Each year in the US, there are about 1.04 million divorces, affecting about 800,000 children, and it may not be the divorce itself that is hard on children, but how the divorce is handled. How can we navigate the complexities of treating a child with divorced or separated parents?

Published On: 03/17/2022

Duration: 11 minutes, 45 seconds

Referenced Article: “Clinical Complexity With Children and Adolescents”, The Child Psychiatry Report, January/February/March 2021

Joshua Feder, MD, and Mara Goverman, LCSW, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Earn CME credits for this episode through the link in the podcast notes, and if you haven’t subscribed to the online issue give us a try, and take $30 off your first year’s subscription with the promo code PODCAST. Your support helps us operate free of industry influence.

Transcript:

Dr. Feder: Each year in the US, there are about 1.04 million divorces, affecting about 800,000 children. Beyond that, 1.9 million cohabiting (and unmarried) couples break up each year, of whom 60% have children. It may not be the divorce itself that is hard on children, but how the divorce is handled. 

Hi, I’m Dr. Joshua Feder, the Editor-in-Chief of The Carlat Child Psychiatry Report, 

Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice. 

Dr. Feder: And in this episode, brought to you by The Carlat Child Psychiatry team, Mara and I will discuss how you can better navigate the complexities of treating a child with divorced or separated parents. 

Mara: So Dr. Feder, is there anything we should consider before we begin treating a child with divorced parents?

Dr. Feder: Yes! Before treating your patient, it's crucial that you make sure that the parent bringing the child has the authority to consent for outpatient treatment. Ask for a copy of the custody paperwork and clarify what the legal custody arrangement is. 

Mara: There are a few different types of legal custody arrangements that you will probably encounter when looking over custody paperwork. “Physical custody” refers to the child’s living arrangements, while “legal custody” refers to decision-making authority that parents have after separation or divorce. 

Dr. Feder: “Sole legal custody” describes a situation where the court has decided that only one parent (the custodial parent) has decision-making authority; in this case, only the custodial parent should be signing contracts, information releases, and consent forms for treatment. 

Mara: By contrast, “joint legal custody” describes a situation where either parent can consent for medical treatment. In most states, under joint legal custody, consent is needed from only one parent, unless the court papers specifically instruct that both parents must consent for medical treatment.

Dr. Feder: Be sure to talk about payment too. Even if only one parent has custody, you will need to establish who is paying for services, including what insurance company, if applicable. Do not assume that the custodial parent is paying for treatment since such expenses might be shared or even covered only by the non-custodial parent. 

Mara: Such complexities reinforce that the clinician must always make an effort to involve both parents in treatment discussions and document this effort.

Mara: How do we involve both parents in cases of separation or divorce? 

Dr. Feder: From the very start, try to speak with parents together. This will help you assess their ability to suppress hostilities and work collaboratively in the interests of their child. 

The expectation of collaboration makes parents more open to expert advice, defusing the power struggles between parents that often characterize the post-divorce landscape, and improving such things as medication compliance in both households. 

Mara: To make this work, it helps to review some of the common problems inherent in family and parental interactions so that you can adjust your approach.

Dr. Feder: Definitely, Mara! Unfortunately, guilt or anger may cause parents to disengage from co-parenting or, alternatively, to become intensely involved in the process. They may perceive routine and necessary psychiatric treatment as proof of their inadequacy. With ADHD, for example, parents may resist accepting the diagnosis and go to heroic lengths such as changing schools several times or hiring help to supervise the child. 

Mara: These reactions can also undermine treatment plans, ranging from the subtle, like forgetting to give their child medicine, to the overt, such as explicitly telling their child that they “don’t believe in ADHD”. 

Dr. Feder: Alternatively, one parent may blame the child’s difficulties on the other parent. You may also experience direct hostility from parents.

Mara: Here are some tips that you can use to de-escalate hostility and facilitate cooperation between your patient's parents :

1. Try to reframe parent disagreements as opportunities to help their child. There is an advantage to having multiple points of view at the table. Welcome these differences by using them to better define shared values and determine what is important— like their child’s homework, friends, time with each parent, sibling relationships, etc.

Dr. Feder: 2. Establish agreed-upon systems. Try to set out a clear and reasonable plan for such things as tracking medication dosing, sleep hygiene, homework completion, or other target symptoms or goal areas. A neutral, calm tone can help you establish a trusting relationship with both parents.

Mara: 3. Create a holding environment for your patient and their parents. A calm, concerned expert can depoliticize a child’s suffering. Use plain, neutral education to inform a skeptical parent about the evidence base for treatment. Think with parents about their child’s strengths and how to build on those, as well as their child’s challenges and ideas that might help address them.

Dr. Feder: 4. Take the long view. Help parents understand that the best plans are arrived at by trying things out, seeing how they work, staying in contact, and changing course if needed. This requires regularly scheduled appointments, not simply ad hoc follow-up visits. Using this reflective stance, parents can brainstorm together with you, try ideas, and see what works and what doesn’t. This process supports the development of each parent’s sense of confidence in their care of the child, building a more collaborative environment for treatment.

Mara: 5. If parents cannot or will not be present in the same meeting, schedule regular time with each parent separately to gather information, talk about treatment planning, and negotiate workable treatment plans. This will double your time on the case, and it underlines the importance of your role in supporting the child through a difficult life circumstance.

Dr. Feder: In divorce, the usual complexities of clinical practice are amplified. Children of divorce do better when parents co-parent in a collaborative manner. Faced with parents who are often suffering and don’t like each other, the clinician can be a trusted, neutral figure who elicits the best from each parent.

Mara: As a bottom line message, here are the four major principles for helping children in separated or divorced families:

Dr. Feder: 1. Clarify custodial rights before starting the assessment. Stay up to date on your state’s laws.

Mara: 2. Cultivate an expectation of collaboration from the start. Actively seek all points of view to find shared values and goals.

Dr. Feder: 3. Get objective data from both households whenever possible (eg, medication logs, sleep logs, etc).

Mara: 4. Take the long view. Employ a calm, reflective, iterative approach to support effective treatment and build parental confidence and collaboration over time.

And, lastly, it’s important to remind parents that they can find common ground in working together to support their child. Inform parents that they can augment their child’s treatment benefits through mutual cooperation in our treatment plans and that their cooperation will greatly enhance progression towards achieving their shared goal of supporting their child’s growth and development, flexibility, and resilience. 

Dr. Feder: The clinical update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully people check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information you can trust. 

Mara: As always, thanks for listening and have a great day!

__________

The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.