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Children’s Mental Health and Intervention in View of
Violence, Parental Alcoholism and Parental Separation
By: Gary Direnfeld, MSW, RSW
parent sees the physician, complaining of a child’s behaviour and possibly
even somatic concerns. The child may present with any number of issues such as,
school anxiety, inattention, depression, anxiety, social withdrawal, aggressive
behaviour, non-compliance, substance abuse, headaches, and/or stomachaches.
Attention is typically drawn directly to the child and interventions tend
to be behavioural in nature. The parent is advised on appropriate discipline
strategies. As for the somatic complaints, while there may be medical
investigations, they tend to be ambiguous at best in terms of determining a
physiological basis for the somatic complaints. Despite behavioural and medical
intervention, problematic behaviour and somatic complaints continue unabated.
the child’s behaviour problems and somatic complaints, may be lurking a number
of contributing problems. The child may be subject to witnessing domestic
violence, or the child may be coping with the effects of parental alcoholism, or
if the parents are in the throws of a separation, the child may be caught in the
legal web of their parents’ high-conflict entanglements. Of course, just like
you can have a broken leg and the flu at the same time, the child may be subject
to several or all of these underlying problems, concurrently.
Persons with specific training and expertise, best provide intervention in view of these variables. Inappropriate intervention is akin to arranging the deck chairs on the Titanic. While it may look good, the ship still sinks. Hence it is vital for physicians to understand the challenges underlying these issues to appreciate what appropriate intervention may be and may not be.
violence is not gender specific. Either gender may offend. However, the
rationale for violent behaviour between adult intimate partners is known to
differ by gender. Statistically, men are more apt to engage in violent behaviour
as control strategies than their female counterparts. Women are more apt to
engage in violent behaviour as a defensive strategy to cope with their
partner’s behaviour. Further, lethality studies demonstrate that women are at
substantially greater risk of harm, the result of male partner violence than are
men of women. Violence between intimate partners is not at all restricted to
heterosexual partners, and is seen similarly in same sex partners.
Schwartz, MD, CCFP (EM), FCFP, Director, Division of Prehospital Care and Staff,
Emergency, Sunnybrook and Women's Health Sciences Centre; Assistant professor,
Family Medicine, University of Toronto, Toronto, Ontario looks at domestic
violence in the context of abuse against women. He provides a definition of
violence against women as well as incidence statistics in terms of female versus
male victimization rates. Accordingly:
against women may be defined as "physical or psychological abuse directed
by a man against his female partner, in an attempt to control her behaviour or
intimidate her." While abuse may take many forms including sexual,
emotional, psychological and financial this [his] article will focus on
physical abuse, or violence against women (VAW). It should also be noted that
males constitute 15% of victims (62 male victims vs 344 female per 100,000
population in 2001) and that domestic violence occurs in same-sex relationships
with approximately the same frequency as in heterosexual relationships.
of the incidence of children witnessing domestic violence vary widely. However
the most recent and scientifically rigorous estimates suggests 1 in 100 Canadian
children are exposed to domestic violence.
Further, the impact of witnessing domestic violence on children is known to have
serious consequences for their psychological, social, academic, behavioural and
who witness domestic violence are at risk for emotional and physical harm.
Canadian research suggests that children who are exposed to adults or teenagers
physically fighting in the home are less likely to have positive or effective
interactions with their parents, and have lower levels of social competence than
other children. They are also more likely to be living in households with high
parental depression, and to experience depression, anxiety, health problems and
stress-related disorders themselves.
family violence is also linked to negative behaviour in children, including
physical aggression, indirect aggression, emotional disorders, social
withdrawal, hyperactivity, bullying and delinquent acts against property.
addition to witnessing domestic violence, statistically, in
a national survey of more than 6,000 American families, 50 percent of the men
who frequently assaulted their wives also frequently abused their children.
Thus wife assault and child abuse are often co-occurring events.
for domestic violence requires sensitivity to issues of trust and safety, often
achieved by specific training or experience in screening for these matters.
Intervention typically begins with a view to determining safety issues and
making sure family members are and will be safe from harm or retaliation the
result of disclosure. Further, while all persons in the Province of Ontario are
required to report even suspected child abuse, the onus on health care
professionals is perceived to be even greater. Noteworthy, one cannot discharge
the obligation to report to a third party. Section 72 (3) of the Child and
Family Services Act states:
physicians must report suspected child abuse even if it is known that a third
party such as a counsellor may also report.
safety issues have been addressed, then intervention can proceed to address the
sequelae of issues emanating from the domestic violence.
definition of alcoholism has been the subject of much public scrutiny.
Definitions vary from physiological to psychosocial. In view of the
discrepancies in definition, a
23-member multidisciplinary committee of the National Council on
Alcoholism and Drug Dependence and the American Society of Addiction
Medicine conducted a 2-year study of the definition of alcoholism in
the light of current concepts printed in the Journal of the America
committee agreed to define alcoholism as a primary, chronic disease
with genetic, psychosocial, and environmental factors influencing its
development and manifestations. The disease is often progressive and
fatal. It is characterized by impaired control over drinking,
preoccupation with the drug alcohol, use of alcohol despite adverse
consequences, and distortions in thinking, most notably denial. Each
of these symptoms may be continuous or periodic.
terms of impact on self and others, reaching criteria alcoholism increases the
risk of academic, vocational, social, familial or marital problems. Children of
parents who consume alcohol on a regular and problematic basis are at risk of
social and school related problems during their childhood as well as social,
vocational, marital and parenting problems in their adulthood. As a clinical
group, these children are known as, Children of Alcoholics or COAs (or ACOA for
adult children of alcoholics). Characteristics of Children of Alcoholics are
well reported by the Canadian Task Force on Preventive Health Care:
up in a household with alcoholic parents is more likely to produce lower
self-esteem, greater dysphoria and more anxiety in adulthood. Rates of emotional
problems, especially anxiety, depression and nightmares are doubled in children
of relapsed alcoholics as compared to children of non-alcoholics or to children
of recovered alcoholics. COA are more likely to describe their childhood as
unhappy, and to have a greater level of depressive affect, when compared to the
alcoholism, in addition to creating an adverse family environment, increases the
risk for maladjustments as measured by scores on the Child Behaviour Checklist (CBCL).
Children of alcoholic parents scored significantly higher on the total behaviour
problem scale, as well as on both the internalizing and externalizing scales of
the CBCL. They also scored significantly higher on the somatic complaints scale.
In a comparison of COA and children of non-alcoholics, the former reported more
alcohol and drug problems, stronger expectancies for positive reinforcement from
alcohol, higher levels of behavioural undercontrol, more neuroticism and more
psychiatric distress. They also showed lower academic achievement and lower
verbal ability than controls.
Canadian Guide to Clinical Preventive Health Care also provides a “Children
of Alcoholics Screening Test”.
While the 10-item questionnaire can provide evidence of concern for parental
alcoholism, the issue that remains for the physician is that of intervention. In
view of parental alcoholism and despite distress in the child, the intervention
for minor children must include one or both parents if the source of the
child’s distress is to ever be addressed. Placing the child alone in
counselling only serves to maintain the dysfunction of the parent(s) if focus is
never directed to the parents. In view of denial as a function or symptom of
alcoholism, parents can in fact apply pressure on the referring physician and
even service providers to treat the child on an individual basis. The challenge
for the referring physician and even the service provider is to not
inadvertently collude with the parents, keeping the underlying issue of parental
alcoholism a secret. If treatment is only provided on an individual basis, there
is the illusion of help and the child continues to be subject to the vagaries of
the parental alcoholism.
and in view of the Child and Family Services Act, while the child may not be
subject to abuse in the traditional sense, the child may be subject to neglect,
the result of parental alcoholism. Indeed if this is determined to be the source
of the child’s distress, the physician has an obligation to report this matter
to child protection authorities:
(1). Despite the provisions of any other Act, if a person, including a person
who performs professional or official duties with respect to children, has
reasonable grounds to suspect one of the following, the person shall forthwith
report the suspicion and the information on which it is based to a society
(child protection agency):
The child has suffered physical harm, inflicted by the person having charge of
the child or caused by or resulting from that person’s,
failure to adequately care for, provide for, supervise or protect the
pattern of neglect in caring for, providing for, supervising or protecting the
in view of parental alcoholism and resultant impact on the child, intervention
must not only include the parent but may require a report to child welfare
authorities. It should be noted that physicians as well as members of the public
can make a call to a child protection agency on a consultation basis to
determine if the concerns actually reach criteria for reporting. By obtaining a
consultation on the matter, the physician could be put to ease that his or her
reporting obligations have been met and in view of a need to report, could then
literature on divorce has had much to say about the impact on children. It used
to be argued that any divorce had dire consequences for children. Now however,
the outcome data suggests that it is not divorce per se that determines the
outcome for children, but rather the degree of parental conflict children are
subject to by separated parents. In effect, the higher the parental conflict the
greater the risk in terms of the impact on children and their psychosocial
adjustment and well-being.
determinative of high parental conflict include an inability of the parents to
achieve an ongoing parenting plan, substantially different parenting styles and
expectations, and use of litigation to settle matters. Underlying these more
external markers are often seen power and control imbalances between the
parents, domestic violence, alcohol and drug abuse as well as parental mental
health problems, most notably, personality disorders, depression and anxiety.
subject to high conflict parental separation are at risk of the same set of
presenting problems as children subject to witnessing domestic violence and
parental alcoholism. However, when these parents seek help from their physician,
while the entrée is the child, what is sought by the parent is support for
their position in the litigation process. This may occur knowingly or
unknowingly to the physician. When knowingly, the parent overtly solicits
letters of support from the physician. When unknowingly, the parent may more
manipulatively seek the physician’s counsel, by meeting with the child to hear
the child’s custody and access preference and then bear witness to it.
in view of the child’s symptoms, may succumb to parental pressure for support
or alternately make a referral for counselling on behalf of the child.
view of the ongoing parental dispute and likely unsettled parenting regime, many
mental health practitioners will meet with the child and be inducted to support
the parental position on the basis of a one-sided account of the issues at hand:
of practice for conducting custody and access assessments from the fields of
child psychiatry, psychology and social work prohibit such one-sided assessments
and indeed may be grounds for disciplinary action by the respective college.
Certainly in the context of a trial, such one-sided reports are frowned upon by
the Courts, yet are still frequently sought by litigators and parents alike. It
may be that the utility of the document is less for Court, but more for
intimidation on the way to Court so as to bring about a settlement.
terms of intervention, here it becomes vital to understand the issues underlying
the child’s distress so as not to inadvertently become a pawn in the
parents’ settlement process of custody and access issues.
view of the many underlying matters that may be contributing variables to
children’s mental health issues, it becomes imperative for the physician to
screen for domestic violence, parental alcoholism and high conflict separation
issues. While there are many tools or instruments or questionnaires available,
the average family physician has nary the time to commit to a detailed or
prolonged screening process. Notwithstanding, there are a few questions, easily
asked that can give a clue that these issues may be active. Thereafter more
informed treatment may be directed.
respect to domestic violence, a physician may privately ask a parent if there is
any hitting, throwing of objects, slamming of doors, yelling or screaming that
goes on inside the home. If so, then the physician can probe deeper and explore
safety issues for that parent and child. Some parents may argue that the child
hasn’t seen or been privy to domestic violence, but closer scrutiny usually
reveals that the child was in the home, often hiding or may have been witness to
the aftermath of domestic violence such as by viewing injuries like swollen
lips, bloodied nosed, black eyes, other bruising or damage to property, let
alone the impact of the parent emotionally dishevelled by abusive events. In
view of a positive finding of domestic violence, the physician is better able to
refer appropriately and for women, should consider referral to women’s
shelters for counselling and ancillary services. Further, it may be necessary to
refer to child protective services and if uncertain, the physician should call
the local child protection agency for a consultation to determine the necessity
for parental alcoholism, the physician can perform a quick alcohol-screening
inventory. This can begin by asking about the quantity of alcohol consumed
daily, weekly and monthly. Many persons respond with his or her own assessment
of their alcohol consumption and the most frequent reply is to say one is a
social drinker. This phrase is remarkably subjective and totally obscures the
quantitative data. Hence the physician must resist accepting the parent’s
assessment of their drinking and return to the request for quantitative data.
Simply add up the number of standard alcoholic beverages consumed on a regular
of alcohol consumption include light, moderate, heavy, abusive, and binge. These
categories are differentiated by quantity of standard alcoholic beverages
consumed and pattern of consumption. While some persons may believe that beer is
less consequential than wine and that both are less consequential than liquor,
this is but another myth. A beer yields the same alcohol equivalent as 4 ounces
of wine and the same alcohol equivalent as an ounce of liquor. Hence it really
doesn’t matter what form the alcohol comes in, just the number of standardized
definition for men, approximately 6 standard alcoholic beverages per week is
categorized as light drinking, 12-14 as moderate, 24-26 as heavy and 36 or more
as abusive. Rates for women are about
2/3’s that of men. Furthermore, abusive drinking infers that that level of
consumption places the drinker at a high likelihood of contracting an alcohol
related physical disorder, such as liver disease, diabetes, pancreatitis, and
Korsakov’s syndrome. It is noteworthy that any level of regular drinking
increases the risk of these and other associated diseases, but that the more
alcohol consumed on a regular basis, the greater the risk.
drinking is defined as five or more standard alcoholic beverages per occasion,
at least once per month on a monthly or so basis. The risks associated with
binge drinking are injury and death, the result of misadventure, accident/poor
judgement, loss of consciousness, falls and violence.
the quantity of alcohol consumed and consumption pattern has been established,
the physician can discuss alcohol use as a concern in the home. Thereafter the
physician is in a position to counsel the patient on alcohol as a contributing
factor to the child’s distress and recommend treatment as may be required. It
is noteworthy here that the single most researched and most effective relapse
prevention program remains Alcoholics Anonymous. Virtually every community
offers at least one group program and people can usually consult the Internet
for locations nearest them.
for the matter of parental separation, one need only ask the parent the status
of the relationship with the other parent and about any unresolved issues. Even
unresolved financial or support issues can adversely affect the child. The
physician may learn that matters are with the lawyers and/or Courts. If matters
are apparently settled, it may be that the parental conflict has continued and
the child’s relationship to the other parent is at issue. In view of child
problems emanating from the parental separation, it becomes imperative to
include both parents in the treatment process. Counselling referrals should only
be made to persons with clinical-legal expertise.
practitioners of child problems related to issues of parental separation have a
number of strategies for working with such families. Intervention may require a
parallel process in terms of working with the parents separately as opposed to
seeing parents together. The specialized practitioner will assess for issues of
domestic violence and alcoholism as well as parental mental health issues which
together may be contributory to distress in the child. What becomes important in
terms of the referral from a physician, is that the physician refers to
practitioners with specialized knowledge, training and experience in working
with children whose distress is traceable to parental conflict. Even when a
referral is appropriately made, if the practitioner cannot gain access to both
parents, service may be withheld until such time as both parents are accessible.
Working on a one-sided basis may inflame the parental conflict and worsen the
child’s living conditions. Lawyers who might be advising their client to avoid
treatment in an effort to manage the litigation process may complicate this
matter. Hence not every referral will result in immediate treatment. However,
this may be appropriate to the circumstances.
specialized practitioners dealing with child problems emanating from parental
separations will be knowledgeable of the impact of legal matters on child
functioning and may direct parents to less adversarial resources for settling
disputes, assuming they are not already engaged in a process of their choice.
Less adversarial approaches to dispute resolution are seen to reduce risk to
children’s mental health problems.
thinking used to be that in view of children’s mental health, any counsellor
might suffice. It is now known that like sub-specialties in medicine, there are
subspecialties in counselling with regard to children’s mental health issues.
Hopefully this article raises the physician’s awareness of issues inherent to
assessment and treatment of children such that intervention is more
appropriately aligned to the needs of the child. The aim is to avoid the
iatrogenic effects of inappropriate treatment and as stated earlier, avoid
arranging the deck chairs on the Titanic.
 Brian Schwartz, MD, Cover Story: Violence against women, CMAJ, October 15, 2004, http://www.cma.ca/index.cfm/ci_id/10013255/la_id/1.htm
Fallon, B., MacLaurin, B.,
Daciuk, J., Felstiner, C., Black, T., et. al. (2005). Canadian Incidence
Child Abuse and Neglect-2003: Major Findings.
Ottawa, ON: Minister of Public Works and
Government Services Canada.
Closed Doors: The Impact of Witnessing Domestic Violence on Children in
Canada Fact Sheet, http://www.unicef.ca/portal/Secure/Community/502/WCM/WHATWEDO/ChildProtection/pdf/bodyshop/Canada_Fact_Sheet_Domestic_Violence.pdf
 D. Wolfe, P. Jaffe and S. Wilson. (1990). Children of battered women. Newbury Park, CA: Sage.
 Child and Family Services Act, R.S.O. 1990, c. C.11, s.72, (3), Province of Ontario.
 R. M. Morse and D. K. Flavin, The definition of alcoholism, The Journal of the American Medical Association, Vol. 268 No. 8, August 26, 1992
 McNamee JE and Offord DR, Children of alcoholics. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 470-85.
 IBID / see: http://www.ctfphc.org/Full_Text/Ch41full.htm#CTF%20Recs
 Child and Family Services Act, R.S.O. 1990, c. C.11, s.72, (1), 1, i, ii, Province of Ontario.
Janet R., and Vivienne Roseby, In the
Name of the Child: A Developmental Approach to Understanding and Helping
Children of Conflicted and Violent Divorce.
New York: The Free Press. 1997: 9-10
 Abel EL, Kruger ML, Friedl J., How do physicians define "light," "moderate," and "heavy" drinking? Alcohol Clin Exp Res. 1998 Aug;22(5):979-84.
Direnfeld, MSW, RSW
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