Medical Neglect Allegations in the Context of Conflicted Divorce/Separation Child Custody: What Should the Health Care Provider Do?

Abstract

Pediatricians and child health providers face with situation in which families disagree about recommended treatments. Managing these disagreements is more challenging during periods of divorce or separation particularly when parents are in dispute over custody or medical decision-making. Parental disagreement exists along a continuum. General principles apply 1) the worse the conflict, the worse the outcome for children, 2) when conflict is combined with other factors such as separation, the outcome is often worse, and 3) the pediatrician/primary health care provider can mitigate this. This manuscript provides a review of the subject and suggestions for the practicing provider.

Parental divorce is undoubtedly one of the most significant events in a child’s life and may have `consequences on both immediate, and long term, growth, physical, emotional, and mental health. There has been a lot of research in this area, but children are never randomized to divorce/no divorce. Divorce has been discouraged by religion, political systems, and society for a long time because marriage has been thought of as the core for building a family. Consequently, divorce has in the past been accompanied by social stigmatization that may in turn contribute to negative effects. In the latter half of the twentieth century, divorce has begun to be accepted as a social normality (Auersperg et al. 2019).

Pediatricians and Child Healthcare Providers encounter families with varying degrees of security vs. conflict. We should be very sensitive at detecting conflict and attenuating its effect on the child’s experiences. Divorce and separation are so common that we should be very skilled at taking a relationship history and assessing the current risk for conflict. Additionally, we should be sensitive to the effects of conflict on the child’s emotional and physical/medical wellbeing.

Just like other adverse childhood experiences, parental divorce has been shown to have a negative association on depression, anxiety, distress, suicide (attempts and ideation), alcohol, drug consumption and smoking (ibid). However, the trend is that more recent studies show a weaker effect. Only a small number of studies in the meta-analysis reported the timing of the divorce on the subsequent mental health indicator and even less on the degree of parental conflict before and after divorce.

For the clinician interacting with a family that is beginning to separate/divorce, or in the contemplation phase, it is most important to assess for safety. Specifically, has there been or are there concerns for Intimate partner violence (IPV), substance or alcohol abuse, mental illness, and/or involvement with CPS. These difficult issues should be discussed with the adult while not in the presence of the child or should be screened with paper or digital information gathering tools. If the parent who is divorcing or is divorced starts making negative statements to us about the other parent in front of the child, this should be discouraged, and an alternative venue should be provided for this communication.

Screening women in all health care settings for IPV has been proposed and endorsed by the American College of Obstetricians and Gynecologists as well as the American Medical Association, but not by the US Preventive Services Task Force, the World Health Organization, or the Canadian Medical Association. A recent Cochran review concluded that there was “insufficient evidence to recommend asking all women about abuse in healthcare settings.” They stated, “it may be more effective at this time to train healthcare professionals to ask women who show signs of abuse or those in high-risk groups, and provide them with a supportive response and information, and plan with them for their safety” (O’Doherty et al. 2015). It appears that women prefer self-administered computer screening to self-administered written or face-to-face interview screening (Chisholm et al. 2017). Numerous screening tools for IPV in women exist including: HITS (Hurt, Insulted, Threatened with harm, Screamed – 86% sensitive, 99% specific), Ongoing Abuse Screen/Ongoing Violence Assessment Tool (86% sensitive, 83% specific), STaT (Slapped, Threatened, partner has thrown, broken or punched Things – 96% sensitive, 75% specific), HARK (humiliation, afraid, rape and kick screening tool, 87% sensitive, 95% specific), CTF-SF physical violence (Childhood Trauma Questionnaire, short form – 70% sensitive, 94% specific), CTF-SF sexual violence (83% specific, 89% specific) and the Women Abuse Screening Tool (88% sensitive, 89% specific.)

The American Academy of Pediatrics, American Academy of Family Physicians, American College of Emergency Physicians, and the Emergency Nurses Association encourage clinicians to be aware of the dynamics and risk factors of IPV and to be prepared to respond and refer appropriately. Recent guidelines from the American College of Surgeons Trauma Quality Improvement Program and the Committee on Trauma recommend universal screening for child abuse, elder abuse, and IPV in the emergency department (ACS Trauma Quality Improvement Program 2019).

If IPV is reported, the clinician should provide support and warm referrals. Studies that asked women what they would like from health care providers in this circumstance included the following: 1) use active listening skills, 2) be sensitive and non-judgmental of what is occurring, 3) validate women’s feelings but not pressure them to make a decision, and 4) provide support in accessing necessary resources (Chisholm et al. 2017). Reports of intrapersonal violence are not uncommon and may involve either or both partners and may not cease when the relationship ends (Rodriguez et al. 2019, Brooks et al. 2017, and Cardinali et al. 2018).Measurable adverse effects on children from divorce are not consistent across all studies. In childhood, there appears to be an increase in children’s behavior problems that is mediated by factors related to the mother’s sensitivity, the stimulation of the home environment, the child’s parent’s intelligence and socioeconomic status and, parental depression (Weaver and Schofield 2015, Mandemakers and Kalmijn 2014, and Peters et al. 2014(Peters et al. 2014)). Societal factors may also mediate the disadvantage of children of divorce on their physical and emotional wellbeing. In high resource countries where divorce is becoming more common, there are fewer effects on physical and mental health. However, in cultures where divorce is rare, the adverse effects are more severe (Smith-Greenway Smith-Greenway and Clark 2017).The post-divorce level of conflict appears to have a strong effect on physical and mental health of the children, as does the quality of the parent child interactions (Sanders et al. 2013; Leys et al. 2019). Co-existence of child abuse has a significant effect on the subsequent mental health of children (Afifi et al. 2009). Across the board, a history of parental divorce does not have a significant effect on psychiatric or somatic complaints (Angarne-Lindberg and Wadsby 2012) but there are significant and additive effects of high conflict divorce on the children’s short and long term mental and physical health (Bernet et al. 2015).

During the course of a health supervision visit, it the family reports that there is a change in their household composition, it would be best practice to get a thorough understanding of the emerging family dynamic (see Table 1). Ideally, the clinician should be comfortable making warm referrals for counseling to assist the family with this potentially difficult adjustment.

Table 1.

Taking a Divorce History

Have you separated?

When did the separation occur? (How old was the child? How long ago?)

Have you begun the process of mediation?

Are you making decisions of child custody?

Do you sense that there will be agreement on the important issues?

Where the child will live?

Visitation?

Contact with extended family?

Holidays?

Child support payments?

Alimony?

Is everyone getting some counseling to assist with the adjustment?

Pediatricians and child health providers can offer support and advice to families who are transitioning. The effects on this transition on the child’s health, growth and development should be minimized. They should continue to provide the medical home especially for children with chronic illness and should communicate with both parents about the child’s healthcare. How the adults adjust to the new challenges of co-parenting is a key factor in children’s physical and mental health (Lamela and Figuieredo 2016).

If there is a deterioration in child health, the health care team should attempt to solve problems of communication and assist with conflict through advice and referrals for counseling and mental health intervention. When they cannot, a decision to report to other authorities must be made. A scale or metric to conceptualize this process can be found in the ‘Loss of child Well Being’ scale developed (Duerr et al. 2015). The 6-point scale they tested ranges from no problem, need for improvement, disadvantage to the child, and impairment of child, endangerment of child, and acute danger for the child. Some degree of conflict is expected in the early phases of divorce/separation and there is often much anger in one or both parties. They should make every effort to address this in healthy ways and with therapy and not share it with the children or put the children in the middle of the conflict. The American Academy of Pediatrics has issued a revised clinical report recently reiterating advice for Pediatricians on assisting families dealing with divorce and separation (Cohen and Weitzman 2016).

Parental Alienation is another term for severe parental conflict that enlists the child (children) in the adult conflict and may lead to estrangement. Children’s responses to parental divorce conflict have been studied extensively and may be greatly influenced by parental behavior (Stokkebekk et al. 2019). A feature of parental alienation is to restrict the contact or sabotage the interaction of the child with the other parent, and they may claim that the child is refusing contact (Verrocchio et al. 2016). Children may engage in contact refusal for reasons other than parental alienation (Freeman 2016). Clinicians should become very familiar with the adult behaviors that characterize parental alienation, how it could be measured and detected by mental health professionals, and could develop a strategy to respond to them and try to re-direct the parent (Harman et al. 2019and Bernet et al. 2018). There are legal systems that have addressed this problem and treatments are somewhat available, albeit very expensive and generally not covered by insurance (Darnall 2011). Parental Alienation was made illegal in Brazil in 2010 (http://www.planalto.gov.br/ccivil_03./Ato2007-2).

An excellent discussion of estrangement and review of the literature on Parental Alienation can be found in Gomide et al., (Gromide et al. 2016). The concept is not without critics as the behavior of a “protector parent” and an “alienating parent” are very similar. Children may reject a parent for real reasons of their own safety or the parent’s impairment. It is critical to assess risk for real maltreatment by a parent (or step-parent). The responsibility generally goes to custody evaluators. While all that is playing out, the medical team should focus on the child’s health and communicate with both parents unless there are legal restrictions in place.

Not infrequently, parents will complain to their pediatrician that the child’s medical care is being neglected by the other parent. The health care provider must have a thorough understanding of the definition and management of medical neglect (Jenny 2007), and neglect in general (Dubowitz 2009; Hornor 2014). It is best not to dismiss this complaint but to do an assessment and suggest and implement methods in which the situation may be improved. One may find that the alienating parent will not wish to support and improve the skills of the targeted parent.

When parents disagree about the diagnosis or management of a condition, it is also very important to re-assess the diagnosis. Many cases of medical child abuse are maintained by one parent and the other parent is not informed of or not authorized to reduce or refuse inappropriate and unwarranted medical treatments or interventions. A trial of separation is one of the methods to identify and manage Medical Child Abuse (APSAC Taskforce 2017) but the perpetrator will staunchly oppose this as they would know that the false symptoms of disease that they have been reporting will not manifest while in the other parent’s care.

Some medical conditions, by their nature, are a good fit to the legal definition of medical neglect. Examples are type 1 diabetes or a hormonal insufficiency in which the child needs to take a specific medication daily in order to not become severely ill. Other conditions are more subtle and would not result in a life-threatening condition if they were not medically treated, ie. ADHD.

Recommendations

Screens for Intimate Partner Violence should be done privately and can be done by a confidential written format by someone from the office staff and subsequently reviewed by the medical provider. This should not be shared with the child unless the child initiates the report. If reported, a safety plan should be instituted, and appropriate authorities should be involved. Discuss social situations at every well child check. Medical providers may see well children on 27 well child visits over the course of birth to age 18. After the child can understand and communicate it may be best to discuss sensitive adult relationship issues or transitions in a setting where the child does not overhear the discussion.

Be clear that the expectation of the office is that the parents will be civil to one another and to the child and that the office will make every effort to communicate health information to both parents. For example, both parents should have access to the patient portal, so they have a full understanding of the child health care unless there are specific visits with concerns of child maltreatment or intimate partner violence. These should not be shared. It is important for a child with ongoing medical needs that each parent have a supply of the child’s medication and equipment and receive necessary education so that they are comfortable and confident to provide appropriate medical care. Each parent should also be expected to seek medical care for any illness or medical event that occurs while they are caring for their child. They should also be encouraged to communicate with the other parent when this occurs.

If the parents cannot agree to the diagnosis or the course of a medical treatment for the child, the physician should follow the standard of care and use best practices when treating the child. Clinical practice guidelines can be especially helpful in these circumstances.

The onus is on the parent to provide documentation if there are restrictions to the rights of a parent to seek or consent for medical care. In the absence of documentation to the contrary, it is safe for the pediatrician to assume that the parent accompanying the child has the right to consent for medical care. If there is documentation provided that restricts one parent’s right to seek medical care, it should be renewed at some interval and not assumed to be in effect permanently.

Be aware of situations when a pediatrician may be manipulated to further the alienation agenda. For example, the parent of a new patient who came to establish care asks the doctor for a note in support of cessation of the other parent’s parenting time. Even if the parent and the child report a risk of self-harm if the child must visit the other parent, the physician should clearly state the limits of his/her knowledge. They could write “If the child’s fear of the other parent is warranted then cessation of parenting time may be advised.”

If the parent exhibits an alienating behavior while the physician or staff is present it may be appropriate to point this out and try to redirect rather than to do nothing which may be perceived as tacit approval of the appropriateness of this behavior (See Table 2).

Table 2.

Parental Alienating Behaviors

PA Behavior	Explanation and examples that may be seen or experienced by a pediatrician or office staff	Refocusing for the Best Interest of the Child
		Encouraging Communication between Parents
Denigrating the other parent	Making negative statements about the other parent in front of the child during the office visit. “If John didn’t stuff Sally with junk food she wouldn’t have such a stomachache.” Or automatically responding negatively to the other parent’s suggestions about the care of the child.	Speak privately with the parent and remind them to speak about the other parent the same way that they would like to be represented by the other parent when the child is in their care. Disparaging the other parent is upsetting to the child and may lead to behavioral issues or somatization. Encourage healthy communication for example, by making lists of dietary choices the child likes and that are healthy to share between both parents. Same method could be used for bedtime rituals, favorite activities, and common rules of behavior.
Limiting Contact	Asking the pediatrician to write a letter to the courts supporting suspension of the other parent’s parenting time.	Explain that there are agencies that specifically make recommendations to the court regarding visitation and they should discuss this with their legal representation. If pressured to write a letter, clearly state the limits of your knowledge. For example, “If the child’s fear of the parent is warranted, then cessation, limitation, or supervision of parenting time may be advised.”
Interfering with the child’s communication with the other parent	Not allowing the child to talk on the phone with the other parent or not answering the phone when the other parent calls the child.	Suggest calling the other parent when child has news to share and let child share the news with the other parent spontaneously when the child is excited to share. Set a time that everyone can count on for calls on a routine. Set up a code with the other parent that indicates the call is urgent or time sensitive information so that in between routine calls, imperative information can get a quick response.
Interfering with symbolic communication with the other parent.	Not allowing the child to talk about or look at pictures of the other parent.	Suggest a family tree of photos of family members that includes the other parent, so the child can benefit from knowing their family.
		Reinforce that talking about people and events are important and suggest treating talking about the other parent as just another topic of interest for the child like events at school or play.
Withholding love and approval of the child when the child is positive towards the targeted parent	Becoming cold and emotionally punishing with the child expresses interest and affection for the other parent.	Reinforce modeling positive behavior to all persons the child interacts. Suggest that the parent would never punish or chastise the child for talking positively about a teacher, friend or playmate. Keep that same approach of polite behavior with regard to the other parent to model for the child positive expressions about people.
Allowing the child to choose whether to spend time with the other parent as opposed to enforcing parenting time	Making statements that suggest that time with the other parent is optional.	Set a schedule. Routine benefits the child. If events arise that the schedule needs adjustment, then discuss how best to negotiate schedule changes between the parents. Talking Parents is an app that assists in parental communication and scheduling.
Forcing the child to reject the other parent.	Encouraging the child to be cold, rude, disrespectful towards the other parent.	Parents want to model polite behavior to all persons. Suggest that encouraging disrespectful behavior may interfere with the child being respectful to others, not just the other parent. Model the behavior toward the other parent that should be used by the child with all people.
Telling the child the other parent does not love him or her.	Making statements such as “Well, if your mother really loved you she would be here.” Or “It’s clear that your father doesn’t really care about you.”	Everyone needs to feel loved and cared for, especially children. It hurts to think that someone doesn’t care for you. Suggest the parent refrain from telling a child that any person including the other parent doesn’t care for them. Their self-identity and confidence can be affected for their lifetime by thinking that they are being rejected by a parent.
Telling the child the other parent is dangerous.	Asking the child questions that imply that the child is not safe with the other parent or making statements that suggest that the child is not safe.	A feeling of being safe is important to all humans. If there is a safety issue there is a procedure to have that investigated, but not directly through making the child feel unsafe.
Confiding in the child about legal matters	Providing information to the child about legal matters such as, “The courts have told your mother that she can come to appointments, I don’t know why she isn’t here.”	Remind the parent how unsettling pending court decisions can be for the child. No discussion should occur about legal matters with the child.
Asking the child to spy on the other parent	Asking the child to obtain information from the other parent and report back to the parent such as “Find out if your father got a raise. If so, I will need to know so that I can get him to pay more money for your medications.”	Suggest that the child should not be put in the position by either parent to spy and report on the activities of the other parent. Parental information should be shared adult to adult by the parents and not through the child.
Asking the child to keep secrets from the other parent	Asking the child to withhold information from the other parent such as “Don’t tell your mother we came to the doctors today. If she finds out, she will cause trouble for us.	Remind the parent that we model behavior for our children. Asking someone to withhold information can lead to teaching the child to not tell the truth or trouble the child trying to keep secrets from a parent. If the situation seems that it will cause trouble that needs to be discussed with your legal representative otherwise share directly parent to parent without asking the child to withhold information.
Referring to the other parent by his or her first name to the child.	Saying to the child, “Tell Joan she needs to pay me for the medications I have to buy.”	Remind the parent that the other parent may also model this behavior to the child toward you.
		Model respectful behavior for the child for all adults by using the correct term for the relationship to the child such as “Your Mother” “Your Father” “Your Mom” “Your Dad”.
Referring to a new significant other as “Mom” or “Dad”	When speaking with the child or in front of the child, calling someone other than the actual parents of the child as a parent such as introducing the stepparent as the parent.	Sometimes the child feels comfortable calling a stepparent by a term such as Mom or Dad. Finding out the child’s comfort with that term and what the family has determined to be the accepted term for the stepparent can help the family to determine what they feel comfortable with and discussing making the other parent comfortable by acknowledging this is not a replacement for their role.
Referring to the child with a new name	If the mother starts to refer to the child with her maiden name as the child’s last name or the father refers to the child with a different name than is on the records.	Remind the parents name confusion for the child can be an issue in self-identity. What was agreed to in the legal documents for the child should remain the consistent name for the child.
Withholding information	Encouraging the doctor and medical staff to not share information with the other parent and/or not sharing that information him-or herself such that the other parent is out of the loop on the care and needs of the child.	Give the example that you would never leave your child with a baby-sitter without telling them information to care for the child. The same information needs to be shared with all caregivers including the other parent. Help the parent to write down a list of information needed to care for the child, and have primary caregiver give it to other parent. Encourage both parents to use the patient portal to keep up with medical care.
Undermining the authority of the other parent	Conveying to the child that the other parent’s rule and regulation are not relevant or necessary such as “I don’t care what your father says, you don’t need to wear glasses.”	Consistent expectations are important for the child’s ability to feel they are achieving acceptable behaviors. Encourage parents to share expectations of the child in a written plan that is developmentally appropriate. Give the example if everyone you met had different expectations for you, how frustrated that would make you and you would never know what to do or how to perform your job.
		Medical and health needs for the child should be shared with the child’s best interest the final determination of need.

Adapted with permission from Dr. Baker from: Baker, A.J.L. & Fine, P.R. (2013). Educating divorcing parents: Taking them beyond the high road. In A. Baker & S.R. Sauber (Eds.), Working with alienated children and families: A clinical guidebook (pp. 90–107). New York: Routledge.

Finally, without trivializing their circumstances, remind parents that divorce is rather common and that there is reduced stigmatization of this phenomenon. Parents should be encouraged to seek therapy, express their feelings and frustrations and be offered support and need not be concerned about shame or stigma. Caution parents that anger is an expected emotion to the circumstances, but decisions made in anger may squander limited family resources on conflict instead of therapy. Further explain that although they may be angry in the first few months or even up to a year, prolonged anger or anger that is shared with the children can cause real harm.

Inform parents about the known consequences of conflict exposure and risk to mental health of the child. Provide information to both parents to encourage respectful co-parenting. Identify families who are in high conflict situations early so that appropriate referrals to mediation services, parenting classes, and/or support groups can be offered. Become informed about parental alienation to avoid tacit approval of it. An additional resource is soon to become available from the American Academy of Pediatrics: John Blackstone, PsyD and David L. Hill, MD, FAAP, Co-parenting through Separation and Divorce; Putting your children first.

Conclusion

In summary, families rely on the support and recommendations of healthcare professionals during stressful and challenging periods of their lives. Families in transition may inject conflict into the provider-patient relationship that will need to be addressed to serve the goal of optimizing the health of the children. High conflict divorce/custody puts a tremendous strain on children and if unresolved can become a form of emotional abuse. Clinicians should strive for transparent communication with all parents regarding all aspects of the child’s healthcare. Co-operative Co-parenting is the optimal solution to divorce/separation and should be the expectation. As providers, we can develop skills of motivational interviewing and intervention to re-direct parents toward this goal.

Biographies

John Esper Wright

, MD, FAAP is Clinical Professor of Pediatrics at East Carolina Brody School of Medicine in Greenville, North Carolina. He is a board-certified child abuse pediatrician working at the TEDI BEAR Child Advocacy Center and provides consultation services at Vidant Medical Center in Greenville, NC. He served as medical director for the Broward County Child Protection Team for 18 years before moving from Florida to North Carolina.

Rachel K. Heinze

, MD is a pediatric resident at the University of Wisconsin School of Medicine in Madison, Wisconsin.

Mary Ellen Wright

, PhD, APRN, CPNP-BC is currently an Assistant Professor, ClemsonUniversity School of Nursing with 37 years of advanced practice experience, teaching and research. Her current research focuses on social support in complex situations to promote family health that include substance use disorders, marginalized populations and domestic and interpersonal violence.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest to report.