The legal basis for ethical withholding and withdrawing of life-sustaining medical treatment in children

Withholding and withdrawing life-sustaining medical treatment are common in paediatric practice, especially in intensive care units. However, not all clinicians apparently adhere to principles in ethical guidelines or to the principles which are to be found in judgments from common law cases arising when doctors and parents dispute treatment. This article examines selected ethical guidelines and compares them to judgments in leading cases. The rationale to forgo treatment is usually the child's "best interests" in both clinical practice guidelines and legal cases but in the former "best interests" may remain ill defined. Although "best interests" must essentially pertain to the individual child, the interests of others are not irrelevant. In legal cases "best interests" of the child are defined in terms such as "burden versus benefit", "futility", "indignity", "intolerability", "prolonging death rather than saving life" and "quality of life". These or like terms should form the basis of ethical decisions in discussions with parents when contemplating withholding or withdrawing life-sustaining treatment.     

The Denial of Visitation Rights: A Preliminary Look at its Incidence, Correlates, Antecedents and Consequences

The issue of visitation denial has inspired considerable debate and legislative activity. This article presents empirical evidence on the scope of the problem and the relationship between visitation and child support payment behaviors. Visitation denial is shown to be a problem, although reported levels of denial fall below both levels of non-contact by absent parents and non-payment of child support noted in previous research. Visitation difficulties appear to become established fairly early on in the separation/divorce process and fail to deviate over time. Although non-payment of child support cases do not always involve a visitation problem, the two phenomena are related with visitation problem cases being more likely to involve non-payment of child support. The data do not permit a deciphering of causal order in cases that involve both types of non-compliance. However, both phenomena appear to stem from conflict patterns between the parents which are detectable at early stages of the divorce process. These findings inspire several recommendations, including interventions with divorcing parents aimed at enhancing their communication skills and reducing levels of anger and hostility and the need to develop mechanisms in which visitation and child support grievances can be jointly aired.     

Associations between Parent and Child Reports Of Interparental Conflict/Violence And Child Difficulties in A Family Mediation Setting*

We examined the association between parents’ (N = 52 mothers and 52 fathers) and children's (N = 27) reports of interparental conflict and child difficulties in a family mediation setting. Parents’ reports of conflict were moderately associated with children's reports of exposure to parental conflict, but only fathers’ reports of conflict were associated with children's reports of negative responses to parent conflict. While mothers and fathers agreed on their child's difficulties, only mothers’, not fathers’, report of child difficulties were moderately related to child reports of child difficulties. Mothers’ and fathers’ reports of conflict generally were not strongly associated with reports of child difficulties. In contrast to parent reports, children's reports of exposure to parents’ conflict were moderately and significantly related to self‐reported child difficulties and moderately related to parents’ reports of child academic difficulties. The magnitude of the association between the child's report of interparental conflict and self‐report of difficulties was stronger than the association between parent report of conflict and parent report of child difficulties, suggesting that parents may not fully understand their child's exposure to parent conflict/violence or the problems their child is experiencing.

Key Points for the Family Court Community:
• Family law stakeholders prioritize the creation of parenting arrangements that are in the best interest of the child; however, it is unclear how to gather information about the child and the child's perspective in order to inform such arrangements.
• The study results suggest that parents may not agree with each other or with the child about important family issues, such as parent conflict and child difficulties. For example, parents may not fully understand their child's exposure to parental conflict/violence when in the midst of custody negotiations.
• More research is needed to determine the best method for gathering information about the child during custody proceedings. In the meantime, it is important to gather information from multiple sources and to consider the agreement and differences across such sources of information.

     

High Conflict Divorce,Violence, and Abuse: Implications for Custody and Visitation Decisions

Today, judges are faced with the daunting task of determining the best interests of the child and making appropriate custody awards to that end. The best interests of children becomes a critical question when domestic violence is involved; yet, determining what constitutes domestic violence is often debated. Research is often divided on what constitutes domestic violence. One body of research focuses on conflict, another focuses on domestic violence. What the first group identifies as intense emotional distress and disagreement, the other identifies as abuse. Judges making custody determinations in such cases are faced with the difficult challenge of distinguishing between a divorce with “high conflict” and a domestic violence case with ongoing abuse. This article will summarize the legal, philosophical, and historical understandings of the “high conflict” family and its potential impact on children. It will also provide practical judicial guidelines for making the important distinction between high conflict and domestic violence and subsequently crafting appropriate and safe child custody awards.     

JOINT CUSTODY AND THE PRESCHOOL CHILD

A longitudinal study of 25 families, with children aged 14 months—5 years, in joint custody, is reported. Varying motivations that lead divorcing parents to undertake and sustain joint custody are discussed, together with the stresses and gratifications of these arrangements for the parents and children. Findings are that where both parents are motivated primarily by interest in the child, where the parenting is sensitive and where the child is shielded from interparental conflict, young children do well. Such families were not the majority in this study. Significant differences emerged in the adjustment of the 1–3 age group as compared with the 3–5 age group which point to greater difficulties for the 3–5 year-olds.     

Building and Enhancing Efficacious Coparenting in Parenting Coordination

Parenting coordination is a dispute resolution process to assist the subset of separating/divorcing parents who remain entrenched in high conflict coparenting post‐separation/divorce. Based on factors known to impact positive child outcomes, its goals include assisting parents to protect children from their conflict and implementing a framework that will assist the child to have a good relationship with both parents. Despite significant efforts, parenting coordination often falls short of achieving its intended goals, which include not only healthy child adjustment but also efficacious coparenting, which is itself an important mediator and moderator of child outcomes. This article raises questions and concerns about the extent to which child outcomes may be limited if the goals of parenting coordination are limited to establishing and implementing a disengaged, parallel model of coparenting, while avoiding or giving up on efforts to build and enhance cooperative coparenting. Given preliminary findings indicating some parents note change here express dissatisfaction with the process and outcomes, it is necessary to consider whether the seemingly intractable subset of parents referred for parenting coordination might benefit from something more or different. We discuss two innovations: One aims to strengthen individual parent readiness and responsiveness and the other brings parents together in a child‐centered team‐building approach. Though cooperative coparenting is a challenging and unrealistic goal for some parents, further research is necessary to understand more fully which interventions help which families, when and in what manner.     

CHILD SUPPORT GUIDELINES:

Since 1984, all U.S. jurisdictions have established child support guidelines. Using computerized worksheets, we compared the guidelines of New York, New Jersey, and Connecticut (which use the “Income Shares” model also employed by 30 other jurisdictions). We calculated how child care, alimony to a prior spouse, and subsequent children change the support obligation. We found that, generally, Connecticut requires the most child support, New York is second, and New Jersey third. However, if children require child care, New York requires the most support. In Connecticut, child care costs have virtually no impact. When a noncustodial parent is paying alimony to a prior spouse, support is dramatically greater in Connecticut than in New Jersey, with New York in between. Only New Jersey reduces the support paid by the noncustodial parent who has subsequent children. New York's and Connecticut's mathematical guidelines do not consider subsequent children.     

Hybrid processes within parenting plan assessments: Rationale and an illustrative model

Parenting plan Assessments, also known as child custody evaluations, are forensic psychological investigations into the needs of children, the parenting capacities of their caregivers, and the resulting fit between the children's needs and caregiver capacities. Typically, they result in recommendations that are, in the opinion of the assessor, formulated to meet the best interests of children regarding a parenting plan, child sharing, parental responsibilities and ancillary services that are likely to support the children's optimal functioning as well as the functioning of the now reconfigured family. Such assessments are part of a pathway to untangling conflicts between the parents regarding the most appropriate parenting plan for the reconfigured family. Paradoxically, the assessment process can exacerbate the conflict, entrench parental polarization, and create lingering feelings of helplessness, frustration, and disempowerment in the parents. This article provides a rationale for the use of a hybrid process that incorporates alternative dispute resolution as an integrated part of the parenting plan assessment and provides an illustrative model of such a hybrid process.     

CHILD SUPPORT GUIDELINES:

Since 1989, federal law requires states to have presumptive child support guidelines and review them using economic data on child-rearing costs at least once every 4 years. This article reviews the child support guidelines models adopted by states, how they relate to estimates of child-rearing expenditures, the extent that states are updating their guidelines, and some of the more controversial guidelines provisions (i.e., adjustments for shared-parenting time, additional dependent children, and low-income nonresidential parents). We find that many states are not updating their core formulas and schedules. As a result, several state guidelines produce support award amounts that are below the costs of raising children.     

Child support order: how do judges decide without guidelines? Evidence from France

The paper presents a model of family judges’ child support orders when no guidelines are available. Based on the French case, it argues that judges weigh up their wish to comply with their institutional environment against their discretion and their willingness to find a compromise, by basing their decision on the parties’ average offer. Using experimental data consisting of child support awards set by approximately 80 French judges, the findings of the paper suggest that family judges promote parents’ child support offer when there is an agreement between them, particularly when their offer is lower than the amount deemed necessary to preserve the child’s interest. There is also some evidence that female judges are likely to be more generous than male judges, although in small amounts and under certain circumstances.     

The relationship between parents and adult children in the economic culture of rural Netherlands, 1880–1910

This study examines the complexity of contradictory interests in the relationship between parents and adult children among agricultural wage laborers in rural Netherlands about 1900. One important potential issue of conflict was the marriage of children. In the case of wage laborers, Hajnal's independent livelihood theory is not really helpful in explaining regional differences in age at marriage. Marriage is viewed as a problem of balance and competition between the livelihood problems of parents and children. Two main issues of wage laborers are dealt with: the help adult children give to elderly parents and the control of the earnings of unmarried adolescent and adult children by their parents. Regional variations in children's help and parental control are measured and explained using four independent variables: extent of property ownership by wage laborers, extent of their production for the market (and need for unpaid family labor), wage level, and percentage who belonged to traditional religions in the village. Statistical analysis suggests that the property of agricultural wage laborers was most important in explaining variation in parent–child relationships. Wage level and religion also showed considerable explaining power, particularly for wages earned by unmarried children.     

“I WANT MY MOMMIES”: THE CRY FOR MINI‐DOMAS TO RECOGNIZE THE BEST INTERESTS OF THE CHILDREN OF SAME‐SEX COUPLES*

In child custody cases, courts will look to the best interests of a child to maintain visitation/custody rights only with the child's biological parent, not third parties. However, with a same‐sex couple, it is inevitable that one parent will not be the biological parent. Thus, when that parent is in a mini‐DOMA state, where same‐sex couples from non‐mini‐DOMA states do not have to be recognized, that parent will be viewed as a third party and lose all visitation/custody rights if the couple separates. This note advocates that mini‐DOMAs allow both the biological and nonbiological parents of a same‐sex couple to have visitation/custody rights of their children if it would be in the best interest of the children to do so.     

An Interdisciplinary Case Management Protocol for Child Resistance or Refusal Dynamics†

High‐conflict parental separation cases associated with child's estrangement or contact refusal take an unusually large amount of court time and generate high emotional costs for parents and children. This paper reports on a study of a research‐based pilot project and protocol, called the Parenting Conflict Resolution (PCR), which is intended to reduce parental conflict, improve interparental communication, and support or restore the parent–child relationship. The protocol was developed at the Superior Court in Quebec City (Canada), and involves single judge case management, and lawyers' commitment to have the child's best interests as their primary consideration and to guide their clients to trust the process. The assigned judge and lawyers have the ongoing involvement of a mandated psychotherapist, taking a family systems approach with the case. The PCR also requires the parents to participate in a psycho‐educational, introspective group program to work on co‐parenting and communication skills. Ongoing communication between the professionals involved in the PCR is required to ensure cohesion and accountability. This pilot project was implemented with 10 high‐conflict families, 6 of which presented with the child's resistance or refusal to see one parent. A qualitative data study was undertaken into the experiences of all the participants. The most salient result is the resumption of parent–child contact in all six contact refusal cases. Discussion highlights key elements to successfully address these cases: (a) interdisciplinary program delivery, (b) systemic understanding of the contact problems, (c) focus on the child's best interest, (d) single judge assigned to the case, (e) lawyers' support of the parents' participation, and (f) psychotherapist reporting to the court.     

COPARENTING ARRANGEMENTS IN A JURISDICTION WITH STATUTORY GUIDELINES

Some states have recently moved away from the traditional winner-loser model of child custody to one focused on coparenting. Under the old approach, divorce decrees typically "awarded" custody to one parent while relegating the other to a "visitor" with poorly defined status. The new system is premised on the child's need for a continuing relationship with both parents and promotes this goal by upgrading the noncustodial parent's status and time-share, assigning substantive rights and responsibilities to both parents. To give effect to the shared parenting idea, Texas adopted joint custody and statutory visitation guidelines legislatively. The policy covers all major aspects of parental rights and duties with great specificity (not just child support, for which all states must have guidelines). It applies equally to divorce and paternity cases. Judges are authorized to deviate from standard visitation guidelines but must state a rationale for doing so on request. Parties may also negotiate and agree to arrangements at variance with the guidelines, subject to approval by the court. This article describes the statutory regime in Texas and its implementation in the family court system. Based on a sample of divorce and paternity cases in the state's largest jurisdiction, it documents innovative court interventions and a wide array of coparenting and support arrangements.     

Reforming Relocation Law: A Reply to Prof. Thompson

This article provides a response to Prof. Thomson's critique, noting many points of agreement and also the broader consensus that is emerging among experts in the field. The research evidence, and the wider body of knowledge on children's well‐being generally, supports the proposition that relocation is a risk factor for children after parental separation but provides no support for a general presumption either in favor of, nor against, relocation. Nor should it be assumed that the interests of children are the same as those of their primary caregiver. We defend our three questions arguing the need in an adult‐centric debate to focus resolutely on children's interests rather than on adult rights. Both Prof. Thompson's approach and our own involve guided decision making with the child's best interests as the paramount consideration—his through weak presumptions based upon research about how judges respond to relocation issues and ours through focused questions based on research on how parents and children respond to relocations issues. We do not consider that codifying the existing practices of the courts represents real reform. We identify various risks involved in using presumptions, but note that, in jurisdictions with limited publicly funded resources for individual case assessment, presumptions, burdens or guidelines may be needed to offer rough justice to impecunious parents.

Key Points for the Family Court Community
• Notes points of emerging agreement on relocation within the research community
• Explores the differences between the use of presumptions and focused questions and highlights the role of empirical research of the lived experience of children and families postrelocation disputes
• Identifies how the level of public resourcing for the family law system may impact upon decisions about the substance of the law concerning relocation

     

HOW EFFECTIVE ARE COURT‐AFFILIATED DIVORCING PARENTS EDUCATION PROGRAMS? A META‐ANALYTIC STUDY

In this meta‐analytic study, we looked at all empirical studies that examined the effectiveness of court‐affiliated divorcing parents education programs (DPEs). Overall, we found that DPEs were generally effective. Nineteen studies with a DPE treatment group and no‐treatment control group had an overall significant moderate positive effect (d= .39); those who participated in DPEs were about 50% better off in terms of program outcomes compared to those who did not participate. The studies examined five specific outcomes: co‐parenting conflict, parent‐child relationships, child well‐being, parent well‐being, and relitigation; with most of these specific outcomes we found significant moderate effects ranging from d= .19–.61. However, there were important methodological limitations in this body of research, which are discussed. While more research is needed to confirm the positive potential of DPEs, we probably know enough to justify continuing and even increasing support for this recent social policy innovation.     

The relationship between parents and adult children in the economic culture of rural Netherlands, 1880–1910

This study examines the complexity of contradictory interests in the relationship between parents and adult children among agricultural wage laborers in rural Netherlands about 1900. One important potential issue of conflict was the marriage of children. In the case of wage laborers, Hajnal's independent livelihood theory is not really helpful in explaining regional differences in age at marriage. Marriage is viewed as a problem of balance and competition between the livelihood problems of parents and children. Two main issues of wage laborers are dealt with: the help adult children give to elderly parents and the control of the earnings of unmarried adolescent and adult children by their parents. Regional variations in children's help and parental control are measured and explained using four independent variables: extent of property ownership by wage laborers, extent of their production for the market (and need for unpaid family labor), wage level, and percentage who belonged to traditional religions in the village. Statistical analysis suggests that the property of agricultural wage laborers was most important in explaining variation in parent–child relationships. Wage level and religion also showed considerable explaining power, particularly for wages earned by unmarried children.     

THE EVOLUTION—OR END—OF MARRIAGE?: REFLECTIONS ON THE IMPASSE OVER SAME‐SEX MARRIAGE

The debate over legalizing same‐sex marriage implicates the question of whether doing so would signal the end—or destruction—of the institution of marriage. The appeal to preserving a millennia‐old tradition of marriage against change fails to reckon with the evolution that has already occurred. Invocations of gender complementarity between parents as essential to child well‐being also conflict with growing recognition in family law that children's best interests can be served by gay and lesbian parents. Canada's path toward same‐sex marriage suggests that impasse need not be inevitable. In the United States, this impasse stems in part from the problem that same‐sex marriage serves as an emblem of everything that threatens marriage.     

Reengineering the Child Support Scheme: An Australian Perspective on the British Government's Proposals

After years of problems with the Child Support Scheme in Britain, the Government has decided to attempt reform again, less than four years after a previous major change was implemented in 2003. The author evaluates these reform proposals, drawing upon his experience in leading a recent major review of child support policy in Australia. While many of the reform measures offer a sensible way forward for child support policy, Britain risks going backwards in terms of community acceptance of the child support obligation. The Government needs to consider the likely impact of its policy settings on private agreements about child support. Ways are proposed both to protect the Treasury and to promote the wellbeing of children by adopting different policy settings that ensure the resident parent has an incentive to bargain for the level of child support required by the new formula. The new formula itself is evaluated in the light of the international research on the costs of children. Ways are also suggested for developing a co-ordinated approach across government to the provision of support services for parents who do not live together.     

Coparent Support and Conflict in African American Single Mother-Headed Families: Associations With Maternal and Child Psychosocial Functioning

This longitudinal investigation examined main and interactive effects of coparent support and conflict on mother and child adjustment in 248 low-income, African American, single mother-headed families. The findings indicated that coparent conflict was a more robust predictor of mother and child maladjustment both cross-sectionally and longitudinally than was coparent support. Moreover, findings revealed that coparent conflict and support interacted to predict one parenting behavior, monitoring, both cross-sectionally and longitudinally. Coparent relationships characterized by high levels of support and low levels of conflict were associated with the highest levels of parental monitoring behavior, whereas coparent relationships characterized by low levels of support and high levels of conflict were associated with the lowest levels of monitoring. The findings highlight the importance of examining both positive and negative aspects of coparent relationships in this at-risk, but understudied, group.