From The Carlat Child Psychiatry Report, March 2021, Clinical Complexity With Children and Adolescents

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Topics: Collaborative care | custody agreement | Divorce | Free Articles | Medication | Separation

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 (www.census.gov/data/developers/data-sets/acs-1year.html). It may not be the divorce itself that is hard on children, but how the divorce is handled (ie, amicably or not). This article will help you support divorced parents as they make treatment choices that are in the best interests of their child and the family system.

Legalities and paperwork
Before treating your patient, 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. “Physical custody” refers to the child’s living arrangements, while “legal custody” refers to decision-making authority that parents have after separation or divorce. “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 will need to sign contracts, information releases, and consent for treatment forms. 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 (Benitez BR, The Therapist, May/Jun 2001; www.tinyurl.com/35zj77f4).

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

Building a working relationship
How do we involve both parents in cases of separation or divorce? 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. 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.

Emotions impacting treatment
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. These reactions can also undermine treatment plans, ranging from the subtle (forgetting to give their child medicine) to the overt (explicitly telling their child that they “don’t believe in ADHD”). Alternatively, one parent may blame the child’s difficulties on the other parent. You may also experience direct hostility from parents.

Some tips for addressing these challenges include:

1. Reframe disagreements as opportunities to help patients. 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—eg, homework, friends, time with each parent, sibling relationships, etc.
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.
3. Provide a holding environment. 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 the child’s challenges and ideas that might help address them.
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.
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.

CCPR Verdict: 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 and reminds them that they can find common ground in working together to support their child.