co-Director of Family Therapy Training in the
Child and Adolescent Psychiatry Training Program in
the Department of Psychiatry and Human Behavior
at the Alpert Medical School of Brown University.
References
Ahrons C, Rodgers RH. Divorced families: A multi-
disciplinary developmental view. New York: W.W.
Norton; 1987.
Bernstein AC. Revisioning, restructuring, and rec-
onciliation: Clinical practice with complex postdi-
vorce families. Family Process 2006; 46:6778.
Whiteside MF. Remarried systems. In: Combrinck-
Graham, L, ed. Children in family contexts: Per-
spectives on treatment. New York, NY: Guilford
Press; 2006:163189.
Teens and Self-Injury
From page 1
teenagers who utilize NSSI have made at
least one suicide attempt and 55% have
had multiple attempts. For this reason,
it is important to take these actions seri-
ously and ascertain what the behavior is
communicating.
It has become increasingly common to
hear about adolescents who hurt them-
selves physically. Recent studies have
found that one-third to one-half of adoles-
cents have engaged in some type of self-
injury. This behavior is difficult to under-
stand by adults in their lives. They may ask
many questions such as: How worried do I
need to be? Does this mean that she wants
to kill herself? Is he doing it just to get
attention? What is the best way to respond?
Who can help me to understand what this
means?
Disorders associated with NSSI
Historically NSSI was thought to be
primarily associated with developmental
disorders, eating disorders, and border-
line personality disorder in adults. More
The adjustment to divorce pres-
ents a considerable challenge to
families with children and initi-
ates a developmental shift felt
throughout the family system.
Continued on next page