By Theola Labbé-DeBose
Washington Post Staff Writer
Tuesday, April 14, 2009
Sean Smith knows his two children, ages 5 and 7, eat balanced meals. Still, he wanted to make sure they got all the right nutrients. So when the Rockville resident heard about special kids' vitamins, chewable like Gummi Bears, he wanted his children to take them.
Their mom disagreed. Carolyn Rutsch also knows the kids eat healthy. So, she said, why would they need vitamins?
A typical difference of views, one of many small disagreements in parenting. But Smith and Rutsch are divorcing, and nothing about raising their children is as simple as it used to be.
Decisions about children's health, the small, everyday choices intrinsic to child-rearing, take on an added complexity when parents are split up.
Experts say that with legal questions of child custody focused on safety, visitation schedules and child support, how to handle health care for children without serious medical problems often becomes a lower priority on the long list of issues to settle -- if it comes up at all.
Along with such minor issues as taking vitamins or not, there are larger questions: Will co-pay costs be shared? Should doctor's appointments be at a time that works for both parents, or go by the schedule of the parent who's with the child the majority of the time?
The answers depend on several factors, experts say, including the kinds of custody and financial arrangements that have been reached, either informally or through a court order. The divorce decree may spell out which parent will carry the insurance and how medical bills are to be split. For divorced parents, as well as for parents who never married, states such as Oregon require parenting plans that can be as detailed as how often a child is supposed to brush his teeth.
No matter what health-care arrangement may exist on paper, the biggest contributing factor to successful coordination between separated parents is the quality of their co-parenting relationship, said Brette McWhorter Sember, a former divorce lawyer and mediator who has written several books on divorce and co-parenting.
"In general, I've found that when parents are fighting over health decisions, it is generally indicative of some other underlying conflict," McWhorter Sember said.
Courtney Blair, an allergist based in Sterling and McLean, said the importance of coordination between households is seen in what happens when it fails. Children with serious asthma arrive sick in her office on a Monday because the medication schedule wasn't precisely followed during a weekend visit with the other parent. In one instance, she recalled, a child with a peanut allergy had a reaction because the parent in charge that weekend allowed the child to eat a cookie from a gift shop without checking the ingredient list.
When that happens, a heated blame game ensues, she said. "When there's one parent that's not on the ball and not as vigilant, it's something that drives a wedge through even the most stable couple," Blair said. "If the parents aren't together and one parent isn't being as vigilant, the anxiety for the other parent goes through the roof."
There are also such issues as insurance plans that allow for just one asthma inhaler at a time, she said, which means that the device must go between houses. If it's clear that parents aren't getting along, Blair said, she sometimes gives extra samples for the other parent's house, or she tries to talk to the child about making sure he or she takes the proper dose. "But that gets tricky, because you're putting a lot of responsibility on a child."
In cases where parents don't communicate about appointments, access to medical records can be one way to stay up-to-date. Kaiser Permanente has an electronic medical records program that allows authorized users to access a child's medical records online, including a summary of doctor visits, a complete overview of what happened and any needed follow-up.
"The opportunity for a parent to access information 24-7 . . . in many ways that personalization and convenience is what parents are seeking in a divorce situation," said Robert Pearl, president and chief executive of Kaiser Permanente's Mid-Atlantic Permanente Medical Group, who advocates for greater use of online health records.
Jacqueline Fletcher, a writer in Minnesota, heard heartbreaking anecdotes while talking to hundreds of stepmothers across the country for her book "A Career Girl's Guide to Becoming a Stepmom." There were stories about parents clashing over the cost of braces, health-care reimbursements and co-pays.
"It shouldn't come down to wrestling over $10 for a co-pay visit, but in so many families, it becomes a fight over that because many parents focus on money as a way to displace what the real issue is," said Fletcher, who is a stepmom. "It's a way that the parent can still be angry but not really honest about how they're feeling."
California psychotherapist Jann Blackstone-Ford said that with more parents sharing custody, they are forced to coordinate nearly every aspect of their child's upbringing. If the parents are still angry or have poor communication, dealing with health issues in a split-custody arrangement can mean they are constantly looking for ways to one-up the other.
"What happens is, information is power," Blackstone-Ford said. "You get one parent bringing them to one doctor and another parent bringing them to another doctor because they don't trust the other parent's judgment."
No medical detail between separated parents is too small, said Blackstone-Ford, who initially clashed with her husband's ex-wife; the two women later became friends and founded a nonprofit, Bonus Families, to help others. "It doesn't matter which parent goes to the appointment with the child, but they should volunteer as much information as possible. . . . When you keep the information and use it as a weapon, that's when you're failing as a parent," she said.
On a positive note, experts say that a child's serious illness can bring together the most disagreeable parents, and even their new partners. That can be of great assistance in the child's treatment, said Lynn Hardesty, who manages the Patient and Family Support Program at the Center for Cancer and Blood Disorders at Children's National Medical Center.
Hardesty said she always starts with a new family by talking with the mother and father, and then, depending on the family dynamics, she tries to incorporate new partners if there is a long-term relationship or a remarriage.
"Sometimes [those other adults] are the caregivers who have the best chance to help children do some things that are difficult, like take the medicine that tastes nasty or have blood drawn," Hardesty said. "They can be supportive but a touch more removed."
For Smith and Rutsch, the couple who disagreed on their children's taking vitamins, they worked toward a compromise. Smith was concerned that their 5-year-old daughter was getting a lot of colds. He had read about the benefits of additional Vitamin D and thought their daughter could use an extra boost. "I figured it wouldn't hurt," Smith said.
Meanwhile, Rutsch relied on the pediatrician, who never mentioned supplements.
"I didn't have a strong negative reaction, but I didn't have a big positive reaction. I said, 'If you want that to be your thing, then you buy them,' " said Rutsch, who lives in Northwest.
Smith takes care of the children after school until Rutsch arrives home from work, and he sees them on the weekend. He bought the vitamins and gave them to the children in the afternoons. When they ran out, he asked Rutsch to buy the next batch.
Rutsch agreed but remained unconvinced. Knowing that she was still skeptical, Smith said he would buy the vitamins in the future and continue to give them to the children.
"I think it's better to try and find some sort of way to agree and work together," Smith said.