Helping Children and Families Deal With Divorce and Separation
- George J. Cohen, MD, FAAP,
- Carol C. Weitzman, MD, FAAP,
- COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH,
- SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS
For the past several years in the United States, there have been more than 800 000 divorces and parent separations annually, with over 1 million children affected. Children and their parents can experience emotional trauma before, during, and after a separation or divorce. Pediatricians can be aware of their patients’ behavior and parental attitudes and behaviors that may indicate family dysfunction and that can indicate need for intervention. Age-appropriate explanation and counseling for the child and advice and guidance for the parents, as well as recommendation of reading material, may help reduce the potential negative effects of divorce. Often, referral to professionals with expertise in the social, emotional, and legal aspects of the separation and its aftermath may be helpful for these families.
Every year, more than 1 million American children experience the divorce or separation of their parents. Poverty, lower levels of parent education, and parents being children of divorce can be factors in divorce.1 Parents of children with chronic or serious illnesses and neurodevelopmental disorders such as cancer and autism spectrum disorders are often at higher risk of divorce, although some studies have shown this is not always the case.2 The separation itself is usually the culmination of other stressors in the family to which the child has been exposed; parental conflict and tension often precede and may lead to behavior problems in the child.1
Many children show behavior changes in the first year of parent separation. Although most adjustment problems resolve in 2 to 3 years after the separation,1 the child’s sense of loss may last for years, with exacerbation on holidays, birthdays, and other special events. Adjustment to a new living situation, continuing parental tensions, and alienation can cause distress in the child.3,4
Children’s manifestations of reaction to parental divorce are related to many factors, including the stage of development of the child,5 the parents’ ability to focus on the child’s needs and feelings, the child’s temperament, and the child’s and parents’ pre- and postseparation psychosocial functioning.1,3
Although infants cannot understand the separation, they react to changes in routine and caregivers and the break in attachment. They may be fussier, irritable, or listless and have sleep and feeding disturbances. At approximately 6 months of age, normal separation and stranger anxiety may be increased.6–9
Separation anxiety is a frequent manifestation of distress at this age, and children may be reluctant to separate from parents even in familiar settings, such as child care or a grandparent’s home. Developmental regression, including loss of toileting and language skills, is not uncommon. Eating and sleep disorders are also common.10,11
At this age, children do not understand the permanence of the separation and will repeatedly ask for the absent parent. They may be demanding and defiant and may have sleeping and eating problems as well as regression in developmental milestones. They often test and manipulate differences in limit setting by the 2 parents. By age 4 to 5 years, they may blame themselves for the separation, begin acting out, have nightmares, have more reluctance to separate, and fear that they may be abandoned.1,3
Self-blame and asking and fantasizing about the reunion of the parents are not uncommon. At this age, mood and behavior changes, such as withdrawal and anger, are frequent, school performance may decline, and the child may feel abandoned by the parent no longer living in the home.1,3
Although by this age, children may understand some of the reasons for the family breakup, they may still have difficulty accepting the situation and may try to take on adult roles.1,3,8,9 They may de-idealize 1 or both parents and still believe that they can reunite the parents. Aggressive delinquent behavior, withdrawal, substance abuse, inappropriate sexual behavior, and poor school performance are frequent responses to the change in family structure.12 Suicidal ideation is increased in junior high school–aged boys of separated mothers13 and is more frequent in men than in women of divorced parents.14 Girls living with divorced fathers are more likely to make suicide attempts than girls living with their divorced mothers.15
Parents also suffer negative effects of separation and divorce. Mothers are likely to feel stressed and humiliated, to use alcohol, and to seek mental health services compared with divorced fathers. Mothers’ problems can persist for prolonged periods after divorce. However, fathers often feel alienated, seem less accepting of their children, and may become depressed and anxious and abuse substances. Grandparents, too, may feel a decreased quality of relationship with their grandchildren, especially in relation to custody arrangements that favor their ex–son-in-law or ex–daughter-in-law.3
Different situations and activities can have different effects on the children of divorce and separation. However, if the parent does not understand the child’s individual need, the child is likely to be frustrated and demonstrate externalizing behaviors, such as tantrums, oppositional behavior, and general acting out.10 Moving away from a familiar milieu may be a negative factor in the child’s adjustment; children who move away from their former home are likely to feel more distress. As adolescents, girls show more hostility and boys are less hostile when they moved as children with the custodial father.16
Nonresidential fathers believed they were more involved with their children than was perceived by the custodial mother but also felt a more negative change over time in their relationship with the children. The custodial mother’s feelings about the relationship with her children were less likely to change.17 Prolonged legal action in the divorce leads to worse coparenting relationships and more negative feelings in the father. However, if the father is the initiator of the divorce, he is likely to feel more fulfilled in his parenting role.18 If the child spends more time living with the father after the separation, the child-father relationship is likely to be more positive regardless of continuing parental conflict.19 Fathers’ greater involvement with their sons has been shown to be important for the sons’ development. The father’s behavior and reactions to the separation, however, are specific areas that often require professional involvement.20,21
Children who end up living in nonnuclear (ie, other than 2 married parents) families are more likely to have a higher incidence of poor health, learning difficulties, attention-deficit/hyperactivity disorder, emotional and behavioral difficulties, and emergency department visits than those in nuclear families.22 Interventions, such as counseling of the mother, that foster positive changes in the mother-child relationship and consistent discipline practices have resulted in increased coping efficacy in children at 6 months and at 6 years after the intervention, including in divorced, separated, and single-parent families.23
Low-income families are more likely to separate, and if the mother is in a new relationship, there is often a decrease in supportive coparenting.24 When there is parental separation, fathers usually have more financial resources than the mothers. This disparity tends to increase the inequality of money available for children and thus results in a significant increase in child poverty.25 After divorce, women are more likely than men to face significant financial challenges, receive public assistance, lose health insurance, and have decreased earning potential. In the recent US Census Bureau report on marriage, 28% of children in divorced families lived below the poverty threshold, compared with 15.9% of the total population. This situation puts children of divorced parents at a higher risk of a number of adverse outcomes.26
History of Child Abuse
Divorce in a family with a history of child abuse is related to a greater incidence of conduct disorder, posttraumatic stress disorder, and suicide attempts in children than does either divorce or child abuse alone.27
Legal sources suggest that mandated parenting classes, recommended by divorce courts, could improve outcomes for all members of the family.1 Adolescents’ rating of family harmony predicted their own self-image and emotional development. Ten years after the divorce, daughters of high-conflict families reported more depression. Wariness regarding relationships was higher in children from divorced homes or homes with parental conflict.28 Alienation of the child and the targeted parent is a frequent problem that needs practical professional input to correct the negative effects on all parties.29 The father’s reactions and behavior to the separation is a specific area that needs professional involvement.19
The divorce patterns of service members and veterans further highlight the potential positive effects of the support for families that the military provides. While they are in the military, couples are less likely to divorce than their civilian counterparts. Once they leave the military, however, this trend reverses. Veterans are 3 times as likely to be divorced as those who have never served in the military. Research indicates that the military environment protects families from the stresses that often lead to divorce and that veterans’ marriages become less stable once they leave the supportive military setting.30,31
The legal profession reports that there is momentum building for more focus on the child in divorce disputes.32 Courts and legislators also are looking at divorce as a sign of problems in parenting and the need to improve education of parents about the effects on the child of parental discord.33 Attention can be given to the child’s reactions as he or she becomes an adolescent and also to the changes in parents’ lives.34 Legal research internationally is looking at past, present, and future relocation as related to children in divorced and separated families.35 Research suggests that previous moves and changes in family structure may cause more psychological risk to children.
Although not a common aspect of pediatric practice, pediatricians may be subpoenaed by a court or asked by a parent to provide testimony in a child custody hearing. In such circumstances, pediatricians should be cognizant of the following information. A “subpoena” is a legal document that notifies a witness that he or she is needed to present evidence in court. A subpoena might require testimony (subpoena ad testificandum), the production of documents (subpoena duces tecum), or both. Because a subpoena suspends typical rules regarding medical confidentiality, it is important for the pediatrician to read carefully what disclosures are commanded (and therefore allowed) by the subpoena. A provider receiving a subpoena for a medical record that he or she did not create should notify the attorney issuing the subpoena of the appropriate custodian instead of disclosing the record. On receiving any subpoena, the wisest course is to call the attorney who issued the subpoena and discuss with that attorney what testimony or documents are required and what facts or opinions the attorney hopes to elicit.
If a pediatrician is requested by a parent (or a particular party to a custody hearing) to provide testimony, in furtherance of the best interests of children of divorced families and maintenance of good physician-family relationships it may be prudent for the pediatrician to defer those requests to child-abuse pediatric experts (where available) or consult with them before providing any testimony. It is important for the pediatrician to remember that he or she should consider himself or herself an impartial educator of the court about the topic of his or her expertise. A physician has an ethical obligation to provide accurate, unbiased testimony based on sound scientific principles.36 Pediatricians should make every effort to avoid taking sides and testifying on behalf of either parent about the appropriateness of parenting skills. One should seek legal advice from hospital-based forensic teams to explore alternative responses to a subpoena to testify. In the long term, the child’s relationship with the pediatrician is best served by maintaining good relationships with both parents if possible.
When providing testimony in court, the court may deem the pediatrician as a “fact” or “expert” witness. If the pediatrician is providing only “fact” testimony, then exploration/questions into the physician’s qualifications are unnecessary, and a “fact” witness will provide testimony only to the specific facts that the witness has seen, heard, felt, etc. If the pediatrician is to be deemed an “expert” witness, then a formal courtroom procedure of qualifying the witness as an “expert” will be conducted. This legal procedure is a series of questions that demonstrates to the court that the witness has sufficient training, research, writing, professional activities, or other qualifications to serve as an “expert.” Being qualified as an expert on a particular subject matter entitles the expert to offer opinions in court.37 One need not be the foremost authority on the subject matter nor understand every nuance of the subject to qualify.38
The best preparation for any kind of court testimony is to be thoroughly familiar with the medical facts of the case. Although many courts will permit a witness to refer to notes during testimony, the witness should be able to recite the basic facts of the case (patient’s name, age, dates seen, high points of the history, and injuries found) from memory. The expert should be familiar with the patient’s entire chart, because questions may be asked about the patient’s medical conditions unrelated to the issue of custody. If the pediatrician is asked to opine about a matter with which he or she is uncomfortable (ie, rendering an abuse or neglect diagnosis), the pediatrician may either confer with a specialist in that field (ie, a child-abuse pediatrician) before providing that testimony or inform the court of his or her discomfort in rendering a formal opinion on that subject matter. It is important that the pediatrician be cognizant of not providing irresponsible testimony.39 Irresponsible testimony includes testimony for which the expert is insufficiently qualified or testimony based on idiosyncratic theories that have either not been substantiated by well-conducted medical studies or have not gained wide acceptance in the medical community.36 Recommendations from the American Academy of Pediatrics for expert witnesses are listed in Table 1.36
The Legal Framework
Divorce is a legal term that means the dissolution or legal conclusion of a marriage. For children of married parents, the divorce process includes legal protections for children. For unmarried parents, state laws may provide similar protections for children through a custody/visitation action. Specifically, family courts during a divorce or custody/visitation action are charged with determining and securing the best interests of children. This assessment includes the financial and psychosocial needs of the children and typically leads to an agreement or order specifying the amount of time children will spend with each parent and which parent (or parents) is responsible for decision-making with regard to education, health care, family values, and related matters. Some states have marital equivalents such as civil unions or domestic partnerships. Children of parents in civil union or domestic partnership relationships ideally should have the same legal protections as children born to married parents. The nonmedical literature has reported on the variability of legal decisions in cases involving same-sex parents and their children.40
The touchstone for determining whether a person who raises a child has a legal status as parent to that child is biology, marriage, or adoption. Although parenthood status is usually straightforward, circumstances in which parenthood status and parental rights are unclear may involve complex issues of law. A person with a biological or legal adoptive relationship to a child is that child’s legal parent. Similarly, a person whose spouse bears a child is presumed to be a parent of that child. In any case involving a relationship dissolution involving a biological, marital, or adoptive parent, a court is expected to assess the best interests of the child.
A person who raises a child but who does not have a legal relationship to that child through biology, marriage, or adoption may not have the same protections for a continued relationship with the child despite the fact that the effect on the child can be as significant.1 The courts have increasingly found ways to protect such relationships by recognizing them as psychological, de facto, or equitable parenting relationships. These developments vary state by state. As families that formed through the expanding capacity of human reproductive technology separate and divorce, there will continue to be legal challenges and areas without legal precedent regarding custody determinations of the child.
Another area that is important to consider that is far more common than divorce is the issue of the separation of nonmarried heterosexual partners. In 2006, approximately 38% of all births were to nonmarried women. Although nearly 50% of partners were living together at the time of the child’s birth, approximately 45% were separated 5 years later. Less attention is often given to these separations as when there is a legal divorce, but the psychological effect on children is likely as significant.41
The Pediatrician’s Role
Pediatricians may only learn about divorce or separation from the children’s behavioral changes, family moves, and changes in family financial responsibility. Inquiring about family stressors, including parental difficulties, can be a routine part of the pediatric health supervision visit, as noted in the third edition of Bright Futures.42 When pediatricians counsel the family regarding issues of child development and behavior, areas of marital discord or stress are often uncovered. Being aware of these stressors and referring for marital counseling are appropriate and may preserve the marital relationship. Pediatricians are encouraged to consider their own attitudes, religious beliefs, and ethical positions concerning divorce, especially if they have experienced divorce in their own families. Being as objective as possible in counseling children and parents is important. If the separation appears to be definite, early interventions, such as referral to a family counselor, may decrease parental hostility and assist the child and parents in coping with family disruptions to come.
In cases of marital discord, the potential role of pediatricians includes carefully considering the child’s physical and emotional needs and communicating this to parents, listening to each parent’s perspective, and suggesting that they consider consulting a marriage/divorce counselor to develop strategies to address the discord or to help the child through the dissolution of the marriage. A positive, neutral relationship with both parents after a divorce and being the child’s advocate are appropriate goals.
The pediatrician can assess the child’s reactions, the parents’ reactions and levels of hostility, their abilities to understand and meet the child’s physical and emotional needs, their support systems, and any indication of parental mental illness or possible substance use.43,44 Understanding the child’s experience of divorce is essential if the pediatrician is to advise the family. The works of several authors can be particularly helpful.8,35,45–48 Wallerstein49 correctly notes that the family divorce is a process, not simply a single event. Consequently, a child’s understanding of and adjustment to divorce or separation occurs in stages.
Acute parental separation, which may precede the legal divorce by months or years, is typically the time of highest vulnerability for the child. Parental distress is high. One parent may be physically absent and often temporarily lost to the child. The custodial parent may find parenting responsibilities more difficult because of his or her own distress. At a time when children’s needs are increased, parents are at an emotional disadvantage and are often less emotionally available and less able to address the needs of their children.
Decreasing school performance, behavioral difficulties, social withdrawal, and somatic complaints are common reactions of children and accompaniments of divorce that require intervention. A heightened level of sadness is typical, and depression is not uncommon in both children and parents.8,9
A parent conference at this stage might be scheduled. The pediatrician can meet with the parents together, ideally, or separately, if necessary, to assess the current situation and to assist in future planning for the children’s needs. It is important that pediatricians establish appropriate boundaries with parents at this point, clearly informing them that their role is to understand and meet the child’s needs as much as possible, and that the pediatrician is unwilling to take sides in a contentious divorce or be a conduit of information between parents. However, if a pediatrician becomes concerned that living with a particular parent presents a significant risk of current or future abuse or neglect for the child, the pediatrician should make a report to child protective services. If a pediatrician is uncertain whether the family psychosocial dynamics pose sufficient risk to warrant a report to child protective services, it may be prudent to consult a local child-abuse pediatrician. The pediatrician can offer each parent an opportunity to discuss the separation as it affects the child.
The discussion can begin by inquiring how each member of the family is doing at this time of family stress and transition. Do both parents have adequate support systems, such as extended family, clergy, or a personal physician to help meet their own physical and emotional needs? Are there supports that can help parents in their parenting roles? What is the apparent emotional reaction of the children? It may be helpful to interpret these reactions to the parents on the basis of the child’s developmental level and perspective.
Pediatricians can help parents understand their children’s reactions and encourage them to discuss the divorce process with their children. Parents can be helped to answer the children’s questions honestly at their level of understanding. The children’s routines of school, extracurricular activities, contact with family and friends, discipline, and responsibilities ideally should remain as normal and unchanged as possible. Children can be given permission for their feelings and opportunities to express them. Children must understand that they did not cause the divorce and cannot bring the parents back together. It is hoped that they can be told that each parent will continue to love and care for them, but if they cannot be provided with this reassurance, pediatricians can help the involved parent develop strategies to help the child articulate feelings of loss and identify resources to assist the child. The pediatrician can offer families pertinent written material on divorce directed at parents and children (see the reading lists at the end of this report). These resources can be informative for the pediatrician as well. Ideally, children would not be “put in the middle” between divorcing or divorced parents, such as being asked to provide information about 1 parent to the other or when 1 or both parents are seen to be demonizing the other parent. These situations can result in children feeling disloyal to a parent and feeling that they need to choose 1 parent over the other and can result in feelings of guilt, sorrow, and anger. If this is happening, pediatricians need to be comfortable having frank, nonjudgmental, and open discussions with parents and exploring ways to help the family manage these challenges.
Custody options can be discussed, and the parents’ plan may be explored. It may be helpful to remind parents that professional help can aid them in a nonbiased evaluation of the situation and approaches to resolution. If there are legal issues, including custody, finding an attorney who considers the child’s best interest of highest importance is essential. Legal custody and parental rights and responsibilities can vary in their physical and legal arrangements, from sole 1-parent custody, to various forms of shared arrangements, to equal or joint custody.3 Varying statutory requirements exist to protect the interests of children.
More important for the child’s mental health than the type of custody is the quality of parenting that the child receives from each parent through the divorce and postdivorce periods as well as the child’s own resilience. Regardless of the type of custody arrangement, it is important that the pediatrician be informed in writing by both parents of who has legal permission for access to the child’s medical record, who is responsible for informed consent, who is to pay for the child’s health care, and with whom the pediatrician may discuss health information about the child in accordance with regulations of the Health Insurance Portability and Accountability Act. If the noncustodial parent has legal visiting rights and access to health information, it is important that immunization and other pertinent health records be given to both parents in case of an emergency or urgent situation. Any conflict between parents about these issues should be resolved in accordance with legal custody agreements and may require written authorization by both parents. In an emergency situation, the pediatrician can always act to protect the child. It is a good idea for parents to inform the child’s school of the change in the family structure, request that report cards be sent to both parents, and identify which parent has the authority to grant permission for the child’s school-related activities. For additional guidance, pediatricians can refer to the existing American Academy of Pediatrics’ clinical report “Consent by Proxy for Nonurgent Pediatric Care.”50
Although many children have long-lasting emotional and adjustment problems associated with their parents’ divorce, most adjust and function well over time, particularly those who have supportive relationships and are well adjusted before the separation/divorce. Professional counseling may be necessary and has shown to be effective in helping children adjust to divorce and separation.34,37,38,51,52 It is important that pediatricians recognize that a divorce is a process and not an event; substantive periods of change during the process can demand new adjustments on the part of children and parents. Although the legal divorce is an important issue for parents, it may be insignificant to a younger child who knows little of the legal process or very significant for the older child who experiences further proof that his parents will not reconcile. Among troublesome issues for children may be the parents’ dating and sexual activities. Parental discretion and truthfulness are important for the maintenance of respect for the parents. Stepfamilies introduce another adjustment challenge for children and their parents.
As children develop and mature, their emotions, behaviors, and needs with regard to the divorce are likely to change. A custody arrangement that made sense for a younger child may need adjustment for a preadolescent or adolescent. For adolescents, with their advancing maturity, awakening sexuality, and important steps toward their own adulthood, their parents’ divorce is reinterpreted and may require rediscussion and readjustment. Many behavioral and emotional reactions from the separation can be reawakened at times of subsequent loss, at anniversaries, with the child’s advancing maturity, and with the need to adjust to new and different family structures.49 Ideally, the pediatrician will be able to maintain a professional relationship with both parents so as to continue to help them care for their children in a comfortable and positive manner.
Suggestions for Assisting Children and Families
Be alert to warning signs of dysfunctional marriage or coparenting relationships and impending separation. Consider inquiring orally or by written questionnaire about family changes or problems at each visit.
Discuss family functioning in anticipatory guidance and offer advice pertinent to divorce, as appropriate. Remind parents that what they do during and after a divorce is very important in terms of their child’s adjustment.
Always be the child’s advocate, offering support and age-appropriate advice to the child and parents regarding reactions to divorce, especially guilt, anger, sadness, and perceived loss of love. The child needs to be reassured that he or she did not cause the separation and cannot solve the problem.
Establish clear boundaries around divorce and define what role a pediatrician can play in divorce. Try to maintain positive relationships with both parents by not taking sides with 1 parent or the other. If there is concern for an ongoing or future abusive or neglectful situation, referral to child protective services is indicated. If a pediatrician is uncertain whether his or her statutory obligation to report has been met, discussion of the case-specific situation with a child-abuse pediatrician may be prudent. Encourage open discussion about separation and divorce with and between parents, emphasizing ways to help the child adjust to the situation and identifying appropriate reading materials.
Refer families to mental health and child-oriented resources with expertise in divorce if necessary.
Readings for Parents
Barnes RG. You’re Not My Daddy: Winning the Heart of Your Stepchild. Grand Rapids, MI: Zondervan Publishing House; 1997
Benedek EP, Brown CF. How to Help Your Child Overcome Your Divorce. Washington, DC: American Psychiatric Press; 1995
Davis RF, Borns NF. Solo Dad Survival Guide: Raising Your Kids on Your Own. Chicago, IL: Contemporary Books; 1999
Engber A, Klungness L. The Complete Single Mother: Reassuring Answers to Your Most Challenging Concerns. Holbrook, MA: Adams Media; 2000
Ricci I. Mom’s House, Dad’s House: A Complete Guide for Parents Who Are Separated, Divorced or Remarried. New York, NY: Simon & Schuster; 1997
Stahl PM. Parenting After Divorce: Resolving Conflicts. Atascadera, CA: Impact Publishers; 2007
Stoner KE. Divorce Without Court. Berkeley, CA: Nolo, Inc; 2006
Teyber E. Helping Children Cope With Divorce. New York, NY: John Wiley & Sons; 2001
Zero to Three. Talking to Very Young Children About Divorce. Washington, DC: Zero to Three; 2012. Available at: http://main.zerotothree.org/site/DocServer/ONE_PAGE_FINAL_5-14-12.pdf?docID=13461
Emery RE. The Truth About Children and Divorce. New York, NY: Viking-Penguin; 2004
Long N, Forehand R. Making Divorce Easier on Your Children. New York, NY: McGraw Hill; 2002
Readings for Children
Blume J. It’s Not the End of the World. Scarsdale, NY: Bradbury Press; 1972
Cole J. How Do I Feel About My Parents’ Divorce? Brookfield, CT: The Millbrook Press; 1998
Holyoke N. A Smart Girl’s Guide to Her Parents’ Divorce. Middleton, WI: American Girl Publishing Co; 2009
Lindsay JW. Do I Have A Daddy? Buena Park, CA: Morning Glory Express; 2000
Rogers F. Let’s Talk About It: Divorce. New York, NY: G.P. Putnam Sons; 1996
Rogers F. Let’s Talk About It: Step Families. New York, NY: G.P. Putnam Sons; 1997
George J. Cohen, MD, FAAP
Carol C. Weitzman, MD, FAAP
Committee on Psychosocial Aspects of Child and Family Health, 2015–2016
Michael Yogman, MD, FAAP, Chairperson
Nerissa Bauer, MD, MPH, FAAP
Thresia B. Gambon, MD, FAAP
Arthur Lavin, MD, FAAP
Keith M. Lemmon, MD, FAAP
Gerri Mattson, MD, FAAP
Jason Richard Rafferty, MD
Lawrence Sagin Wissow, MD, MPH, FAAP
Sharon Berry, PhD, LP – Society of Pediatric Psychology
Terry Carmichael, MSW – National Association of Social Workers
Ed Christophersen, PhD, FAAP – Society of Pediatric Psychology
Norah Johnson, PhD, RN, CPNP-BC – National Association of Pediatric Nurse Practitioners
Leonard Read Sulik, MD, FAAP – American Academy of Child and Adolescent Psychiatry
George J. Cohen, MD, FAAP
Stephanie Domain, MS
Section on Developmental and Behavioral Pediatrics Executive Committee, 2015–2016
Nathan J. Blum, MD, FAAP, Chairperson
Michelle M. Macias, MD, FAAP, Immediate Past Chairperson
Nerissa S. Bauer, MD, MPH, FAAP
Carolyn Bridgemohan, MD, FAAP
Edward Goldson, MD, FAAP
Laura J. McGuinn, MD, FAAP
Peter J. Smith, MD, MA, FAAP
Carol C. Weitzman, MD, FAAP
Stephen H. Contompasis, MD, FAAP, Web site Editor
Damon R. Korb, MD, FAAP, Discussion Board Moderator
Michael I. Reiff, MD, FAAP, Newsletter Editor
Robert G. Voigt, MD, FAAP, Program Chairperson
Pamela C. High, MD, MS, FAAP – Society for Developmental and Behavioral Pediatrics
Beth Ellen Davis, MD, MPH, FAAP – Council on Children With Disabilities
Linda Paul, MPH
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
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