Law of Child Custody

bundet

180 Child Custody Evaluation LANDSCAPE OF CHILD CUSTODY EVALUATION TODAY An important starting point is a consideration of the frequency with which the courts must make decisions about custody and placement of children. Although seemingly straightforward, this is more difﬁcult to determine than it appears. First, there is no uniform formula used to derive a “divorce rate,” making interpretation and comparison of data difﬁcult. The percentage of marriages that end in divorce for some cohorts in the United States, however, may be as high as 40%, and the rate of divorce has increased dramatically over the past 40 years, the divorce rate in the United States approximately doubled between 1960 and the end of the twentieth century (Hughes, 1996). Although the above statis- tics may be debated, what remains clear is that a substantial number of marriages end in divorce, a fair number of which have produced children (e.g., anywhere between 36% and 48% of married couples who divorce report having children in the family below the age of 18; Clark, 1995). Thus, family courts may be faced with issues of child custody in a large number of cases. But even with a high divorce rate among couples with children, the courts do not need to make decisions about child custody if the parties agree about what would be in the best interests of the children. Contrary to common perceptions about divorcing parents ﬁghting over their children, in the majority of cases, they do not litigate issues of custody. Maccoby and Mnookin (1988), in a study of California divorces, reported that 70% of divorcing parents had reached an agreement about the custody of their children. Similarly, McIntosh and Prinz (1993) reported that in only 14% of the 603 family divorce ﬁles they reviewed in a metropolitan South Carolina county was custody of the children disputed; agreements presumably were reached in over 85% of the cases. Although this indicates that child custody evaluations are not common, the current divorce rate in this country sug- gests that signiﬁcant numbers of child custody evaluations are being conducted for the courts. Of course, the above ﬁndings do not necessarily mean that the majority of parents agree about what is in their children’s best interests regarding matters of custody, only that they choose not to litigate such issues. Weitzman (1985) reported that 57% of the fathers she interviewed reported retrospec- tively that they had wanted physical custody of their children. Only 33% of this group reported that they mentioned this to their wife, and only 13% reported that they sought custody in the divorce petition. Similarly, about one-third of the fathers in Maccoby and Mnookin’s (1988) study reported that they would have liked to have been the primary residential parent, yet more than 50% of them reported not seeking custody. Consistent with the above, contemporary research sug- gests that, despite changing conceptions about parenting and sex roles, mothers almost always become the primary parent subsequent to divorce. Although there is some varia- tion as a function of children’s age and sex, according to U.S. Census data, 84% or more of children live primarily with their mother postdivorce (U.S. Bureau of the Census, 1989). Whether this reﬂects that mothers remain the pri- mary parents and caretakers of children despite changes in societal attitudes and thinking, that fathers perceive the legal system as biased toward women with respect to issues of custody and thus do not seek custody, or that the courts are truly biased with respect to issues of custody remains to be determined. The Family Bar’s Perception of Mental Health Professionals in Cases of Contested Custody Once the report comes out in your client’s favor all you have to do is convince the court that this evaluator is truly an expert whose recommendations must be followed or the well-being of the client will be imperiled. Then again, if the evaluation is against your client, it is all psychobabble, erroneous data, and dangerous conclusions and clearly the court should not abdicate its responsibility to do what is right for the children because of the temptation to follow the speciﬁc recommendations of this charlatan. (Oddenino, 1994, in an article written for attorneys about how to use custody evaluations to their clients’ advantage) Although mental health professionals are involved in con- tested custody cases with some frequency, a separate ques- tion is how valuable attorneys and judges ﬁnd their input. There is a small body of research that indicates that judges and attorneys consider the input and opinions of mental health professionals cautiously in cases of contested custody and they look to other sources of information to inform their decisions (Otto, Edens, & Barcus, 2000a). In a survey of 57 judges and 23 trial commissioners in- volved in family law cases, although custody evaluations were frequently cited as an efﬁcient means of collecting information about the family, “professional advice” ranked twelfth on a list of 20 potential custody decision-making cri- teria (Settle & Lowery, 1982). Similarly, in interviews with 13 family law judges presiding on the west coast of Florida, Kuehnle and Weiner (2000) reported that one of the most val- ued aspects of child custody evaluations was the independent information-gathering function that the experts served. Law of Child Custody 181 In a study of Virginia judges conducted by Melton, Weithorn, and Slobogin (1985), mental health testimony was endorsed as no more than occasionally useful in cases of contested custody. Felner, Rowlison, Farber, Primavera, and Bishop (1987) reported that only 20% of the attorneys and 2% of the judges they surveyed identiﬁed the recommenda- tions of a mental health professional as one of the ﬁve most critical pieces of information in terms of custody decision making. In a survey examining the value that family law judges placed on different sources of information when mak- ing decisions about custody and placement of children, the expert opinions of mental health professionals were rated as less signiﬁcant than the testimony of the parties and of the children themselves (Reidy, Silver, & Carlson, 1989). Thus, mental health professionals should enter the arena cautiously and with the understanding that although attorneys and judges may value their input, they are not beholden to it. LAW OF CHILD CUSTODY Legal Standards The starting point for child custody evaluations, as is the case with any forensic evaluation (Grisso, 1986), is the law. Be- cause decisions about children, their best interests, and their custody and placement are ultimately legal issues that are to be decided by legal decision makers (judges in most jurisdic- tions, but juries in others, e.g., Texas), psychologists and other mental health professionals who conduct custody eval- uations must know the law on which legal decision makers base their opinions. Only by knowing the law can mental health professionals assess those factors with which the court is most concerned. According to Common Law, children were considered chattel. In cases of divorce, like all chattel, their ownership and custody reverted to the father (Wyer, Gaylord, & Grove, 1987). The late nineteenth century, however, saw the de- velopment of the “tender years” doctrine, which held that mothers were considered uniquely qualiﬁed or better able to contribute to a child’s development. Thus, the law presumed that children’s best interests would be served by placement with their mother after divorce (Wyer et al., 1987). This pre- sumption, of course, could be overcome in particular cases (e.g., by showing that the mother was unﬁt in some way). The tender years doctrine controlled custody decision making until the 1960s, when signiﬁcant changes in family law occurred. With shifting conceptualizations of sex roles and movement to a “no fault” divorce law, sexist presump- tions of parental capacity were challenged. Because mothers were no longer considered better able than fathers to provide for their children’s development solely as a function of their sex, the tender years doctrine was abandoned for the “best interests of the child” standard, which has been adopted by all U.S. jurisdictions (Rohman, Sales, & Lou, 1987). Put most simply, the best interests standard dictates that decisions about custody and placement of children should be made in their best interests, as opposed to independent inter- ests that the parents or others may have. Anything more than a superﬁcial analysis, of course, makes clear that the best interests standard provides the legal decision maker and cus- tody evaluator with little direction regarding how a child’s interests are to be determined or what factors are to be con- sidered (Gould, 1998). As a result, the majority of states have attempted to operationalize and deﬁne the best interests stan- dard legislatively. Michigan’s 1970 Child Custody Act (see Table 11.1) has served as a model for many state legislatures in their attempts to identify factors that the legal decision maker and custody evaluator are to consider with respect to determining the child’s best interests. Child custody evaluators are provided with con- siderable guidance and direction by Michigan’s custody law and corresponding laws in other jurisdictions. A review of the Michigan law reveals that both psychological (e.g., “the mental… health of the competing parties; capacity and TABLE 11.1 Michigan Child Custody Statute Michigan’s child custody statute directs that custody evaluations are to be made “in the best interests of the children” and are to be based on: • The love, affection, and other emotional ties existing between the parties involved and the child. • The capacity and disposition of the parties involved to give the child love, affection, and guidance and continuation of educating and raising the child in his or her religion or creed, if any. • The capacity and disposition of the parties involved to provide the child with food, clothing, medical care, or other remedial care recognized and permitted under the laws of this state in lieu of medical care, and other material needs. • The length of time the child has lived in a stable, satisfactory environment and the desirability of maintaining continuity. • The permanence, as a family unit, of the existing or proposed custodial home. • The moral ﬁtness of the parties involved. • The mental and physical health of the parties involved. • The home, school, and community record of the child. • The reasonable preferences of the child, if the court deems the child to be of sufﬁcient age to express preference. • The willingness and ability of each of the parents to facilitate and encourage a close and continuing parent-child relationship between the child and the other parent. • Any other factor considered by the court to be relevant to a particular child custody dispute. Source: Michigan Child Custody Act of 1970, 1993 amended. 182 Child Custody Evaluation disposition of the competing parties to provide love, affection, guidance, continuance of education, and continued religious education” and nonpsychological factors (e.g., “moral ﬁtness of the competing parties”) are to be considered by the court, as well as case-speciﬁc factors not anticipated by the legislature (i.e., “any other issues considered by the court to be relevant to a particular child custody suit”). Although how the child’s best interests are operationalized varies from state to state, Schutz, Dixon, Lindenberger, and Ruther (1989) found signif- icant consistencies in their review of state custody statutes (see Table 11.2). Of course, the child custody examiner must be familiar with the speciﬁc law in the jurisdiction in which he or she practices. Although the legislatures’ attempts to operationalize the best interests standards provide custody evaluators and legal decision makers with some direction, how decisions are to be made remains unclear. Perhaps most signiﬁcant is that the relative importance of the statutorily identiﬁed factors, or the weight they are to be given when considering custody and placement of children, go unstated. This probably reﬂects an acknowledgment by legal and mental health professionals alike that questions of custody and what is in the best inter- ests of children may vary dramatically from case to case. Another important legal issue central to the custody decision-making process is the deﬁnition of and distinction between different types of custody (Schutz et al., 1989). More speciﬁcally, state law typically makes reference to and distin- guishes between decision-making authority for the children (referred to as legal custody or parental responsibility in some jurisdictions) and the issue of physical placement or residence of the children (referred to as residential or physical custody in some jurisdictions). The courts, therefore, must make rul- ings not only about the living arrangements and visitation schedule for the children postdivorce, but also about who will be involved in making decisions about them. The court also can mix these decisions. For example, it is not uncommon for courts to grant one parent physical custody of the children (with regular visitation) and both parents legal decision- making authority for the children (i.e., joint legal custody). Legal Presumptions Not only does the law in a speciﬁc jurisdiction identify on which factors decisions about placement and custody of a child should be based, but the law also reﬂects many pre- sumptions about custody and placement of children. These legal presumptions identify what the law assumes to be in the best interests of children in cases of contested custody. These presumptions, however, can be overcome or abandoned in a particular case with a showing of cause. Sex and Parenting Capacity The legal presumption that women are better able to meet the needs of children (i.e., the tender years doctrine) has been abandoned essentially by all jurisdictions and replaced by the best interests of the child standard (Schutz et al., 1989; see above for further discussion). Thus, judges are to make no presumptions about parenting ability and sex. However, many in the ﬁeld offer anecdotal accounts of mental health professionals and members of the bar who, although they ac- knowledge that the best interests standard controls, act as if the tender years doctrine remains in place, at least insofar as they appear to hold personal beliefs that women, as a function of being women, are better parents than men. Moreover, data indicating that the large majority of children reside primarily with their mother postdivorce (U.S. Bureau of the Census, 1989; see above for further discussion) also raise questions about whether societal attitudes, behavior, and roles are con- gruent with legal presumptions. Custody Arrangements In some jurisdictions, legal presumptions are in place regard- ing what kinds of custody arrangements are in the best TABLE 11.2 Consensus Child Custody Decision-Making Criteria Included below are criteria appearing consistently in states’ custody statutes. Children: Age and sex. Adjustment to current and prior environments, including the length of time in each. History of child abuse/victimization. Educational needs. Special mental health or medical care. Wishes or desires regarding placement, if of sufﬁcient age. Separation of siblings. Parents: History of spouse abuse. Economic status and stability. Wishes and desires regarding placement and custody. Mental and physical health. Substance abuse. Level of hostility. Flexibility. Parenting skills. Caretaking involvement before and after separation. Likelihood that parent would remove children from the jurisdiction. Likelihood that parent would alienate the affections of the children. Other Factors: Religion. Prior custody determinations. Agreements between the parents. Source: Adapted from Schutz et al. (1989). Child Custody Evaluation Practice Guidelines and Standards 183 interests of children. This is important for the child custody examiner to realize because the legal presumptions for the varying types of custody may differ. For example, some state laws presume that it is in the best interests of children to have one primary residence rather than live equal or essentially equal periods of time with each parent. In contrast, with re- spect to the issue of parental responsibility or legal custody, some state laws direct that it is in children’s best interests to have both parents involved in making decisions about them (e.g., regarding their education, religious training, health care needs; Florida Statutes 61.13(2)(b)2, 2000). Although any legal presumptions can be overcome, it is important that child custody examiners be aware of the legal presump- tions in their jurisdiction because they serve as starting points from which the legal decision maker will consider a particular case. Placement of Siblings The law in many jurisdictions makes reference to how deci- sions regarding placement of siblings should be made. For example, in some states, it is presumed that it is in the best in- terests of siblings to live in the same household, as opposed to splitting siblings between parents in a Solomon-like solu- tion. Thus, in cases of disputed custody, the legal decision maker is likely to start from this perspective, but a decision that “splits” siblings may follow if the decision maker is con- vinced in a particular case that placement of the siblings in different households would be in their best interests. Sexual Orientation There is less consistency regarding how states treat parents’ sexual orientation as it relates to the children’s best interests and decision making regarding custody. Perhaps just as im- portant as the formal law is the attitude of judges and at- torneys who are involved in child custody cases. It will be important, of course, for the examiner to be familiar with the legal presumption regarding parents’ sexual orientation and describe for the court how the child might be affected by each parent’s sexual orientation, as well as the literature regarding sexual orientation and parenting (see, e.g., American Psycho- logical Association, 1995; Falk, 1989; Patterson, 1995). CHILD CUSTODY EVALUATION PRACTICE GUIDELINES AND STANDARDS As described above, the mental health professional’s child custody evaluation will, in part, be informed by the law controlling child custody decision making in the jurisdiction in which he or she practices. The child custody evaluation process, however, is also shaped by relevant practice guide- lines and standards. To date, three national organizations have promulgated custody evaluation guidelines, all of which attempt to identify a standard for child custody evaluation and provide the examiner with some direction regarding evaluation process. Although some state psychological asso- ciations have developed child custody evaluation guidelines, we do not discuss them here. Guidelines for Child Custody Evaluations in Divorce Proceedings (American Psychological Association [APA], 1994) In 1994, APA published guidelines for psychologists con- ducting child custody evaluations that focus less on the sub- stantive nature of such evaluations and more on the format and process of the evaluation (e.g., the goal of the evalua- tion; the role and orientation of the examiner; the com- petence and ability of the examiner; and procedural matters related to conﬁdentiality, informed consent, record keeping, ﬁnancial arrangements, and use and interpretation of data). It is difﬁcult to disagree with any of the guidelines adopted by the APA. As such, the guidelines are not objectionable, but they do not provide much direction in terms of the substantive areas of inquiry. Because of their basic nature, failure to perform one’s duties in a manner consistent with the guidelines is quite likely to constitute substandard practice. Model Standards of Practice for Child Custody Evaluations (Association of Family and Conciliation Courts [AFCC], undated) The AFCC is an interdisciplinary group of attorneys, judges, and mental health professionals interested in matters of family law and child custody. Although psychologists who are not AFCC members cannot necessarily be held to the organization’s standards, psychologists conducting child custody evaluations should, nonetheless, be familiar with them. Like the APA evaluation guidelines, the AFCC guidelines offer direction to the evaluator regarding role deﬁnition, structuring the evaluation process, and competence. They are, however, more substantive than the APA guidelines in that they identify areas of inquiry in the evaluation process (e.g., quality of the relationships between parents and child; quality of the relationships between parents; domestic vio- lence history; psychological adjustment of parents). As such, 184 Child Custody Evaluation the AFCC guidelines provide more direction to the custody evaluator, as they focus not only on the process of the evalu- ation but also on its substance. Practice Parameters of Child Custody Evaluation (American Academy of Child and Adolescent Psychiatry [AACAP], 1997) The most recently developed custody evaluation guidelines were developed by the AACAP. These AACAP guidelines include sections devoted to both the process and substance of the evaluation and are the most detailed of any that currently exist. Not only do the guidelines identify areas of inquiry for the examiner to address, they also identify evaluation tech- niques and discuss some special topics (e.g., parents’ sexual orientation; grandparents’ rights; child sexual abuse allega- tions; reproductive technology issues). Although the guidelines are informative and provide the examiner with considerable direction, they suffer from nu- merous shortcomings. They are overly broad in some sec- tions (e.g., offering generic recommendations about report writing) and overly detailed in others (e.g., offering sugges- tions about how examiners should dress and present them- selves when appearing in court). The AACAP guidelines also offer poor practice recommendations in relation to some issues. For example, it is recommended that examiners refuse to listen to tape recordings, whereas no such prohibi- tion is offered for similar kinds of materials (e.g., videos, journals, other documents that may be produced by the par- ties). Although examiners should be sensitive to evidentiary issues when considering what types of third-party infor- mation they review (see below for further discussion), a wholesale recommendation against reviewing one type of information that may be of value in some cases while failing to identify limitations of or problems with similar types of information reveals a weakness of the AACAP guidelines. Finally, some sections appear to be shaped more by guild concerns than matters related to professional practice. For example, the AACAP guidelines describe psychological testing as of little help in custody evaluations, in part, be- cause parental psychopathology is not the primary issue be- fore the decision maker and introduction of psychological test data results in a “battle of the experts.” Although there is some basis for the discussion of the limitations of psy- chological testing, singling out such data as the only type of information that may be interpreted differently by opposing experts is, at the very least, unusual and demonstrates that such publications are, to some extent, political documents. Moreover, the naïveté of the apparent assumption that all psychological tests are pathology-focused also reveals a limitation of the guidelines. THE CHILD CUSTODY EVALUATION PROCESS As described above, child custody evaluations are involved and time-intensive procedures. Ackerman and Ackerman (1997) surveyed 200 psychologists who conducted custody evaluations on a regular basis. The mean length of time per evaluation was reported to be 26.4 hours, including such ac- tivities as administering psychological tests (a mean of 5.2 hours per evaluation), interviewing parents (4.7 hours per evaluation), interviewing children (2.7 hours per evaluation), interviewing signiﬁcant others (1.6 hours per evaluation), re- viewing records (2.6 hours per evaluation), report writing (5.3 hours per evaluation), and testifying (2.2 hours per eval- uation). Similarly, Bow and Francella (2001) performed a national survey of 198 psychologists and found highly con- sistent results. In general, the time spent per evaluation was quite similar, but the distribution of time spent per method of assessment varied somewhat (e.g., time spent interviewing parents increased to more than 7.0 hours and report writing increased to 7.3 hours per evaluation). That custody evaluations are intensive should not be sur- prising when the task is considered in some detail. Jameson, Ehrenberg, and Hunter (1997) surveyed 78 psychologists in western Canada who conducted child custody evaluations and had them rate the signiﬁcance of 60 custody decision- making criteria culled from legal and psychological author- ities. A factor analysis of the psychologists’ responses revealed three major factors around which decisions regard- ing custody hinge in the opinions of psychologists: interper- sonal relationships (including both parent-child relationships and parent-parent relationships); the parents’ understanding of and sensitivity to the children and their needs; and the par- ents’ ability to meet their children’s needs as determined by their emotional stability, history of parenting, and parenting skills and knowledge. Thus, in a custody evaluation, it is the examiner’s responsibility to describe for the court the chil- dren, their adjustment and needs; the parents (and potentially others, such as stepparents), their adjustment, their parent- ing abilities, and their understanding of and relationships with their children; and the likely outcomes of proposed custody arrangements (for a discussion of whether psycholo- gists should offer an “ultimate opinion” on custody, see Martindale & Otto, 2000; for a discussion of this issue more generally, see Melton, Petrila, Poythress, & Slobogin, 1997). Moreover, the custody examiner must access any and all information relevant to understanding these issues. Appointment, Notiﬁcation, and Consent Although it is not a violation of any ethics code or custody guidelines to conduct a custody evaluation while retained by The Child Custody Evaluation Process 185 one party (i.e., either the mother or father), it is agreed gener- ally that child custody evaluations ideally are performed when all parties agree on the examiner and have him or her appointed by the court to conduct the evaluation (Ackerman & Ackerman, 1997; Gould, 1998; Martindale & Otto, 2000; Otto, 2000; Stahl, 1994). In contrast to each party retaining an expert to conduct an independent evaluation, court ap- pointment of one expert reduces overall costs and time of the evaluation process and minimizes opportunity for bias and forensic identiﬁcation (see Otto, 1989, or Zusman & Simon, 1983, for further discussion of this issue). Court appoint- ment also increases the parties’ comfort with the evaluation process and reinforces the perception that the examiner is an impartial expert. Moreover, in some jurisdictions, court ap- pointment may afford the custody examiner some protection from malpractice claims. Except in the case of pro se litigants, examiners should have preliminary discussions regarding the case with the attorney representing each party (see Table 11.3). The exam- iner should make clear to the attorneys his or her qualiﬁca- tions, evaluation process, fees and payment procedures, and requirements for court appointment. Ideally, the examiner will have a model appointment order from which the attor- neys can draft an order for the judge to review and sign. Once appointed by the court, the examiner should seek from the attorneys any third-party information that they be- lieve is relevant to the issues in the case. This may include legal documents (e.g., court orders and injunctions related to the case; arrest reports; depositions of knowledgeable per- sons, including the parties); ﬁnancial documents; and mental health, medical, school, and employment records. Although opinion varies regarding whether it is best to review such records prior to or after interviewing the parties, all agree that access to third-party information is crucial in such cases (also see following). The ﬁnal preliminary task is to inform the parents about the evaluation process—a particularly important aspect of the evaluation that unfortunately is neglected by many evalua- tors. The parents should be informed about the examiner’s role, the nontherapeutic nature of their contact with the ex- aminer, the absence of conﬁdentiality and privilege, fees and likely costs of the evaluation, the nature of the evaluation process (i.e., the extent of interviewing and testing that may be required), how long it will take to complete the evaluation, and how feedback will be provided (e.g., in the form of a re- port and/or testimony). Of course, any questions the parents have should be answered. Taking the time to fully inform parents about the evaluation process may increase their par- ticipation and cooperation because they will know what is ex- pected of them. Parents who express concern about or refuse to comply with some aspects of the evaluation after discus- sion with the examiner should be directed to their attorneys because it is the examiner, not the parties or their representa- tives, who ultimately decides the shape and direction the evaluation takes. Examiners also should consider obtaining assent from the children who are to be evaluated. In language they can un- derstand, children should be informed about the examiner’s role, the purpose of the evaluation, and how the information will be used. The Clinical Evaluation As described above, the custody examiner will assess various issues with a particular family, and this requires a far-ranging inquiry and assessment of each parent, the children, informed third parties and, in some cases, signiﬁcant others (e.g., potential stepparents, potential stepsiblings, grandparents). Information is gained via clinical interviews with the parties, interviewing of informed third parties (e.g., teachers, baby- sitters, neighbors), and administration of psychological tests (see Tables 11.4 and 11.5). Evaluation of the Parents With each parent, examiners may consider starting with an abbreviated social history. In addition to providing some in- formation that may be of relevance to the court, starting the discussion by obtaining information that is likely to be less threatening may help in establishing rapport and alleviat- ing the parties’ anxiety. Factors addressed in the social his- tory that may be of relevance include educational history (e.g., history of poor academic achievement, which may indi- cate that the parent will have difﬁculty assisting the child in meeting academic goals); employment history (e.g., involve- ment in a career that has limited or may interfere with the TABLE 11.3 Appointment, Notiﬁcation, and Consent Preliminary Issues Except in pro se cases, have preliminary discussions with attorneys representing the parties. Make qualiﬁcations and evaluation approach known to all parties. Seek appointment via court order. Provide a model or draft order to the attorneys for review. Postcourt Appointment Request relevant third-party documents from the parties. Notify parents of: Role. Nontherapeutic nature of contact. Absence of conﬁdentiality and privilege. Fees and costs. What the evaluation will entail. Length of time the evaluation will take. Notify children of nature and purpose of the evaluation using age-appropriate language and concepts. 186 Child Custody Evaluation TABLE 11.4 Clinical Inquiry in Child Custody Evaluation: Parents Social history: Family history. Educational and occupational history. Medical history. Mental health and substance use history. Legal history. Parent’s description of marital relationship and family structure. Parent’s attitude and concerns regarding the other parent, his or her access to the children, nature of visitation, etc.: Discussion with children about the separation and divorce. Parent’s communications with the children about the other parent. Evidenced hostility. Ability and willingness to foster the other parent’s contact with the children. Parent’s goals for visitation and decision making should he or she be awarded primary residence. Parent’s prior and current relationship with the children and responsibility for care taking: Reaction to pregnancy and childbirth, and impact of these on relationship and functioning outside the family. Early caretaking. Current caretaking. Punishment/discipline. Leisure and social activities. Interactional style. Allegations of abuse/neglect. Parent’s prior, current, and anticipated living and working arrangements: Who is living in the home. Signiﬁcant others. Daycare, baby-sitting. Schools and school districts. Parent’s emotional functioning and mental health: Prior or current substance abuse/dependence and treatment. Prior or current mental health problems and treatment. Emotional response to the divorce. TABLE 11.5 Clinical Inquiry in Child Custody Evaluation: Children Child’s attitude and preference regarding parents, current living arrangement, visitation, and future placement. Child’s depictions and conceptualization of relationship with each parent: Punishment/discipline. Leisure and social activities. Interactional style. Allegations of abuse/neglect. Child’s emotional functioning and mental health: Prior or current substance abuse/dependence and treatment. Prior or current mental health problems and treatment. Emotional or behavioral responses (i.e., problem behaviors) to the separation/divorce. Child’s prior and current social, academic, and vocational functioning. parent’s ability to parent the children); medical history (e.g., health conditions that limit parenting ability); and mental health history (e.g., psychiatric conditions that may impact a parent’s ability to parent). The development and progression of the marital relation- ship should receive considerable attention. For purposes of organizing this inquiry, it may be most helpful to conceptual- ize three phases of the marital relationship: (a) the period the couple was together but without children; (b) the phase dur- ing which the couple was together and caring for the chil- dren; and © the period postseparation. By focusing on the time when the marriage presumably was more harmonious and the couple was focused on caring for the children, the examiner can begin to understand the parenting abilities, parenting histories, behavioral patterns, and emotional func- tioning of each party. The separation period may be seen as an interim “pilot” phase during which each parent begins to anticipate and adjust to a new life (e.g., as a stay-at-home mother returns to the conventional workforce and attempts to meet the responsibilities of parenting, or as a parent who his- torically worked 80 hours per week attempts to restructure a work schedule that allows assumption of more parental re- sponsibility). How the parents interact with each other re- garding issues of parenting, visitation, and blameworthiness for the divorce during the separation period will provide some insight into how they might be expected to act around these issues in the future. Custody examiners should keep in mind, however, that they are assessing the parties at one of the most emotionally taxing phases of their lives, and their adjustment at the time of the evaluation may not reﬂect what their adjustment will be over time (Schutz et al., 1989). Crucial to interviewing the parents is assessing their rela- tionships with their children. It is important that the parents describe for the examiner their perceptions of their children, both in terms of their response to the separation and impend- ing divorce, as well as over time and in more general terms. How each parent perceives the children and their needs, and how they have attempted to meet those needs, both in the past and during the separation process, is germane to under- standing how the parents may interact with their children postdivorce. Observation of parent-child interactions often provides insight into the nature of their relationships, the par- ent’s feelings about the child, the parent’s knowledge of and ability to interact with the child, and the child’s feelings about the parent (see below). The examiner should obtain from each party a rich descrip- tion of the custody arrangement he or she proposes. First, the examiner should gain a comprehensive understanding of the school or day care arrangements, the place of residence, baby- sitting arrangements, and work schedules that are included in each parent’s proposal. The examiner must then assess how similar this is to what has occurred in the past (either during the course of the marriage or following separation), whether the parent has had to make any changes to accommodate such arrangements during the separation period, and whether he or she will be able to make changes subsequent to the divorce. For example, although a neurosurgeon may propose that he The Child Custody Evaluation Process 187 will cut back his 80-hour work week to 30 hours to be awarded primary residential placement, a failure on his part to make necessary changes related to his work schedule and res- idence (or a failure to consider factors such as the fact that placement with him will require a change in the children’s school or day care) is problematic. In addition to requesting relevant third-party informa- tion from each attorney, the examiner also should make this offer/request to each parent. In addition to potentially pro- viding the examiner with valuable sources of third-party in- formation of which the attorney may be unaware (e.g., records, informants), this practice allows each parent to be fully heard. Of course, examiners must employ their pro- fessional judgment and discretion in some circumstances (Gould, 1998) and ultimately decide what sources of in- formation they will consider (e.g., when presented with potentially inadmissible evidence; when provided a list of third-party contacts whose reported opinions are irrelevant to the issues in the case). Finally, the examiner should ensure that the parties have an opportunity to identify issues that they believe to be of impor- tance, including concerns they may have about the other par- ent. In response, each parent should be confronted with and provided an opportunity to respond to concerns or allegations that were made about him or her by the spouse or others. Evaluation of the Children The nature and extent of interactions with children vary con- siderably depending on their age. With younger children (in- fants through 3 years), the examiner may simply choose to observe parent-child interactions (see below). With older children (ages 4 to 11), the interview primarily will be aimed at understanding their adjustment and “world” both prior and subsequent to their parents’ separation. Children 11 and older should be able to provide an accurate depiction of their life and preferences, and also provide information helpful to un- derstanding the family and their parents. Regardless of their age, the examiner should focus on learning more about the children (pre- and postseparation) in three separate but related areas: (a) their relationships and in- teractions with parents, (b) their emotional and behavioral adjustment and functioning, and © their involvement and adjustment to outside activities, including school and after- school activities. As the examiner understands the child, he or she can then draw some conclusions regarding the parents’ understanding of their children’s needs, and their abilities to meet those needs. Moreover, in addition to providing impor- tant information regarding their own adjustment and their relationships with their parents, even young children can sometimes provide information that helps the examiner better understand the parents and their interactions with their chil- dren (Gould, 1998). Opinions vary regarding the appropriateness of asking children their preferences regarding custody (Rohman et al., 1987; Stahl, 1994), but there is near unanimous agreement that younger children should not be asked such questions. A recommended alternative is to query the children regarding the good things and bad things about time with each parent, although this too may have implications for younger chil- dren, particularly when queried postinterview by an over- interested parent. An overriding concern among custody evaluators is that of rehearsed children who have been prepared by a parent to offer a particular storyline. Any time a child volunteers a preference regarding a living arrangement, more important than knowing the child’s stated preference is knowing and understanding the underlying reasoning. Careful questioning of younger children may reveal preparation or rehearsed an- swers (e.g., “Is there anything that your mom or dad told you it was really important to let me know?”). Perhaps most im- portant for the examiner to know and communicate to the child is that, absent unusual conditions (i.e., local legal cus- tom or a judicial decision in a particular case), any informa- tion conveyed by the child to the examiner may be revealed to the court (and to parents). Direct Observation It generally is agreed that interviewing the children with each parent and observing the parent and children engaging in some type of structured or unstructured activity serves to de- crease initial anxiety the children may have about the evalua- tion process and provides helpful information regarding parent-child interactions and the relationship more generally. Examiners should be careful, however, to ensure that each parent is provided similar opportunities with the children, and they must remain aware that such interactions can be af- fected by a number of extrarelationship factors. Thus, obser- vation of the parent and children on more than one occasion may prove helpful. Authorities differ with respect to their recommendations regarding observations of and visits with the parent and chil- dren in the home setting. Possible beneﬁts of a home visit in- clude that it allows for more naturalistic observation of the family and provides an opportunity to consider the parent’s ability to establish a positive and safe home environment. Additionally, younger children may be more comfortable talking about themselves and their family, and may be more likely to do so, in an environment more familiar than the 188 Child Custody Evaluation examiner’s ofﬁce and with stimuli readily available to foster discussion and description (Gould, 1998; Stahl, 1994). Downsides to home visits include their potential costs, as such visits will require a considerable number of hours on the examiner’s part when travel and observation are consid- ered. Schutz et al. (1989) provide direction to examiners considering home visits in the context of child custody evaluations. Use of Psychological Testing in Child Custody Evaluation Although surveys indicate that use of psychological testing in child custody evaluations is common (at least among psy- chologists; see below for a summary of this research, as well as Otto et al., 2000b), the utility of testing in this context has been questioned by a number of commentators. Many of the psychological tests used by child custody evaluators have been criticized on the grounds that they do not assess con- structs or issues most relevant to the child custody question, such as parenting ability, the nature and quality of the parent- child relationship, and the willingness of each parent to facil- itate a close relationship with the other parent (Bricklin, 1994, 1995, 1999; Brodzinsky, 1993). Indeed, use of psycho- logical measures that assess general constructs such as intel- ligence, psychopathology, or academic achievement requires the evaluator, at a minimum, to make an inference from the global construct assessed to a more speciﬁc behavior or ca- pacity that is relevant to child custody questions (e.g., ability to meet the child’s emotional and behavioral needs). Grisso (1984, cited in Melton et al., 1997) offered a cogent summary of the problem: Too often we rely on assessment instruments and methods that were designed to address clinical questions, questions of psychi- atric diagnosis, when clinical questions bear only secondarily upon real issues in many child custody cases. Psychiatric inter- views, Rorschachs, and MMPIs might have a role to play in child custody assessment. But these tools were not designed to assess parents’ relationships to children, nor to assess parents’ child- rearing attitudes and capacities, and these are often the central questions in child custody cases. (p. 484; emphasis in original) Other evaluation tools and methods purported to assess constructs more speciﬁc to custody questions have been criti- cized on the grounds that they do not comport with basic ethical, scientiﬁc, and practice requirements under which psy- chologists and other mental health professionals must operate (see Heinze & Grisso, 1996; Otto et al., 2000b; and below). In a recent handbook on family law, judges were warned, “We . . . believe that judges should be wary of a recent trend to make use of supposedly scientiﬁc tests claimed to distin- guish between potential custodians” (National Interdisci- plinary Colloquium on Child Custody [NICCC], 1998, pp. 321–322). Moreover, all three sets of professional cus- tody evaluation guidelines (see above) offer cautions regard- ing the use of psychological testing in the evaluation process. A number of assessment techniques are used in the context of a child custody evaluation, all of which can be placed into one of three broad categories: (a) clinical assessment instru- ments, (b) forensically relevant instruments, and © forensic assessment instruments (see Heilbrun, Rogers, & Otto, in press). The appropriateness of using and relying on results of a psychological test in a child custody evaluation will depend on a number of test- and case-speciﬁc factors. Based on their review of the APA Ethical Principles and Code of Conduct (1992), the Standards for Educational and Psycho- logical Testing (American Educational Research Association, American Psychological Association, National Council on Measurement in Education, 1999), and Heilbrun’s (1992) guidelines for considering use of psychological tests in foren- sic evaluations, Otto et al. (2000b) offered a template con- sisting of a number of questions forensic examiners should ask themselves when considering using a psychological test or assessment measure in the context of a custody evaluation (see Table 11.6). Clinical assessment instruments measure general psycho- logical constructs (e.g., psychopathology, intelligence, acade- mic achievement, personality), were developed for therapeutic applications, and most typically are used in nonforensic set- tings. If the examiner believes that these tests validly assess general constructs that are relevant to decisions revolving around child custody, then their use in these evaluations is ap- propriate. For example, in those jurisdictions where emotional stability of the parties is one factor to be considered in making decisions about the custody and placement of children, use of the Minnesota Multiphasic Personality Inventory 2 (MMPI-2; TABLE 11.6 Considering Use of Tests in Child Custody Evaluations Is the test commercially published? Is a comprehensive test manual available? Are adequate levels of reliability demonstrated? Have adequate levels of validity been demonstrated? Is the test valid for the purpose for which it will be used? Has the instrument been peer-reviewed? Do I possess the qualiﬁcations necessary to use this instrument? Does the test require an unacceptable level of inference from the construct it assesses to the psycholegal question(s) of relevance? Source: Adapted from Otto et al. (2000b). The Child Custody Evaluation Process 189 Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1994) to assess psychopathology and emotional stability as it may be related to parenting is appropriate. Similarly, if an examiner uses the Parenting Stress Index (PSI; Abidin, 1995) to assess how interactions with the child affect the parent, this too would appear to be appropriate use of a validated clinical as- sessment instrument for purposes of a custody evaluation. Forensically relevant instruments are assessment tech- niques that evaluate constructs or issues that most typically arise in the course of forensic evaluations, but are not limited to forensic assessments. Tests of defensiveness, malingering, and psychopathy [e.g., Paulhus Deception Scales (Paulhus, 1999), Crown-Marlowe Scales (Crown & Marlowe, 1960), Structured Interview of Reported Symptoms (Rogers, Bagby, & Dickens, 1992), Test of Memory Malingering (Tombaugh, 1996), Psychopathy Checklist–Revised (Hare, 1991)] are ex- amples of such instruments. Perhaps with the exception of measures of general defensiveness (for an example, see Paulhus, 1999, for a description of the Paulhus Deception Scales), forensically relevant instruments are unlikely to prove helpful in the large majority of child custody evaluations. Forensic assessment instruments (FAIs) are developed speciﬁcally for application in forensic settings. Their purpose is to assess constructs relevant to particular legal issues. Rogers and Webster (1989) observed that in many forensic evaluation contexts, the best validated tests and assessment instruments are general clinical tests, which are least relevant to the psycholegal questions the courts look to mental health professionals for assistance in answering (i.e., the constructs assessed by the best-validated, traditional clinical measures are not directly related to the legal issue at hand). This obser- vation applies in the child custody evaluation context, in which the general clinical assessment instruments that are used typically have better validity data than existing child custody evaluation measures. The constructs they assess (e.g., psychopathology, intelligence, academic achievement, normal personality) are not directly legally relevant, although they may provide useful information nonetheless. At the current time, there are a number of child custody evaluation instruments that are proffered by their authors as assessing constructs directly relevant to child custody decision making: the Bricklin Perceptual Scales (BPS; Bricklin, 1990a; Bricklin & Elliott, 1997), the Perception of Relationships Test (PORT; Bricklin, 1989), the Parent Per- ception of Child Proﬁle (Bricklin & Elliott, 1991), the Parent Awareness Skills Survey (PASS; Bricklin, 1990b), the Cus- tody Quotient (Gordon & Peek, 1989), and the Ackerman- Schoendorf Parent Evaluation of Custody Test (ASPECT; Ackerman & Schoendorf, 1992). Other instruments, such as the Uniform Child Custody Evaluation System (UCCES; Munsinger & Karlson, 1994), which is intended for use in data collection in custody evaluations, are better described as structured clinical approaches to child custody assessment and, thus, are not discussed here. Integrating these tests into the assessment process may be appealing to mental health professionals and the judiciary because, unlike general clini- cal assessment instruments, they ostensibly address the spe- ciﬁc questions involved in forming an opinion in a custody case, such as “Does the parent have adequate parenting skills?” or “With which parent is the child most bonded?” Such questions are not easily answered by making inferences from results of standard measures of psychopathology, intel- ligence, and personality. However, essentially all of the FAIs developed for use in child custody evaluation have been sub- jected to signiﬁcant criticism. In their review of the above in- struments, Otto et al. (2000b) recommended that none of these assessment techniques be employed by child custody evaluators, given their signiﬁcant psychometric and concep- tual limitations. (The interested reader is directed to re- views of these FAIs by Arditti, 1995; Bischoff, 1992, 1995; Carlson, 1995; Cole, 1995; Conger, 1995; Fabry & Bischoff, 1992; Hagin, 1992; Heinze & Grisso, 1996; Hiltonsmith, 1995; Kelley, 1995; Melton, 1995; Melton et al., 1997; Shaffer, 1992; Wellman, 1994.) Although a number of researchers (see below) have inves- tigated child custody evaluators’ general assessment prac- tices and their use of tests more speciﬁcally, it is unclear how accurately these results depict current practice. All of the surveys to date have been based on the self-report of practi- tioners, have been conducted using small samples, and have oversampled psychologists. Thus, the studies described below may overestimate the use and signiﬁcance of psycho- logical tests in custody evaluations. In the ﬁrst published study of custody evaluation practices, Keilin and Bloom (1986) surveyed a national sample of psy- chologists, psychiatrists, and master’s-level practitioners. Of the 82 surveys that provided usable data, 78% were completed by doctoral-level psychologists, 18% were completed by psy- chiatrists, and 4% were completed by master’s-level practi- tioners. No single measure was used by a majority of the respondents when assessing children. Intelligence tests were the instruments most frequently employed by the examiners, with 45% of respondents using some measure of intelligence in the majority (85%) of their cases. The next most frequently used measure was the ThematicApperception Test (TAT; Mur- ray & Bellak, 1973) or the Children’sApperception Test (CAT; Bellak & Bellak, 1992); 39% of the respondents reported using these measures in most (75%) of their evaluations. The 190 Child Custody Evaluation next three most commonly used assessment techniques with children were miscellaneous projective drawings, the Rorschach Inkblot Technique (Rorschach, 1942), and the Bender Visual Motor Gestalt Test (Bender, 1946). Respondents identiﬁed the MMPI (Hathaway & McKinley, 1989) as the most commonly used assessment technique with adults; 70% of the evaluators reported using this instru- ment in child custody evaluations, and those who used it em- ployed it in almost all (88%) of their cases. The next most commonly used instruments were the Rorschach Inkblot Technique (42%) and the TAT (38%), and evaluators who em- ployed these instruments reported using them in a majority of their cases. Measures of adult intelligence also occasionally were employed, with the Wechsler Adult Intelligence Scale (WAIS; Wechsler & Stone, 1955) being used by 29% of the re- spondents. Those who used the WAIS reported employing it in a majority (67%) of the cases. Ackerman and Ackerman (1997) replicated the Keilin and Bloom (1986) survey to obtain a more current picture of the child custody evaluation process. In the 10-year interim between these two surveys, a number of new or revised stan- dard psychological measures were developed (e.g., MMPI-2, WAIS-III; Wechsler, 1997), as were several of the instru- ments speciﬁcally designed for application in cases of child custody noted earlier. Of the 800 questionnaires mailed to psychologists identiﬁed by various psychological and legal associations as conducting child custody evaluations, 201 us- able protocols were returned by doctoral-level psychologists. Intelligence tests and projective measures were the instru- ments most frequently used with children, consistent with the ﬁndings of Keilin and Bloom (1986). Fifty-eight percent of the respondents reported using intelligence tests in their eval- uations, and those using them reported employing them in about half (45%) of their evaluations. Thirty-seven percent reported using either the CAT or the TAT (in 53% of their evaluations). Also consistent with the earlier ﬁndings of Keilin and Bloom were the respondents’ reports of how they assessed adults. The MMPI/MMPI-2 remained the most fre- quently used assessment instrument: 92% of the psycholo- gists reported using a version of this test in the large majority (91%) of their evaluations. The Rorschach Inkblot Technique remained the second most frequently used test with adults; 48% of the respondents indicated they used the test in the con- text of custody evaluations, and those who used it did so in over half (64%) of their cases. The next most frequently used tests were the revised WAIS (Wechsler, 1981) and the Millon Clinical Multiaxial Inventory (MCMI-II/MCMI-III; Millon, 1987, 1994), with 43% and 34% of the examiners reporting using these tests in their custody evaluations, respectively. Over one-third of the respondents (35%) reported using the BPS (Bricklin, 1990a), one of the better-known forensic assessment instruments designed for use in child custody evaluations. On average, those examiners using the BPS re- lied on it in a majority (66%) of their evaluations. Respon- dents (16%) also reported use of the PORT (Bricklin, 1989), with those using it reporting that it was employed in a majority (64%) of cases. Fewer of the respondents reported using speciﬁc custody measures designed for use with families or adults. Only 11% of the psychologists reported using the ASPECT (Ackerman & Schoendorf, 1992), but those who used it did so in essen- tially all (89%) cases. The only other custody-speciﬁc mea- sures endorsed were the PASS (Bricklin, 1990b), used by 8% of the respondents (who employed it in 94% of their cases) and the Custody Quotient (Gordon & Peek, 1989), used by 4% of the respondents (in 57% of their cases). Recently, however, Hagen and Castagna (2001) performed a reanalysis of the survey results presented by Ackerman and Ackerman (1997) and came up with quite different results. Instead of focusing on the percent of respondents who “had ever used in custody evaluations for children and adults and the percentage of time that each of these tests had been used” (Ackerman & Ackerman, 1997, p. 138), Hagen and Castagna computed the percentage of evaluations in which a particular test was actually used. Other than the MMPI, which was used in 84% of the 43,195 evaluations examined, no test was used in even one-third of the evaluations. Only the Rorschach, the MCMI-II/III, and the WAIS-R were used in more than 20% of them. In light of this alternative view of the Ackerman data, they concluded, It would be highly misleading to represent to the public . . . that there exists at the present time anything approaching a usual and customary practice much less an actual standard of practice for the use of psychological tests in custody evaluations beyond the nearly routine use of the MMPI in the assessment of adults. (Hagen & Castagna, 2001, p. 271) LaFortune and Carpenter (1998) surveyed mental health professionals about the tests and strategies they employed in their custody evaluations. They received completed surveys from a geographically diverse sample of 165 mental health professionals, the majority of whom were psychologists (89%). Respondents reported the frequency of use of various assessment methods on a 1 (never) to 5 (always) scale. Re- garding psychological tests used to assess adults, “parenting scales,” such as the ASPECT and the Bricklin measures (the speciﬁc Bricklin measures were not identiﬁed by the investi- gators), were second in frequency of use (mean response level of 3.28) only to the MMPI (mean response level of 4.19). Unfortunately, the authors did not report frequency of use for individual custody tests. Nevertheless, it appears that The Child Custody Evaluation Process 191 these newer, more speciﬁc instruments enjoyed a fairly sig- niﬁcant rate of use among these respondents. Data regarding instruments used to assess children apparently were not col- lected, so it is unclear whether a similarly high rate of use would have been found. Finally, Bow, and Quinnell (2001; see also, Quinnell & Bow, 2001) replicated the Ackerman and Ackerman (1997) survey regarding the current practice of child custody evalu- ations. Of the 563 surveys mailed, 198 usable questionnaires were returned. These encompassed mental health profession- als from throughout the United States, 96% of whom were doctoral-level psychologists. Reporting of this study is bifur- cated, with one article reporting the general procedures used by child custody evaluators (see Bow & Quinnell, 2001) and a second art

bundet

icle discussing the current use of psychological testing speciﬁcally in this context (Quinnell & Bow, 2001). The use of psychological testing of parents ranked fourth out of 10 custody procedures in importance—behind clinical interviews with parents and children and parent-child obser- vations. Psychological testing of the child ranked sixth. Nev- ertheless, ﬁndings showed that approximately 90% of adults and 60% of children continue to be tested. By far, the MMPI/MMPI-2 was the most frequently used test (i.e., 94% of respondents reported using it), which re- afﬁrms prior ﬁndings (Ackerman & Ackerman, 1997; Hagen & Castagna, 2001; Keilin & Bloom, 1986; LaFortune & Carpenter, 1998). Respondents in this study also reported wide use of the MCMI. Indeed, it emerged as the second most commonly used test (i.e., 52% indicated incorporating its use) out of all categories for both adults and children. Use of projective tests and intelligence tests with adults was essen- tially similar to earlier surveys. For assessment of children, intelligence tests (48%) and projective measures (ranging from 23% to 45%) were the most frequently used instru- ments, and the adolescent version of the MMPI followed closely behind (43%). No measure, however, was used in more than half of the child assessments, and generally, chil- dren appear to be tested somewhat less frequently by these respondents than by those participating in earlier surveys. Of the specialized measures examined, parenting invento- ries were used by more examiners in this survey than by those in prior studies. In fact, the Parent-Child Relationship Inventory (Gerard, 1994) and the Parenting Stress Index (Abidin, 1995) were the fourth (44%) and ﬁfth (41%) most commonly used tests of adults, respectively, out of all cate- gories. This is especially noteworthy considering that in the Ackerman and Ackerman (1997) study, each of these tests were used by only 10% of evaluators overall. In contrast, the use of custody batteries and forensic assessment instruments designed speciﬁcally for use in custody evaluations was sim- ilar to earlier survey results (e.g., BPS: 28% versus 35%; PORT: 23% versus 16%; PASS: 21% versus 8%; and ASPECT: 16% versus 11%). Overall however, study partici- pants reported relatively low usage of these instruments. Third-Party Information As is the case with any forensic evaluation, contact with knowledgeable third parties and review of various documents can provide valuable information (Committee on Specialty Guidelines for Forensic Psychologists, 1991; Gould, 1998; Melton et al., 1997; Schutz et al., 1989; Weithorn, 1987). For example, baby-sitters may offer insights into the parents’ abilities and interactions with the children, teachers may provide information about the children’s adjustment and how involved the parents are in their children’s education, and physicians may inform the examiner about the parents’ ability to protect their children and meet their needs. Custody examiners must use and rely on such information cautiously, however. Some information that the examiner seeks will be conﬁ- dential and/or privileged (e.g., medical, mental health, or school records), and access to such information will require formal release by the parties. Other information, although not conﬁdential or privileged, may be sensitive, and the holder of it may not provide such information without the agreement of the party (e.g., employment or day care records). Some information may be inadmissible (e.g., illegally obtained in- formation, such as stolen documents or audio- or videotapes obtained without the party’s consent). Whenever possible, before considering or reviewing information that the exam- iner believes may be inadmissible, he or she should contact the attorneys involved and request direction from them or the court. In all cases, because the rules of evidence and practice standards indicate that the bases for an examiner’s opinion must be revealed, potential third-party informants must ﬁrst be instructed about how and for what purposes the informa- tion will be used, and that nothing they reveal will remain conﬁdential or privileged. Of course, third parties cannot be forced to reveal information to the examiner (e.g., day care personnel cannot be forced to speak with the examiner), al- though the attorneys representing the parties may seek reve- lation of information that the parties seek via subpoena. Report Writing and Testifying Although custom varies across jurisdictions, it is good prac- tice to write a report that describes the evaluation procedure, information gained, and opinions formed. In addition to forc- ing the examiner to integrate his or her ideas, the report provides for the efﬁcient communication of information to 192 Child Custody Evaluation the parties, their attorneys, and the court (Martindale & Otto, 2000). The report should summarize, using language and concepts understood by laypersons, the evaluator’s conceptu- alization of the parents, their children, and their adjustment, needs, abilities, and limitations. The report and any associ- ated testimony should highlight the most important issues relevant to the custody decision in the case at hand, and the reasoning underlying the examiner’s conclusions and recommendations should be made clear. The examiner has failed if, after reviewing the report, the reader cannot describe (a) the examiner’s conceptualization of the children, their parents, and the unique family situation, and (b) how the examiner reached these opinions (regardless of whether the reader agrees with the opinions, conclusions, or recommen- dations). The foundation of these opinions can be considered during the deposition or hearing process (Martindale & Otto, 2000). Summary Central to conducting an evaluation that assists the legal de- cision maker in cases of contested custody is knowledge of (a) the law on which custody decisions are based, (b) practice guidelines, © sources of information that may provide im- portant information about the children and their parents, and (d) techniques designed to provide some insight into the par- ties and their adjustment. Also critically important, however, is knowledge of research related to developmental psychol- ogy, parent-child interactions, and custody outcome. Some of the most relevant research is discussed below. RESEARCH RELEVANT TO CHILD CUSTODY EVALUATION AND DECISION MAKING Parenting and Child Development Ideally, parents provide an environment that allows their children to develop and reach their maximum potential intel- lectually, emotionally, and in other important ways. As a re- sult, psychologists and other mental health professionals who conduct custody evaluations should be knowledgeable about parenting behaviors and their impact on children’s development. The Impact of Parents on Their Children’s Development A central premise of the involvement of mental health pro- fessionals in custody disputes is that parents may have psy- chological characteristics or engage in behaviors or activities that lead to less than optimal outcomes in terms of the devel- opment and socialization of their children. This is based on the almost self-evident belief that parental behavior exerts a strong inﬂuence on the psychosocial development of children and therefore should be weighted heavily regarding the de- termination of the best interests of the child. Recently, how- ever, this basic assumption of parental inﬂuence has been challenged in the developmental psychology literature by an alternative position claiming that children’s socialization is not inﬂuenced signiﬁcantly by the behavior of their parents (Harris, 1995, 1998; Rowe, 1994). In reviewing the literature, Harris (1998) argued, “Do parents have any important long- term effects on the development of their child’s personality? This article examines the evidence and concludes that the an- swer is no” (p. 458). Rather than parental behavior, genetic inﬂuences and children’s peer groups are construed to play more determinative roles in the psychosocial development of children. If supported, such an argument obviously would have far-reaching impact in terms of the weight that should be given to any “psychological” characteristics of the parents when making custody determinations. Leading developmental psychologists have criticized se- verely the basic premise that parents are inconsequential in the development of their children and have provided various counterarguments and research ﬁndings to contradict this claim. Although an exhaustive review of this issue would go well beyond the scope of this chapter (for an overview, see Collins, Maccoby, Steinberg, Hetherington, & Bornstein, 2000), the key point from this debate as it relates to child custody issues appears to be that the relationship between parenting and children’s development and socialization is complex and multifaceted. Simple linear relationships and main effects models, although characteristic of early theoriz- ing about parent-child inﬂuence, do not account for the multiplicity of interacting factors that inﬂuence children’s de- velopment and socialization. The implication of this conclu- sion for those involved in child custody decision making is that overarching statements regarding the effects of parental behavior on child development should be made with consid- erable reservation and with acknowledgment of the potential mediating and moderating role of a host of other factors un- related to the parents’ behavior. As noted previously, the legal system provides relatively limited direction to mental health professionals regarding what speciﬁc factors are to be considered relevant in deter- mining the best interests of the child. Consequently, evalua- tors may have considerable latitude in terms of what parental characteristics are incorporated into their evaluation and the weight that is given to each factor in terms of their rele- vance to children’s psychosocial development. The following Research Relevant to Child Custody Evaluation and Decision Making 193 section reviews the extant empirical research regarding the relationship between parental characteristics and children’s psychosocial development, focusing on those variables that have been shown (or have been presumed) to serve as signif- icant risk factors for maladjustment. Clinical and develop- mental researchers have examined a wide range of parental factors, including (a) general features of psychopathology and personality (e.g., depression, substance abuse, antisocial personality disorder); (b) broad parenting styles (e.g., authori- tarian, permissive, authoritative); and © more circumscribed parenting behavior (e.g., degree of monitoring, disciplinary practices). Empirical research examining the effects of these variables on children’s development is summarized below, along with citations for more thorough reviews of this literature. Mental Disorder It seems almost a truism that various forms of parental men- tal disorder are important factors for examiners to consider in custody evaluations. It has been noted that “many mental health experts would place concerns about parental mental and emotional health or status at the top of any list of essen- tial criteria in determining the appropriate custodian for a postdivorce child” (NICCC, 1998, p. 31), and this contention generally has been supported in surveys of custody evalua- tors. Nevertheless, the existence of mental disorder should not be dispositive in terms of custody unless it can be shown “to be relevant to that parent’s care of the child and to have a negative inﬂuence on the child’s condition or development” (p. 32; emphasis added; see also Jenuwine & Cohler, 1999). This is of particular importance as mental health profession- als have been criticized in the past as focusing on psycho- pathology and diagnosis in the context of custody evaluations to the exclusion of more central issues related to parenting and parent-child interactions (APA, 1994; Brodzinsky, 1993; Grisso, 1984, cited in Melton et al., 1997). As such, the re- search detailed below should be considered from the context of how mental disorder may (or may not) impact parenting practices that, in turn, are associated with negative develop- mental outcomes for children. Furthermore, it is important to note that the relationship between parental mental disor- der and children’s functioning may not be a causal one (Jenuwine & Cohler, 1999). The vast majority of research in this area is correlational or quasi-experimental, and inferences that parental mental disorder causes impaired parenting, which in turn causes child maladjustment, are largely unsubstantiated. All of the disorders described below have some hereditary component, and children’s impairment might be attributable more to direct genetic effects (or, more likely, interactions between hereditary factors and various environmental variables) rather than speciﬁcally to inadequate parenting caused by mental disorder (e.g., Collins et al., 2000; Rowe, 1994). Moreover, most of this research has failed to consider the effects of socioeconomic factors, which may account for signiﬁcant variance in the relationship between parental men- tal disorder and child adjustment (Oyserman, Mowbray, Meares, & Firminger, 2000). Also, there is evidence to sug- gest that the behavior of children (particularly externalizing behavior problems) may exert a strong inﬂuence on parent- ing practices (e.g., Dishion & Patterson, 1997). All of these caveats should be considered when attempting to draw conclusions about the relationship between any given men- tally disordered parent and the behavior of his or her child. Given these limitations, we review below empirical research related speciﬁcally to what is known about parental depres- sion, schizophrenia, substance abuse, and antisocial conduct as they relate to children’s psychosocial development and adjustment. The impact of parental depression on child development is one of the most widely researched areas in developmental psychopathology, although it is noteworthy that most of this research has focused on depressed mothers rather than fa- thers. Maternal depression has been associated with various negative outcomes for children, including internalizing and externalizing behavior problems and social and achieve- ment difﬁculties (see, generally, Cummings & Davies, 1999; Downey & Coyne, 1990; Field, 1995; Hammen, 1997; Lovejoy, Graczyk, O’Hare, & Neuman, 2000; Oyserman et al., 2000). For example, ﬁndings from one comprehensive review indicated that children of parents with major affective disorders are two to ﬁve times more likely to develop some type of psychopathology than children of nondisordered parents (Beardslee, Bemporad, Keller, & Klerman, 1983). The empirical research examining the association between parental depression and child behavior and emotional prob- lems has used diverse methodologies over various time frames and age ranges. Although depression appears to be as- sociated with dysfunction during all stages of childhood, the effects of maternal depression may be pronounced particu- larly during infancy and may have a negative impact well beyond the ﬁrst year (Field, 1995; Lovejoy et al., 2000; Oyserman et al., 2000). For example, maternal depression is associated with the development of insecure parent-child at- tachment (see below), which predicts various adjustment dif- ﬁculties during later childhood (Cummings & Davies, 1999). The speciﬁc mechanisms by which parental depression leads to child dysfunction are not completely clear, although several mediating factors have been investigated. Depressed 194 Child Custody Evaluation parents tend to provide fewer supportive statements, be more critical and intrusive, and display more depressive affect (e.g., sadness) when interacting with their children. They also report communication difﬁculties, disaffection, and increased levels of hostility and resentment, which generally have been corroborated by observational studies (see Lovejoy et al., 2000, for a comprehensive review of observational studies). Depression also has been associated with various deﬁcits in child management practices (see below) and subsequent de- viance in adolescence (see, generally, Cummings & Davies, 1999; Lovejoy et al., 2000; Oyserman et al., 2000). Although not as widely researched as parental depression, early reports of the effects of having a parent with schizo- phrenia suggested that these children were particularly at risk for developing various adjustment problems and forms of psychopathology (see, generally, Jenuwine & Cohler, 1999; Mednick, Parnas, & Schulsinger, 1987; Nuechterlein, 1986; Weintraub, 1987). For example, parents with schizophrenia tend to have children who are disproportionately likely to evince later schizophrenia, personality disorders, and antiso- cial behavior, as well as social functioning deﬁcits, various information-processing anomalies and cognitive deﬁcits, neurological soft signs, and autonomic abnormalities. How- ever, the existing studies have reported widely varying rates and types of subsequent dysfunction among children of par- ents with schizophrenia, which make conclusions regarding the speciﬁc effects of this disorder on children’s development difﬁcult to determine (Jenuwine & Cohler, 1999; Oyserman et al., 2000). Moreover, many children with parents who suf- fer from schizophrenia do not appear to experience any sig- niﬁcant levels of maladjustment. Although the literature is less developed than the parental depression research, there is some evidence in the parental schizophrenia literature to sug- gest that diagnostic status per se may be less relevant in pre- dicting adjustment problems experienced by offspring than are other factors such as the chronicity of the disorder and the speciﬁc deﬁcits in parenting ability evidenced by the parents (see Goodman & Brumley, 1990; Oyserman et al., 2000; Rogosch, Mowbray, & Bogat, 1992). Another truism in relation to the effects of parents’ behav- ior on children is that exposure to parental substance abuse and dependence will be detrimental to the development and socialization of children (for reviews, see Chassin, Barrera, & Montgomery, 1997; Logue & Rivinus, 1991; Lynskey, Fergusson, & Horwood, 1994; Steinhausen, 1995; Swaim, 1991; West & Prinz, 1987). Speciﬁc childhood outcome factors that have been associated with excessive parental al- cohol and drug use include various forms of externalizing symptomatology (e.g., aggression, delinquency, attention deﬁcits), internalizing behavior problems (e.g., depression, low self-esteem), adolescent drug use, cognitive deﬁcits, and poor school achievement. It should be noted, however, that the majority of this research (particularly longitudinal stud- ies) has been conducted in relation to alcoholism rather than illicit drugs of abuse. Similar to earlier qualiﬁcations noted about the relationship between parental psychopathology and child adjustment, it should be pointed out that the strength of the relationship be- tween parental substance use and childhood dysfunction has varied considerably across studies and that many children of substance-abusing parents do not exhibit signiﬁcant subse- quent psychopathology. Furthermore, there is some evidence that those parents who desist from alcohol dependence (i.e., those “in recovery”) do not have children who exhibit inter- nalizing symptomatology, although relatively little research has been conducted in this area. Parenting practices have been noted as potential medi- ators of the relationship between parental substance use and childhood dysfunction. Speciﬁcally, Chassin et al. (1997) re- view data supporting the deleterious effect of alcohol on parents’ monitoring of children’s behavior, which resulted in increases in association with drug-using peers. Indeed, higher rates of child abuse and neglect are consistently reported among substance-abusing parents (e.g., Black & Mayer, 1980; Mayes, 1995). Other relevant parenting factors that have re- ceived empirical support include increased exposure to stress- ful life events and breakdown of family routines due to parental substance use, and impairments in parent-child at- tachment status among younger children. A ﬁnal area relevant to custody evaluations is research examining the relationship between parental antisocial con- duct and childhood dysfunction. One of the most consistent ﬁndings in the developmental literature is that parents who en- gage in signiﬁcant antisocial behavior tend to have children who evidence various adjustment problems, particularly related to externalizing behaviors such as aggression and delinquency (see, generally, Dishion & Patterson, 1997; Farrington, 1995, 2000; Frick, 1993; Frick & Jackson, 1993; Loeber, 1990; Loeber & Stouthamer-Loeber, 1986; Robins, West, & Herjanic, 1975). Although most of this research has addressed paternal antisocial personality and behavior, mater- nal criminality and antisocial personality disorder (as well as sibling delinquency) also have been shown to be associated with subsequent impairment among offspring. Speciﬁcally in terms of custody evaluations, it should be noted that parental antisocial conduct not only exerts a sig- niﬁcant impact on children’s functioning in childhood and adolescence, it also has been associated with long-term con- sequences reaching well into adulthood. For example, when predicting antisocial behavior at age 32, Farrington (2000) Research Relevant to Child Custody Evaluation and Decision Making 195 reported that having a criminally convicted parent when the individual was between ages 8 and 10 was the single strongest predictor among a host of risk factors (odds ratio  3.7) examined in the Cambridge study of delinquent development. The speciﬁc mechanisms that account for the relationship between parental antisocial personality disorder/criminality and subsequent dysfunction have not been clearly explicated, although research has supported the role of both genetic and family socialization factors and has, to some extent, paral- leled the research examining the effects of parental depres- sion on parenting and childhood psychopathology. Those speciﬁc parenting practices that have received empirical sup- port as predictors of later impairment are reviewed below. Parenting Practices and Child Development Aside from parental mental disorder, various other “psycho- logical” characteristics related to parenting more broadly have been investigated in relation to children’s psychosocial development. In fact, the bulk of developmental research over the past half-century has focused less on diagnosable psychopathology and more on speciﬁc parenting practices. Various practices have been examined in terms of their ef- fects on the development and socialization of children and adolescents, ranging from very concrete microanalyses of observable parental behaviors to more global assessments of latent parenting constructs. Although a wide range of vari- ables has been investigated, much of the research and theo- rizing about parental inﬂuence in the past several years has come to focus on a core set of “family management” factors that appear to be associated strongly with adverse outcomes over the course of development from infancy to adolescence. Much of this research has been conducted in reference to the development of attachment theory (described below), al- though behavioral models also have been prominent. Regard- less of the speciﬁc theoretical orientation of researchers, the data derived from these studies have provided empirical sup- port for several parenting factors that appear inﬂuential in children’s development. Key factors that have emerged from this literature are highlighted below. For more comprehen- sive reviews of these variables, see Campbell (1997), Dishion and Patterson (1997), Edens (1999), Greenberg, Speltz, and DeKlyen (1993), Kelly and Lamb (2000), Loeber and Stouthamer-Loeber (1986), Reitman and Gross (1995), and Shaw and Winslow (1997). The quality of parent-child attachment during the ﬁrst few years of life has received considerable attention in terms of its relationship to children’s later adjustment. Attachment theory was initially proposed by Bowlby (1969) as a general theory of personality development that was based heavily in ethnology and evolutionary theory. Attachment is seen as an organized behavioral system designed to maintain “felt secu- rity” for the infant by preserving proximity to the caregiver and by providing a “secure base” from which to explore the environment. Much of the attachment research has focused on how early relationship experiences inﬂuence infants’ de- velopment of emotional regulation (a key sociodevelopmen- tal milestone), as well as how these early experiences form the basic “working models” of subsequent relationships in later childhood and adolescence. Typically, investigators have assessed speciﬁc patterns of attachment that are observed in infant-caregiver relation- ships. The majority of this research has been an outgrowth of the Strange Situation procedure (Ainsworth, Blehar, Waters, & Wall, 1978), in which the parent brieﬂy leaves a 12- to 18- month-old infant in the company of a stranger. Building on Bowlby’s initial observations of typical reactions to separa- tion and reunion, the response of the infant to the caregiver upon reunion has been the basis for identifying four basic attachment styles: securely attached, insecure-resistant or ambivalent, insecure-avoidant, and insecure-disorganized. Most children are identiﬁed as secure, in that they welcome caregivers upon reunion and seek their proximity if dis- tressed by the separation. Insecurely attached children, how- ever, display various forms of dysfunctional reactions in response to the reunion (see Ainsworth et al., 1978, or Greenberg et al., 1993, for a more thorough description). Although main effect models have been inconsistent, a wealth of data exists showing that insecure attachment before the age of 2 years, in combination with other risk factors, sig- niﬁcantly predicts increased problems with aggression, de- pression, and peer relationships in the preschool, elementary school, and preadolescent age ranges (see Greenberg & Speltz, 1988; Greenberg et al., 1993). In fact, many of the be- haviors and outcomes distinguishing secure and insecure preschoolers are speciﬁc symptoms of childhood behavior disorders such as oppositional deﬁant disorder (Greenberg et al., 1993). Regarding speciﬁc patterns of behavior associ- ated with each attachment status, Renkin, Egeland, Marvin- ney, Mangelsdorf, and Sroufe (1989) found that teachers rated boys who were identiﬁed as avoidant in infancy as more aggressive, whereas ambivalent-resistant attachment was as- sociated with passive-withdrawal. More recent research, summarized by Lyons-Ruth (1996), suggests that disorga- nized attachment status in infancy may be the most predictive of subsequent externalizing behavior problems in the preschool and grade school years. For example, Lyons-Ruth, Alpern, and Repacholi (1993) found that a large percentage of children exhibiting serious hostile behavior problems had 196 Child Custody Evaluation disorganized attachment histories. Similarly, Solomon, George, and DeJong (1995) reported that children with disor- ganized attachment histories were more aggressive (mother- and teacher-report) than nondisorganized children. Speciﬁc parental factors (as well as child variables) have been shown to predict insecure attachment. Aside from obvi- ous risk factors such as abuse and neglect, parents’ emotional expressiveness and their sensitivity and responsiveness to infants’ emotional cues are associated with attachment status (see Campbell, 1997; Crockenberg & Leerkes, 2000; Cummings & Davies, 1999). Although much of this research has been conducted with mothers, similar relationships appear to exist regarding father-child attachment. Collectively, the attachment data clearly indicate that the quality of the parent-child relationship plays a central role in children’s socioemotional development, and the theory itself provides an explanatory mechanism for understanding how parental relationships affect children. Moreover, the impor- tance of this variable is not limited to the infancy and toddler years, in that relationship quality continues to be an important predictor of maladjustment in later childhood and adoles- cence. It is worth noting, however, that other paradigms (e.g., learning theory) can be used to explain the results of the at- tachment data and that much of the research with children beyond the toddler years is not driven from an attachment perspective. In fact, some have argued for a “macropara- digm” in developmental psychology that accommodates re- sults from multiple theories (Reitman & Gross, 1995). Consistent with this macroparadigm conceptualization, developmental researchers have identiﬁed two basic dimen- sions of parenting that seem to play a prominent role in the socioemotional development of children. The ﬁrst of these dimensions has been labeled nurturance, reﬂecting the degree of affective warmth or coldness in the relationship. The second broad dimension, sometimes referred to as con- trol or restrictiveness, relates to the type and degree of super- vision, monitoring, and limit setting used by the parent. These two factors often have been used to classify basic par- enting styles (Baumrind, 1967; Campbell, 1997; Reitman & Gross, 1995), such as authoritative (high nurturance, high control), authoritarian (low nurturance, high control), and permissive (high or low nurturance, low control). Both authoritarian and permissive parenting styles have been linked with undesirable outcomes among children and adolescents, through the use of various research methodolo- gies (e.g., laboratory tasks, home observation, self-report questionnaires). For example, toddlers who have parents whose behavior is consistent with an authoritarian approach tend to show more negative affect and to be more deﬁant and noncompliant in parent-child interactions. Deﬁcits in self-regulation also have been noted. Children and adoles- cents with authoritarian parents are at greater risk for aggres- sion and other forms of externalizing behavior problems and for academic difﬁculties and tend to perform more poorly on measures of moral development, self-esteem, and self- competence. Parenting practices associated with permissive- ness also have been shown to be linked with aggression and poor behavioral controls. More speciﬁcally, a meta-analysis conducted by Loeber and Stouthamer-Loeber (1986) found that boys’ conduct problems were signiﬁcantly related to a lack of parental involvement in 22 of the 29 studies reviewed. Level of parental supervision also was strongly correlated with subsequent delinquency and antisocial behavior. Not surprisingly, parents who engage in what generally can be construed as authoritative approaches to parenting tend to have psychologically healthy children who are more prone to be self-reliant, socially competent, and capable of self- regulation. Moreover, these parenting strategies may serve as a buffer against other risk factors in a child’s environment. As Dishion and Patterson (1997) have noted in their summary of the research: In every instance, the ﬁnding has been that the impact of context on adjustment is mediated through parenting practices. The par- ents can be subjected to severe stress, but if they manage to keep their parenting practices relatively intact, the negative context will not have a signiﬁcant impact on child adjustment. Effective discipline, monitoring, and family problem-solving practices are the strongest protective factors that we have seen in the litera- ture. (p. 211) Divorce The research literature of the 1970s and 1980s took a narrow view of divorce, focusing on family structure and on adverse outcomes (Hetherington & Stanley-Hagan, 1999) and con- ceptualizing divorce in a simple cause-effect model (Kaplan & Pruett, 2000). Divorce was not yet recognized for its longitudinal impact. Using anecdotal, cross-sectional, uncon- trolled studies, early researchers reported that children from divorced families suffered from a wide range of emotional, behavioral, and academic problems when compared to chil- dren from nondivorced families (Kaplan & Pruett, 2000). Mean differences, often using clinical samples, were inter- preted inappropriately and sweeping generalizations were made about the effects of divorce. The accumulation of such negative ﬁndings led to the inaccurate conclusion that being divorced per se caused ill effects in children (Kelly, 1998). Essentially, divorce was viewed as a single traumatic experi- ence. In retrospect, much of this research has been criticized Research Relevant to Child Custody Evaluation and Decision Making 197 for various methodological ﬂaws: Most investigators used cross-sectional methodologies and nonrepresentative, poorly deﬁned samples; data often were derived from single sources or measures of questionable validity; researchers failed to distinguish negative effects resulting from marital discord from negative effects resulting from divorce per se; and sig- niﬁcant mediating or moderating factors were not considered (Hetherington & Stanley-Hagan, 1999). The current model of divorce research does not assume that divorce inevitably leads to poor outcome. Instead, devel- opmental, family systems, and ecological models have been adopted that regard divorce as a family transition or disrup- tion that, depending on a variety of individual, family, and ex- trafamilial factors, places each individual child at risk for variable amounts of time (Hetherington & Stanley-Hagan, 1999). Emphasis is placed on the diversity of children’s ad- justment to divorce and on the interactions among the inﬂu- ences that undermine or support the child’s adjustment (Wolchik, Wilcox, Tein, & Sandler, 2000). Also, replacing the cross-sectional tradition of early research on divorce, leading researchers have adopted a life course, risk, and resiliency perspective (Hetherington, 1999a). From this perspective, it is assumed that “although divorce may be associated with stressful changes and challenges in family members’ lives, it also may present a chance for escape from conﬂict, for more harmonious, fulﬁlling relationships, and the opportunity for greater personal growth, individuation, and well-being” (Hetherington & Stanley-Hagan, 1999, p. 130). Such a com- plex approach is made possible by the use of more sophisti- cated statistical methods (e.g., cluster analysis, structural equation modeling) and research methodologies (e.g., quasi- experimental designs, longitudinal studies, multiple outcome measures, nationally representative samples, studying the adjustment of multiple children in a family). Unlike earlier reports, more recent research examining the impact of divorce on children indicates that many of the problems suffered by children of divorce cannot be ac- counted for by the divorce itself. Instead, events and experi- ences in the years preceding the divorce (e.g., general family conﬂict and marital discord) are of central importance (Cherlin et al., 1991; Kelly, 2000). For example, families on the verge of breakup have been found to be characterized by less intimate interparental and parent-child relationships, less parental commitment to children’s education, and fewer eco- nomic and human resources, resulting in more academic, psychological, and behavioral problems for children even be- fore the marital disruption (Sun, 2001). Moreover, children’s maladjustment subsequent to divorce can be predicted largely by these pre-disruption factors and by the corre- sponding changes in family circumstances during the period surrounding the divorce (Sun, 2001). In general, Cherlin et al. concluded that the differences in outcome between children from divorced and intact families derives from three sources: (a) growing up in a poorly functioning family, (b) severe and extended marital conﬂict, and © parents’ emotional upset, diminished parenting capacities, and ongoing conﬂict that continues after separation. Thus, the presence of prolonged marital conﬂict appears to play a greater role than divorce it- self on children’s adjustment. Teasing apart the differential impact of marital conﬂict and/or divorce proves difﬁcult. Accordingly, there has been a large increase in the number of studies examining complex variables within the marriage that profoundly impact child adjustment, including marital conﬂict, violence, and related parenting behaviors. The results essentially have conﬁrmed that the deleterious effects of the divorce process and/or the postdivorce family structure on children’s adjustment have been overstated and overgeneralized (Hetherington & Stanley-Hagan, 1999; Kaplan & Pruett, 2000; Kelly, 2000). Finally, studies examining the possible association be- tween genetics to divorce-proneness and to children’s adjust- ment to divorce have begun to accumulate (Jockin, McGue, & Lykken, 1996; O’Connor, Plomin, Caspi, & DeFries, 2000). In a prospective longitudinal comparison of children from adoptive and biological families who divorced, ﬁndings for psychopathology (e.g., behavioral problems, substance abuse) appear to be consistent with an environmentally medi- ated explanation for the association between parent divorce and children’s adjustment. Findings for academic achieve- ment and social adjustment, however, were consistent with a genetically mediated explanation (O’Connor et al., 2000). Although the results are intriguing, conclusions derived from a single study should be viewed cautiously. Effects of Divorce on Children’s Adjustment It is a generally accepted fact that children of divorce, com- pared with children in never-divorced families, have signiﬁ- cantly more adjustment and achievement problems (Kelly, 2000). This is not surprising considering that most children of divorce experience dramatic declines in their economic circumstances, abandonment (or fear of abandonment) by one or both of their parents, the diminished capacity of both parents to attend meaningfully to their children’s needs (because they are preoccupied with their own psychological, social, and economic distress as well as stresses related to the legal divorce), and diminished contact with many familiar or potential sources of psychosocial support (friends, neighbors, teachers, school- mates, etc.), as well as familiar living settings. (Lamb, Sternberg, & Thompson, 1997, p. 395) 198 Child Custody Evaluation In the short term, the experience of parental separation and divorce represents a signiﬁcant crisis for the majority of chil- dren and adolescents, who are likely to respond with a multi- tude of conﬂicting emotions. For example, anger, sadness, and deep feelings of loss may be apparent, but in situations of extreme parental conﬂict, considerable relief also may be experienced. Depression, low self-esteem, and anxiety are common under these circumstances, and acting-out may occur. Certain differences between children of divorce and chil- dren of never-divorced families consistently are reported (Amato & Keith, 1991); and a recent, updated meta-analysis suggests that this gap is widening, after a decrease during the 1980s (Amato, 2001). However, recent studies with more so- phisticated methodologies report smaller differences be- tween children of divorce and children of never-divorced families than previously believed (Kelly, 2000). Contrary to early research, most children from divorced homes actually fall within the normal range of adjustment on standardized measures (Amato, 1994). There is, of course, considerable disagreement about the size and signiﬁcance—both statisti- cally and practically—of differences in problems experi- enced (Hetherington & Stanley-Hagan, 1999). Furthermore, although a variety of problems (e.g., teenage pregnancy, sub- stance abuse, delinquency) in some areas of adjustment are nearly twice as common among children of divorce than among children of nondivorced families, it is important to note that these problems tend to cluster together in the same individuals, potentially exaggerating the true range of im- pairment and pathology. The vast majority of children whose parents divorce do not exhibit severe or enduring problems and develop into relatively competent and well-adjusted adults (Amato, 1999). Despite the preceding caveat, disturbances in the social, academic, and physical domains frequently are cited in the literature, in addition to the psychological effects of divorce noted earlier. Poor academic performance and achievement test scores are commonly reported, but differences are mod- est and are reduced further when researchers take into ac- count the effects of changes in socioeconomic status and parental supervision (McLanahan & Sandefur, 1994). The school dropout rate of divorced children is two to three times that of nondivorced children, and they are less likely to earn a college degree (McLanahan, 1999). In addition, divorced children are twice as likely to give birth to a child as a teenager (McLanahan & Sandefur, 1994), to use alcohol, cig- arettes, and marijuana (Kelly, 2000), and to engage in other antisocial or delinquent behavior. Furthermore, children of divorced parents tend to have more illnesses, medical prob- lems, and physician visits, and are three times more likely to receive psychological treatment than never-divorced children (Zill, Morrison, & Coiro, 1993). Finally, children of divorce commonly experience difﬁculty with peer relationships. In keeping with the risk and resiliency perspective of divorce research cited above, many researchers have investi- gated the characteristics of children that cause some to be more vulnerable or resilient than others. The most com- monly investigated characteristics are age, sex, and personal- ity. First, it has long been proposed that young children may be more affected by divorce because they are less prepared cognitively, emotionally, and socially to deal with the chal- lenges and changes of divorce. However, most researchers have reported equally negative effects for older children and adolescents (Amato & Keith, 1991). Contrary to popular belief, the majority of children—and especially older ones who have the ability to form cognitively appropriate conclu- sions—do not assume responsibility or blame for causing their parents’ marital separation (Kaplan & Pruett, 2000). Furthermore, as Emery (1998) has noted, the results of many studies examining the relationship between children’s age and adjustment are inconclusive, as age is often confounded by other factors (e.g., time since parental separation and divorce, age at the time of assessment). The association between sex and adjustment to divorce is more complex than originally believed. Although earlier re- searchers often reported more problems pertaining to divorce for boys and to parental remarriage for girls, ﬁndings of more recent research do not indicate such sex differences (Hetherington & Stanley-Hagan, 1999). When sex differ- ences are found, they tend to be more likely to occur with younger children than with adolescents (Amato & Keith, 1991). In addition, boys from predivorcing families demon- strate difﬁculties in the domains of aggression and impulsiv- ity, whereas girls are more likely to demonstrate difﬁculties with interpersonal relationships (Block, Block, & Gjerde, 1989). Behavior problems appear to increase in children from divorced families during adolescence, with the increased ad- justment difﬁculties being more signiﬁcant for girls than for boys (Hetherington, 1993; Hetherington et al., 1992). Fur- thermore, fathers tend to be more involved with their sons subsequent to divorce, which is encouraging considering that such involvement has been found to be more important for the development of boys than of girls (Amato & Keith, 1991). Overall, divorce appears to be more detrimental to fe- males than males, but the differences seem modest. Instead, Hetherington (1999b) notes the complexity of the gender- age-adjustment issue, in that adjustment and achievement in boys and girls after divorce have been found to vary by age, time since divorce, type of parenting, and type and extent of conﬂict (Kelly, 2000). Finally, intelligent, effective, and Research Relevant to Child Custody Evaluation and Decision Making 199 pleasant children are more likely to evoke positive responses and support from others and to be able to adapt to new chal- lenges and stressful life experiences (Hetherington, 1989), whereas the psychosocial stress of divorce merely serves to exacerbate the difﬁculties of already troubled and poorly ad- justed children (Block et al., 1989; Hetherington, 1989). Adjustment problems tend to diminish in intensity over time, but, on average, children of divorced parents remain less socially, emotionally, and academically well-adjusted than children from nondivorced families (Amato & Keith, 1991). Speciﬁcally, meta-analyses have revealed that young adults whose parents divorced (when compared to those whose parents did not divorce) reported lower psychological well-being and socioeconomic attainment, more pregnancies outside of marriage and earlier marriages, poorer-quality marital relationships, and increased propensity to divorce (Amato & Keith, 1991). Even when issues apparently have been resolved earlier, problems can emerge or reemerge later in life in the face of new challenges and developmental tasks. Again, however, such effects are modest, and the general view of this research is still that of resiliency rather than dys- function (Kelly, 2000). For example, in the National Child Development Study, a long-term follow-up of divorced children into adulthood, 94% of men and 82% of women fell below clinical cutoffs for adult emotional disorders (Chase-Lansdale, Cherlin, & Kiernan, 1995). Unfortunately, however, the most enduring effects of divorce during child- hood lie in the realm of educational attainment, which in turn affects the occupational achievement and socioeconomic se- curity of those who dropped out of school and entered early marriages and parenthood (Kelly, 2000). In the most extensive study to date, both in terms of dura- tion (25 years) and method (e.g., based on hundreds of hours of face-to-face interviews), Wallerstein and Lewis (1998) re- ported anecdotal data on the psychological, economic, and social consequences of marital breakdown on children. Over two decades postdivorce, the young adults in the sample con- tinued to relate sad stories of their “lost childhoods.” The developmental tasks of young adulthood—choosing a pro- fession or career, searching for and selecting a life partner, es- tablishing intimacy, and beginning a family—posed special challenges for these adult children of divorce. Speciﬁcally, burdened with ﬁnancing their own education beyond high school, these children of middle- to upper-class parents were forced to select career lines that, in many cases, fell far below those of their parents. As a consequence, 40% fell below their parents’ socioeconomic level. Furthermore, they commonly expressed deep concerns about marriage and hav- ing children, worrying about committing the same mistakes as their parents. Consistent with other researchers on the topic, Wallerstein and Lewis recognized the resiliency of children, but emphasized that divorce “does superimpose a series of special and difﬁcult tasks on top of the normative tasks of growing up” (p. 375). Parental/Marital Conﬂict and Children’s Adjustment As mentioned, marital conﬂict is a more powerful predictor of children’s adjustment than is divorce itself. Marital con- ﬂict takes its toll via a number of mechanisms, both direct (e.g., simple extended activation of the body’s physiological stress response, modeling effects; Kelly, 1998) and indirect (e.g., less effective parenting). Furthermore, among the most important predictors of the adjustment of the child are a number of central variables: (a) frequency and intensity of parent conﬂict; (b) style of conﬂict (e.g., presence and type of interspousal violence and other acts of marital aggression); © manner in which conﬂict is resolved; and (d) presence of buffers to ameliorate the effects of high conﬂict (e.g., good relationship with at least one parent or caregiver, parental warmth, support of siblings, good self-esteem and peer sup- port; Kelly, 2000). More extreme expressions of parental anger result in a broader range of adjustment problems and signiﬁcantly higher levels of psychopathology. The most harmful conﬂicts are those directly concerning the child, those to which the child is directly exposed, those that lead to physical violence, and those in which the child feels caught in the middle (Davies & Cummings, 1994). Furthermore, high marital conﬂict is associated with less warm parent-child re- lationships (Kelly, 1998). Parents in high-conﬂict marriages engage in more erratic disciplinary practices and are more likely to use anxiety- or guilt-inducing techniques to disci- pline (Kelly, 1998). Although immediately after divorce children exhibit more problems in adjustment than those in high-conﬂict nondi- vorced families, as the children adapt to their new familial structure, the pattern of differences reverses (Hetherington & Stanley-Hagan, 1999). In fact, when divorce is associated with a move to a less stressful situation, children in divorced families show adjustment similar to those in intact families with nondistressed marital relations (Amato, Loomis, & Booth, 1995; Hetherington, 1999b). However, when divorce is associated with continued high levels of conﬂict, adjust- ment of divorced children is worse than that of nondivorced children, perhaps because of the lack of a second residential parent, fewer resources, and higher rates of stressful life events (Hetherington & Stanley-Hagan, 1999). The implica- tions of these ﬁndings is made clear by Hetherington and Stanley-Hagan (1999): “Essentially, if conﬂict is going to continue, it is better for children to remain in an acrimonious 200 Child Custody Evaluation two-parent household than to suffer divorce; but if there will be a shift to a more harmonious household a divorce is ad- vantageous” (p. 134). This relationship is not fully clear-cut, however. As expected, when marital conﬂict prior to divorce was high, divorce resulted in positive outcomes as young adults. Conversely, when marital conﬂict was low and parents divorced (divorce was unexpected), young adults suffered more adjustment problems (Amato et al., 1995). To summarize, children of divorce in general do appear to suffer from a number of problems in behavioral, emotional, and social domains, particularly in the short term after the di- vorce, in comparison to children of families never impacted by such a major family transition. However, the differences are smaller than originally believed, and most children of divorce fall in the normal range of adjustment, developing into competent, stable adults. Furthermore, review of the recent literature yields less than consistent ﬁndings, as re- searchers have employed very different methodologies, in- cluding groups sampled, instruments used, deﬁnition of terms, length of follow-up, and the age of children at the time of divorce (Kaplan & Pruett, 2000). A substantial body of research on the effects of divorce on children has accrued since the 1970s, but there are still many issues left virtually unexplored and others remain open for clariﬁcation. Hetherington & Stanley-Hagan (1999), in their extensive literature review, identiﬁed a number of sugges- tions for new directions of research. First, although not en- tirely new, the need for further longitudinal studies cannot be overstated. There has been an increasing call for research to examine the diverse developmental trajectories and patterns of children’s outcomes subsequent to divorce rather than fo- cusing solely on averages. Cross-sectional studies that have so plagued the early research on the topic cannot address adequately the dynamic interaction of risk and protective fac- tors that inﬂuence the adjustment of children over time. Sec- ond, the use of rigorous methodologies must continue and new strategies for studying this complex topic be proposed and tested. Interdisciplinary efforts, combining the sampling skills of sociologists and the assessment and observational skills of psychologists, are necessary. Third, although re- search on divorce in White, middle- to upper-class families proliferates, there is an unfortunate dearth of information on other cultural, ethnic, and racial factors that affect adjust- ment. This must be rectiﬁed to be able to draw even remotely adequate, generalizable conclusions. Fourth, more studies should take a family systems approach, considering chil- dren’s relationships with custodial fathers, noncustodial par- ents, grandparents, siblings, and other relatively neglected family subsystems. Furthermore, effects of multiple transi- tions and reorganizations of the family (e.g., transitioning into stepfamilies, parental relocation) on children’s adjust- ment must be investigated, given that this is a common real- ity for many families. Fifth, because the family is but one system in which a child is nested, albeit a critical one, more ecological approaches studying the effects of extrafamilial structures or factors (e.g., neighborhood, school, peers, place of worship) must be undertaken. Finally, long-term system- atic examinations of interventions with divorced families must follow. Parenting after Divorce When parents divorce, children of all ages express anxiety about caretaking and custody arrangements (Kelly, 1998). In all families, regardless of the number of structural reor- ganizations or the time since each transition, children’s adjustment is associated with the quality of the parenting environment (Hetherington et al., 1992): the degree to which parents are warm and supportive, communicative, re- sponsive to their needs, exert ﬁrm, consistent control and positive discipline, and monitor their activities (Hethering- ton & Stanley-Hagan, 1999). Especially important in single- parent homes in which, by deﬁnition, no other residential parent is available, is the ability of the custodial parent to provide these family management practices. It is also im- portant for both parents to be able to minimize the conﬂict to which their children are exposed. This includes not fos- tering hostility against the other parent and not allowing the child to get caught in the middle of parental conﬂict (Het- herington & Stanley-Hagan, 1999). Considering the stress involved with divorce, psychologi- cal and health problems often ensue, compromising the abil- ity of parents to be responsive and sensitive to their children’s needs and to be consistently controlling of their behavior (Hetherington, 1993). Children’s personal circumstances and developmental needs are often given inadequate attention, particularly among couples characterized by high rates of litigation and relitigation, high degrees of anger and distrust, intermittent verbal and/or physical aggression, difﬁculty fo- cusing on their children’s needs as distinct from their own, and chronic difﬁculty coparenting and communicating about their children after divorce (Lamb et al., 1997). Furthermore, there is wide variability in the amount of time most individu- als, both parents and children, take to achieve stability. The fact remains, however, that the overall psychological and economic well-being of custodial parents is one of the most powerful predictors of children’s adjustment following di- vorce (Lamb et al., 1997). In accordance with ﬁndings in the broader developmental literature, a recent study found both additive and interactive Research Relevant to Child Custody Evaluation and Decision Making 201 effects between parenting variables and child variables (i.e., temperament) in predicting adjustment problems in children after divorce (Lengua, Wolchik, Sandler, & West, 2000). Utilizing a sample of 231 mothers and children who had ex- perienced divorce within the preceding 2 years, main effects were detected for both parenting (with a focus on parental rejection and inconsistent discipline) and temperament (rep- resented by positive/negative emotionality and impulsivity), in terms of the prediction of child adjustment problems (e.g., depression, conduct problems). Moreover, signiﬁcant interactions resulted: Parental rejection was more strongly related to depression and conduct problems for children low in positive emotionality. That is, positive emotionality ap- pears to act as a protective factor for children, buffering the impact of maternal rejection. Furthermore, inconsistent dis- cipline was more strongly related to adjustment problems (both depression and conduct problems) for children high in impulsivity, suggesting that children with impulse control difﬁculties may be at risk for developing problems of vari- ous kinds. Economics and Remarriage Particularly in mother-headed single-parent households, divorce commonly brings a signiﬁcant decline in economic resources. Whereas fathers suffer a 10% decline in income following divorce, mothers, who continue to be granted pri- mary physical custody of children despite changing concep- tions of gender and parent roles, experience a 25% to 45% drop in family income, further adding to general levels of stress (Furstenberg, 1990). The establishment and mainte- nance of two separate residences made necessary by separa- tion and divorce impose economic burdens on the family as a whole (Lamb et al., 1997). Given how widespread eco- nomic disadvantage is among single-parent mother-headed families, it is unfortunate that economic disadvantage is commonly found to be the most signiﬁcant risk factor for children’s adjustment (e.g., McLanahan, 1999; McLanahan & Sandefur, 1994). Although one way that custodial mothers can improve their ﬁnancial situation is by remarrying (Furstenberg, 1990), the beneﬁts of increased income do not appear to counterbal- ance the additional stresses experienced by children in step- families (Hetherington, 1993). Aside from the stress of adjusting to new family members, remarriage often entails relocation, which means further limiting availability of friends and relatives to provide social and emotional sup- port during stressful times (Lamb et al., 1997). This is extremely problematic because children beneﬁt from regular- ity, consistency, and continuity, which pertain not only to parental involvement, but to peers, extrafamilial caregivers, and schools. Access to the Noncustodial Parent Meaningful economic and psychological involvement of the noncustodial parent is important in terms of children’s post- divorce adjustment. To maintain high-quality relationships with their children, parents need to have sufﬁciently exten- sive and regular interaction with them, but research indicates that the amount of time involved is usually of less import than the quality of the interaction (Lamb et al., 1997). From a developmental perspective, it is recommended that time dis- tribution arrangements ensure the involvement of both par- ents in important aspects of their children’s everyday lives, including bedtime/waking rituals, transitions to/from school, and extracurricular activities (Kelly & Lamb, 2000). To- gether with developmental needs, parents must consider the temperament and dynamic individual circumstances of the individual child, and plans must be continuously adjusted accordingly (Lamb et al., 1997). Although contact with both parents is valuable, when con- ﬂict between the two parents is intense, frequent contact with each actually can be harmful (Lamb et al., 1997). Further- more, when a parent’s adjustment is affected by mental ill- ness or incapacity, serious substance abuse, or domestic violence, the potential costs of continued contact with children may outweigh the beneﬁts (Lamb et al., 1997). Con- versely, families headed by parents whose relationship is characterized by cooperation and ﬂexibility in decisions about custody tend to enjoy greater advantages overall, which is not surprising. Speciﬁcally, more cooperative fami- lies, reﬂected by parents mediating rather than litigating cus- tody, tended to have nonresidential parents who maintained more contact with their children, were more involved in mul- tiple domains of their children’s lives, had a greater inﬂuence in coparenting 12 years after the c

bundet

ustody dispute, and made more changes in their children’s living arrangements over the years (Emery, Laumann-Billings, Waldron, Sbarra, & Dillon, 2001). Moreover, increased contact between parents did not lead to heightened coparenting conﬂict. Research has resulted in conﬂicting ﬁndings regarding the importance of children’s contact with their father. For exam- ple, large-scale national studies have generally found no rela- tionship between frequency of father contact and children’s postdivorce adjustment (Kelly, 2000). However, in a meta- analysis of 57 studies, Amato and Gilbreth (1999) found that more recent studies of father-child contact provide stronger evidence of father impact on child adjustment than do earlier studies. Again, the quality of the relationship (e.g., feelings of 202 Child Custody Evaluation closeness with the child and active parenting of the father) is more important than frequency of visits. The degree to which father involvement impacts child adjustment, however, ultimately is linked to such factors as degree of conﬂict, type of paternal and maternal acceptance, and regular pay- ment of child support (Lamb, 1999; McLanahan & Sandefur, 1994; Pruett & Pruett, 1998). Furthermore, one group of researchers reported that even when economic factors were accounted for, children in father-custody families evi- denced fewer problems than those in mother-headed families (Clark-Stewart & Hayward, 1996). Nevertheless, while “fathers are important…children can develop well in mother-headed families with absent fathers” (Hetherington & Stanely-Hagan, 1999, p. 136). Type of Custody Arrangements At a theoretical level, substantial debate remains about which custody arrangement is in the best interests of children. Besides the beneﬁts and detriments to each parent (and how they indirectly affect a child), effects on the child with regard to single-parent versus joint-custody arrangements are mixed. On the one hand, advocates of joint-custody argue that children are expected to experience both higher quality residential parenting and relationships with nonresidential parents, more cooperative coparenting, and ultimately, better adjustment (Emery et al., 2001; Gunnoe & Braver, 2001). Conversely, critics are concerned that joint custody exacer- bates family conﬂict by requiring sustained contact to col- laborate in the child’s interests and that children will be adversely affected when they are unable to keep their rela- tionships with both parents equal (Gunnoe & Braver, 2001). Moreover, results of research on the adjustment of children from single-parent versus joint custody families also have been mixed. For example, Johnston (1995) asserts that more recent and larger studies ﬁnd few differences in adjustment between children in sole versus joint physical custody, other than higher parental income and education and regular child support payments among joint custody parents. Conversely, Kelly (2000) notes that joint legal custody has been linked to children’s well-being. Yet others have speculated a more complex relationship between type of custody arrangement and adjustment. For example, Gunnoe and Braver (2001) identiﬁed 20 variables that predisposed families to be awarded either sole or joint custody, including demographic factors (e.g., education of mother, hours per week worked by father), parental adjustment (e.g., fathers’ anger), spousal relations (e.g., mothers’ visitation opposition), aspects of both fathers’ parenting (e.g., involvement in child rearing, visitation during separation) and mothers’ parenting (e.g., rejection/acceptance of child), and child adjustment (e.g., male children’s antisocial behavior, impulsivity). After controlling for these factors, which were hypothesized to have confounded apparent effects obtained in previous re- search, results indicated that families with joint custody had more frequent father-child visitation, lower maternal satis- faction with custody arrangement, and more rapid mater- nal re-partnering. All in all, however, children tended to exhibit fewer adjustment problems. Moreover, Maccoby and Mnookin (1992) reported that when conﬂict was low after di- vorce, adolescents in joint physical custody were better ad- justed, but not in high-conﬂict postdivorce families . Finally, in families with extreme and continuing high conﬂict after di- vorce, children (particularly girls) with more frequent transi- tions and shared access were found to have more emotional and behavioral problems than children in sole custody situa- tions (Johnston, 1995). Thus, it appears that interparental conﬂict continues to be a pivotal factor in children’s adjust- ment well after the marriage has been dissolved. The type of custody arrangement and its likely effects cannot be consid- ered in isolation. SUMMARY Child custody evaluations are one of the most difﬁcult areas of forensic practice, given the complexity of the issues at hand (e.g., vague legal doctrines, contentious family dynam- ics, multiple persons and domains requiring assessment) and the intrinsically tenuous nature of any empirically supported conclusions that examiners reasonably can be expected to draw in most cases. Despite these difﬁculties, it seems clear from the preceding review that signiﬁcant improvements in the child custody arena have been made in recent years. These improvements can be seen in the ever-expanding data- base of empirical research concerning the relationship be- tween parenting behavior and child adjustment, the effects of divorce, and the impact of various custody arrangements on children. Improvements also can be seen in terms of the de- velopment of professional guidelines promulgated by various organizations that provide at least some instruction about standards of practice for examiners. Despite these advances, considerable room for improve- ment remains in most areas of research and practice, and sig- niﬁcant problem areas should be noted (see also Nicholson & Norwood, 2000). First, the existing assessment approaches employed by many examiners remain of questionable value for assessing the psycholegal constructs relevant to child custody issues. Moreover, the recent advent of “custody- speciﬁc” tests in particular could be argued to be a step References 203 backward in the process of developing appropriate instru- mentation. Second, the scientiﬁc foundation on which exam- iners should draw their conclusions and/or recommendations, although considerably improved, remains in its infancy. Fur- thermore, research in this area always will be constrained by the inability to use true experimental designs to address the most prominent questions related to custody decision making. Additionally, little is known about how child custody evalua- tors, attorneys, and judges consider information in cases, and on what types of information they base their decisions. A ﬁnal and more general area of concern is that many of the fundamental issues needing to be resolved in custody cases (e.g., what is in a child’s best interest) ultimately are value judgments that may not be directly amenable to scientiﬁc in- quiry, although value judgments made by legal decision mak- ers certainly can be informed by scientiﬁc data (as noted previously). Some of the more damning critiques of this area of practice assert that it is little more than subjective value judgment dressed up as expert opinion or social science data. In fact, there remains a debate within the ﬁeld about the fun- damental appropriateness of the involvement of mental health professionals in child custody evaluations (Emery, 1999; Koocher, 1999; Melton, 1999; O’Donohue & Bradley, 1999; Weisz, 1999). Despite this debate, it is clear that mental health professionals will continue to be involved in these evaluations for the foreseeable future. As such, attention to improving the quality of practice in this area should remain a priority. REFERENCES Abidin, R. R. (1995). Parenting Stress Index. (PSI). Odessa, FL: Psychological Assessment Resources. Ackerman, M. J., & Ackerman, M. C. (1997). Custody evaluation practices: A survey of experienced professionals (revisited). Pro- fessional Psychology: Research and Practice, 28, 137–145. Ackerman, M., & Schoendorf, K. (1992). ASPECT: Ackerman- Schoendorf Scales for Parent Evaluation of Custody manual. Los Angeles: Western Psychological Services. Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum. Amato, P. R. (1994). Life-span adjustment of children to their parents’ divorce. Future of Children, 4, 143–164. Amato, P. R. (1999). Children of divorced parents as young adults. In E. M. Hetherington (Ed.), Coping with divorce, single- parenting, and remarriage: A risk and resiliency perspective (pp. 147–163). Hillsdale, NJ: Erlbaum. Amato, P. R. (2001). Children of divorce in the 1990s: An update of the Amato and Keith (1991) meta-analysis. Journal of Family Psychology, 15, 355–370. Amato, P. R., & Gilbreth, J. G. (1999). Nonresident fathers and children’s well-being: A meta-analysis. Journal of Marriage and Family, 61, 557–573. Amato, P. R., & Keith, B. (1991). Parental divorce and the well-being of children: A meta-analysis. Psychological Bulletin, 110, 26–46. Amato, P. R., Loomis, L. S., & Booth, A. (1995). Parental divorce, parental marital conﬂict, and offspring well-being during early adulthood. Social Forces, 73, 895–916. American Academy of Child and Adolescent Psychiatry. (1997). Practice parameters for child custody evaluation. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 57S–68S. American Educational Research Association, American Psycholog- ical Association, & National Council on Measurement in Edu- cation. (1999). Standards for educational and psychological test- ing (3rd ed.). Washington, DC: American Educational Research Association. American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597–1611. American Psychological Association. (1994). Guidelines for child custody evaluations in divorce proceedings. American Psycholo- gist, 49, 677–682. American Psychological Association. (1995). Lesbian and gay par- enting: A resource for psychologists. Washington, DC: American Psychological Association. Arditti, J. A. (1995). Ackerman-Schoendorf Scales for Parent Eval- uation of Custody. In J. C. Conoley & J. C. Impara (Eds.), The twelfth mental measurements yearbook (pp. 20–22). Lincoln, NE: Buros Institute of Mental Measurements. Association of Family and Conciliation Courts. (n.d.). Model stan- dards of practice for child custody evaluation. Milwaukee, WI: Author. Baumrind, D. (1967). Child care practices anteceding three pat- terns of preschool behavior. Genetic Psychology Monographs, 75, 43–88. Beardslee, W., Bemporad, J., Keller, M. B., & Klerman, G. L. (1983). Children of parents with major affective disorder: A review. American Journal of Psychiatry, 140, 825–832. Bellak, L., & Bellak, S. S. (1992). Children’s Apperception Test 1991 Revision. Larchmont, NY: CPS Inc. Bender, L. (1946). Bender Visual-Motor Gestalt Test . San Antonio, TX: Psychological Corporation. Bischoff, L. G. (1992). The Custody Quotient. In J. J. Kramer & J. L. Conoley (Eds.), The eleventh mental measurements year- book (pp. 254–255). Lincoln, NE: Buros Institute of Mental Measurements. Bischoff, L. G. (1995). Parent Awareness Skills Survey. In J. L. Conoley & J. C. Impara (Eds.), The twelfth mental measurements yearbook (p. 735). Lincoln, NE: Buros Institute of Mental Measurements. 204 Child Custody Evaluation Black, R., & Mayer, J. (1980). Parents with special problems: Alcohol and opiate addictions. Child Abuse and Neglect, 4, 45–54. Block, J., Block, J. H., & Gjerde, P. F. (1989). Parental function- ing and the home environment in families of divorce: Pros- pective and concurrent analyses. Annual Progress in Child Psychiatry and Child Development, 192–207. Bow, J. N., & Quinnell, F. A. (2001). Psychologists’ current prac- tices and procedures in child custody evaluations: Five years after American Psychological Association Guidelines. Profes- sional Psychology: Research and Practice, 32, 261–268. Bowlby, J. (1969). Attachment and loss. Volume I: Attachment. New York: Basic Books. Bricklin, B. (1989). Perception of Relationships Test manual. Furlong, PA: Village. Bricklin, B. (1990a). Bricklin Perceptual Scales manual. Furlong, PA: Village. Bricklin, B. (1990b). Parent Awareness Skills Survey manual. Furlong, PA: Village. Bricklin, B. (1995). The custody evaluation handbook: Research- based solutions and applications. New York: Brunner/Mazel. Bricklin, B. (1999). The contributions of psychological tests to child custody evaluations. In R. M. Galatzer-Levy & L. Kraus (Eds.), The scientiﬁc basis of child custody decisions (pp. 120–156). New York: Wiley. Bricklin, B., & Elliott, G. (1991). Parent Perception of Child Proﬁle manual. Furlong, PA: Village. Bricklin, B., & Elliott, G. (1997). Critical child custody evaluation issues: Questions and answers. Test manuals supplement for BPS, PORT, PASS, PPCP. Furlong, PA: Village. Brodzinsky, D. M. (1993). On the use and misuse of psychological testing in child custody evaluations. Professional Psychology: Research and Practice, 24, 213–219. Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1994). Minnesota Multiphasic Personality Inventory—2 (MMPI-2). Minneapolis, MN: NCS Assessments. Campbell, S. B. (1997). Behavior problems in preschool children: Developmental and family issues. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 19, pp. 1–26). New York: Plenum Press. Carlson, J. N. (1995). Perception of Relationships Test. In J. C. Conoley & J. C. Impara (Eds.), The twelfth mental measurements yearbook (pp. 746–747). Lincoln, NE: Buros Institute of Mental Measurements. Chase-Lansdale, P. L., Cherlin, A. J., & Kiernan, K. K. (1995). The long-term effects of parental divorce on the mental health of young adults: A developmental perspective. Child Development, 66, 1614–1634. Chassin, L., Barrera, M., & Montgomery, H. (1997). Parental alco- holism as a risk factor. In S. A. Wolchik & I. N. Sandler (Eds.), Handbook of children’s coping: Linking theory and intervention (pp. 101–129). New York: Plenum Press. Cherlin, A. J., Furstenburg, F. F., Chase-Lansdale, P. L., Kiernan, K. E., Robins, P. K., Morrison, D. R., et al. (1991). Longitudinal studies of effects of divorce in children in Great Britain and the United States. Science, 252, 1386–1389. Clark, S. C. (1995, March). Advance report of ﬁnal divorce statis- tics, 1989 and 1990. In Monthly vital statistics report (Vol. 43, No. 9). Hyattsville, MD: National Center for Health Statistics. Clarke-Stewart, K. A., & Hayward, C. (1996). Advantages of father custody and contact for the psychological well-being of school- age children. Journal of Applied Developmental Psychology, 17, 239–270. Cohen, R. J., & Swerdlik, M. E. (1999). Psychological testing and assessment: An introduction to tests and measurement (4th ed.). Mountain View, CA: Mayﬁeld. Cole, D. E. (1995). Parent Awareness Skills Survey. In J. L. Conoley & J. C. Impara (Eds.), The twelfth mental measurements yearbook (p. 735). Lincoln, NE: Buros Institute of Mental Measurements. Collins, W. A., Maccoby, E. E., Steinberg, L., Hetherington, E. M., & Bornstein, M. H. (2000). Contemporary research on parenting: The case for nature and nurture. American Psycholo- gist, 55, 218–232. Conger, J. (1995). Perception of Relationships Test. In J. C. Conoley & J. C. Impara (Eds.), The twelfth mental measurements year- book (pp. 747–748). Lincoln, NE: Buros Institute of Mental Measurements. Crockenberg, S., & Leerkes, E. (2000). Infant social and emotional development in family context. In C. H. Zeanah (Ed.), Handbook of infant mental health (2nd ed., pp. 60–90). New York: Guilford Press. Crown, D. P., & Marlowe, D. (1960). A new scale of social desir- ability independent of psychopathology. Journal of Consulting Psychology, 24, 349–354. Cummings, E. M., & Davies, P. T. (1999). Depressed parents and family functioning: Interpersonal effects and children’s func- tioning and development. In T. Joiner & J. C. Coyne (Eds.), The interactional nature of depression: Advances in interpersonal approaches (pp. 299–327). Washington, DC: American Psycho- logical Association. Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113 S. Ct. 2786 (1993). Davies, P. T., & Cummings, E. M. (1994). Marital conﬂict and child adjustment: An emotional security hypothesis. Psychological Bulletin, 116, 387–411. Dishion, T. J., & Patterson, G. R. (1997). The timing and severity of antisocial behavior: Three hypotheses within an ecological framework. In D. M. Stoff, J. Breiling, & J. D. Maser (Eds.), Hand- book of antisocial behavior (pp. 205–217). New York: Wiley. Downey, G., & Coyne, J. C. (1990). Children of depressed parents: An integrative review. Psychological Bulletin, 108, 50–76. Edens, J. F. (1999). Aggressive children’s self-systems and the qual- ity of their relationships with signiﬁcant others. Aggression and Violent Behavior, 4, 151–177. References 205 Emery, R. E. (1998). Marriage, divorce, and children’s adjustment. Newbury Park, CA: Sage. Emery, R. E. (1999). Changing the rules for determining child cus- tody in divorce cases. Clinical Psychology: Science and Prac- tice, 6, 323–327. Emery, R. E., Laumann-Billings, L., Waldron, M. C., Sbarra, D. A., & Dillon, P. (2001). Child custody mediation and litigation: Custody, contact, and coparenting 12 years after initial dispute resolution. Journal of Consulting and Clinical Psychology, 69, 323–332. Fabry, J. J., & Bischoff, R. A. (1992). The Custody Quotient. In D. Keyser & R. Sweetwater (Eds.), Test critiques (Vol. 9, pp. 145–148). Austin, TX: ProEd. Falk, P. (1989). Lesbian mothers: Psychosocial assumptions in family law. American Psychologist, 44, 941–947. Farrington, D. P. (1995). The development of offending and antiso- cial behavior from childhood: Key ﬁndings from the Cambridge study in delinquent development. Journal of Child Psychology and Psychiatry, 36, 929–964. Farrington, D. P. (2000). Psychosocial predictors of adult antisocial personality and adult convictions. Behavioral Sciences and the Law, 18, 605–622. Felner, R. D., Rowlison, R. T., Farber, S. S., Primavera, J., & Bishop, T. A. (1987). Child custody resolution: A study of social science involvement and impact. Professional Psychology: Research and Practice, 5, 468–474. Field, T. (1995). Psychologically depressed parents. In M. H. Bornstein (Ed.), Handbook of parenting: Applied and practical parenting (Vol. 4, pp. 85–99). Mahwah, NJ: Erlbaum. Florida Statutes 61.12(2)9(b)2 (2000). Frick, P. J. (1993). Childhood conduct problems in a family context. School Psychology Review, 22, 376–385. Frick, P. J., & Jackson, Y. K. (1993). Family functioning and child- hood antisocial behavior: Yet another reinterpretation. Journal of Clinical Child Psychology, 22, 410–419. Frye v. United States, 293 F. 1013 (D.C. Cir. 1923). Furstenberg, F. F. (1990). Divorce and the American family. Annual Review of Sociology, 16, 379–403. Gerard, A. B. (1994). Parent-Child Relationship Inventory (PCRI): Manual . Los Angeles, CA: Western Psychological Services. Goodman, S. H., & Brumley, H. E. (1990). Schizophrenic and de- pressed mothers: Relational deﬁcits in parenting. Developmental Psychology, 26, 31–39. Gordon, R., & Peek, L. A. (1989). The Custody Quotient: Research manual. Dallas, TX: Wilmington Institute. Gould, J. W. (1998). Conducting scientiﬁcally crafted child custody evaluations. Thousand Oaks, CA: Sage. Greenberg, M. T., & Speltz, M. L. (1988). Attachment and the on- togeny of conduct problems. In J. Belsky & T. Nezworski (Eds.), Clinical implications of attachment (pp. 177–218). Hillsdale, NJ: Erlbaum. Greenberg, M. T., Speltz, M. L., & DeKlyen, M. (1993). The role of attachment in the early development of disruptive behavior problems. Development and Psychopathology, 5, 191–213. Grisso, T. (1984, June). Forensic assessment in juvenile and fam- ily cases: The state of the art. Keynote address at the Summer Institute on Mental Health Law, University of Nebraska, Lincoln. Grisso, T. (1986). Evaluating competencies: Forensic assessments and instruments. New York: Plenum Press. Gunnoe, M. L., & Braver, S. L. (2001). The effects of joint legal custody on mothers, fathers, and children controlling for factors that predispose a sole maternal versus joint legal award. Law and Human Behavior, 25, 25–43. Hagen, M. A., & Castagna, N. (2001). The real numbers: Psycho- logical testing in custody valuations. Professional Psychology: Research and Practice, 32, 269–271. Hagin, R. A. (1992). Bricklin Perceptual Scales. In J. L. Conoley & J. C. Impara (Eds.), The twelfth mental measurements yearbook (pp. 117–118). Lincoln, NE: Buros Institute of Mental Measure- ments. Hammen, C. (1997). Children of depressed parents: The stress con- text. In S. A. Wolchik & I. N. Sandler (Eds.), Handbook of chil- dren’s coping: Linking theory and intervention (pp. 131–157). New York: Plenum Press. Hare, R. D. (1991). The Hare Psychopathy Checklist—Revised Manual. Toronto: Multi-Health Systems, Inc. Harris, J. R. (1995). Where is the child’s environment? A group so- cialization theory of development. Psychological Review, 102, 458–489. Harris, J. R. (1998). The nurture assumption: Why children turn out the way they do. New York: Free Press. Hathaway, S. R., & McKinley, J. C. (1989). Minnesota Multiphasic Personality Inventory (MMPI). Minneapolis, MN: NCS Assess- ments. Heilbrun, K. (1992). The role of psychological testing in forensic assessment. Law and Human Behavior, 16, 257–272. Heilbrun, K., Rogers, R., & Otto, R. K. (in press). Forensic assess- ment: Current status and future directions. In J. Ogloff (Ed.), Psychology and law: The state of the discipline. New York: Kluwer/Plenum Press. Heinze, M. C., & Grisso, T. (1996). Review of instruments assess- ing parenting competencies used in child custody evaluations. Behavioral Sciences and the Law, 14, 293–313. Hetherington, E. M. (1989). Coping with family transitions: Win- ners, losers, and survivors. Child Development, 60, 1–14. Hetherington, E. M. (1993). An overview of the Virginia longitudi- nal study of divorce and remarriage with a focus on early ado- lescence. Journal of Family Psychology, 7, 1–18. Hetherington, E. M. (Ed.). (1999a). Coping with divorce, single parenting, and remarriage: A risk and resiliency perspective. Hillsdale, NJ: Erlbaum. 206 Child Custody Evaluation Hetherington, E. M. (1999b). Should we stay together for the sake of the children? In E. M. Hetherington (Ed.), Coping with di- vorce, single parenting, and remarriage: A risk and resiliency perspective (pp. 93–116). Hillsdale, NJ: Erlbaum. Hetherington, E. M., Clingempeel, W. G., Anderson, E. R., Deal, J. E., Stanley-Hagan, M., Hollier, E. A., et al. (1992). Coping with marital transitions: A family systems perspective. Mono- graphs of the Society for Research in Child Development, 57 (⅔, Serial No. 227). Hetherington, E. M., & Stanley-Hagan, M. (1999). The adjust- ment of children with divorced parents: A risk and resiliency perspective. Journal of Child Psychology and Psychiatry, 40, 129–140. Hiltonsmith, R. W. (1995). Parent Perception of Child Proﬁle. In J. C. Conoley & J. C. Impara (Eds.), The twelfth mental mea- surements yearbook (pp. 736–738). Lincoln, NE: Buros Institute of Mental Measurements. Hughes, R. (1996). Demographics of divorce [Online]. INTERNET IN-SERVICE ON CHILDREN AND DIVORCE. Available from www.hec.pohio-state.edu/famlife/divorce/index.htm. Jameson, B., Ehrenberg, M., & Hunter, M. (1997). Psychologists’ ratings of the best interests of the child custody and access criteria: A family systems assessment model. Professional Psychology: Research and Practice, 28, 253–262. Jenuwine, M. J., & Cohler, B. J. (1999). Major parental psy- chopathology and child custody. In R. M. Galatzer-Levy & L. Kraus (Eds.), The scientiﬁc basis of child custody decisions (pp. 285–318). New York: Wiley. Jockin, V., McGue, M., & Lykken, D. T. (1996). Personality and divorce: A genetic analysis. Journal of Personality and Social Psychology, 71, 288–299. Johnston, J. R. (1995). Research update: Children’s adjustment in sole custody compared to joint custody families and principles of custody decision making. Family and Conciliation Courts Review, 33, 415–425. Kaplan, M. D., & Pruett, K. D. (2000). Divorce and custody: Devel- opmental implications. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (2nd ed., pp. 533–547). New York: Guilford Press. Keilin, W. G., & Bloom, L. J. (1986). Child custody evaluation practices: A survey of experienced professionals. Professional Psychology: Research and Practice, 17, 338–346. Kelley, M. L. (1995). Parent Perception of Child Proﬁle. In J. C. Conoley & J. C. Impara (Eds.), The twelfth mental measurements yearbook (pp. 738–739). Lincoln, NE: Buros Institute of Mental Measurements. Kelly, J. B. (1998). Marital conﬂict, divorce, and children’s ad- justment. Child and Adolescent Psychiatric Clinics of North America, 7, 259–271. Kelly, J. B. (2000). Children’s adjustment in conﬂicted marriage and divorce: A decade review of research. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 963–973. Kelly, J. B., & Lamb, M. E. (2000). Using child development research to make appropriate custody and access decisions for young chil- dren. Family and Conciliation Courts Review, 38, 297–311. Koocher, G. P. (1999). Afterthoughts on child custody evaluations. Clinical Psychology: Science and Practice, 6, 332–334. Kuehnle, K., & Weiner, I. (2000). A survey of judges’ opinions re- garding child custody evaluations. Unpublished manuscript. LaFortune, K. A., & Carpenter, B. N. (1998). Custody evaluations: A survey of mental health professionals. Behavioral Sciences and the Law, 16, 207–224. Lamb, M. E. (1999). Non-custodial fathers and their impact on the children of divorce. In R. A. Thompson & P. R. Amato (Eds.), The post-divorce family: Research and policy issues (pp. 105–125) . Thousand Oaks, CA: Sage. Lamb, M. E., Sternberg, K. J., & Thompson, R.A. (1997). The effects of divorce and custody arrangements on children’s behavior, development, and adjustment. Family and Conciliation Courts Review, 35, 393–404. Lengua, L. J., Wolchik, S. A., Sandler, I. N., & West, S. G. (2000). The additive and interactive effects of parenting and tempera- ment in predicting adjustment problems of children of divorce. Journal of Clinical Child Psychology, 29, 232–244. Loeber, R. (1990). Development and risk factors of juvenile antiso- cial behavior and delinquency. Clinical Psychology Review, 10, 1–42. Loeber, R., & Stouthamer-Loeber, M. (1986). Family factors as cor- relates and predictors of juvenile conduct problems and delin- quency. In M. Tonry & N. Morris (Eds.), Crime and justice (Vol. 17, pp. 29–149). Chicago: University of Chicago Press. Logue, M. E., & Rivinus, T. M. (1991). Young children of substance- abusing parents: A developmental view of risk and resiliency. In T. M. Rivinus (Ed.), Children of chemically dependent par- ents: Multiperspectives from the cutting edge (pp. 55–73). Philadelphia: Brunner/Mazel. Lovejoy, M. C., Graczyk, P. A., O’Hare, E., & Neuman, G. (2000). Maternal depression and parenting behavior: A meta-analytic re- view. Clinical Psychology Review, 20, 561–592. Lynskey, M. T., Fergusson, D. M., & Horwood, J. L. (1994). The effect of parental alcohol problems on rates of adolescent psy- chiatric disorders. Addiction, 89, 1277–1286. Lyons-Ruth, K. (1996). Attachment relationships among children with aggressive behavior problems: The role of disorganized early attachment patterns. Journal of Consulting and Clinical Psychology, 64, 64–73. Lyons-Ruth, K., Alpern, L., & Repacholi, B. (1993). Disorganized infant attachment classiﬁcation and maternal psychosocial problems as predictors of hostile-aggressive behavior in the preschool classroom. Child Development, 64, 572–585. Maccoby, E., & Mnookin, R. (1988). Custody of children following divorce. In E. M. Hetherington & J. D. Aresteh (Eds.), Impact of divorce, single parenting, and stepparenting on children (pp. 110–149). Hillsdale, NJ: Erlbaum. References 207 Maccoby, E. E., & Mnookin, R. H. (1992). Dividing the child: Social and legal dimensions of child custody. Cambridge, MA: Harvard University Press. Martindale, D., & Otto, R. K. (2000). Communicating with the custody evaluator. Family Advocate, 23 (1), 30–33. Mayes, L. C. (1995). Substance abuse and parenting. In M. Bornstein (Ed.), Handbook of parenting (Vol. 3, pp. 101–125). Hillsdale, NJ: Lawrence Erlbaum. McIntosh, J. A., & Prinz, R. J. (1993). The incidence of alleged sex- ual abuse in 603 family court cases. Law and Human Behavior, 17, 95–101. McLanahan, S. S. (1999). Father absence and children’s welfare. In E. M. Hetherington (Ed.), Coping with divorce, single-parenting, and remarriage: A risk and resiliency perspective (pp. 117–145). Hillsdale, NJ: Erlbaum. McLanahan, S. S., & Sandefur, G. (1994). Growing up with a sin- gle parent: What hurts, what helps. Cambridge, MA: Harvard University Press. Mednick, S., Parnas, J., & Schulsinger, F. (1987). The Copenhagen high-risk project, 1962–1986. Schizophrenia Bulletin, 13, 485–496. Melton, G. B. (1995). Ackerman-Schoendorf Scales for Parent Evaluation of Custody. In J. C. Conoley & J. C. Impara (Eds.), The twelfth mental measurements yearbook (pp. 22–23). Lincoln, NE: Buros Institute of Mental Measurements. Melton, G. B. (1999). Due care, not prohibition of expert opinions. Clinical Psychology: Science and Practice, 6, 335–338. Melton, G. B., Petrila, J., Poythress, N. G., & Slobogin, C. (1997). Psychological evaluations for the courts: A handbook for attorneys and mental health professionals (2nd ed.). New York: Guilford Press. Melton, G. B., Weithorn, L. A., & Slobogin, C. (1985). Commu- nity mental health centers and the courts: An evaluation of community-based forensic services. Lincoln: University of Nebraska Press. Michigan Child Custody Act of 1970, MCL § 722.23 (1993 amended). Millon, T. (1987). Millon Clinical Multiaxial Inventory—II (MCMI-II). Minneapolis, MN: NCS Assessments. Millon, T. (1994). Millon Clinical Multiaxial Inventory—III (MCMI-III). Minneapolis, MN: NCS Assessments. Munsinger, H. L., & Karlson, K. W. (1994). Uniform Child Cus- tody Evaluation System. Odessa, FL: Psychological Assessment Resources. Murray, H. A., & Bellak, L. (1973). Thematic Apperception Test (TAT). San Antonio, TX: Psychological Corporation. National Interdisciplinary Colloquium on Child Custody. (1998). Legal and mental health perspectives on child custody law: A deskbook for judges. Danvers, MA: West Group. Nicholson, R. A., & Norwood, S. (2000). The quality of forensic psy- chological assessments, reports, and testimony: Acknowledging the gap between promise and practice. Law and Human Behavior, 24, 9–44. Nuechterlein, K. H. (1986). Childhood precursors of adult schizo- phrenia. Journal of Child Psychology and Psychiatry and Allied Disciplines, 27, 133–144. O’Connor, T. G., Plomin, R., Caspi, A., & DeFries, J. C. (2000). Are associations between parental divorce and children’s adjustment genetically mediated? An adoption study. Developmental Psy- chology, 36, 429–437. Oddenino, M. (1994). Helping your client navigate past the shoals of a child custody evaluation. American Journal of Family Law, 8, 81–95. O’Donohue, W., & Bradley, A. R. (1999). Conceptual and empir- ical issues in child custody evaluations. Clinical Psychology: Science and Practice, 6, 310–322. Otto, R. K. (1989). Bias and expert testimony of mental health pro- fessionals in adversarial proceedings: A preliminary investiga- tion. Behavioral Sciences and the Law, 7, 267–273. Otto, R. K. (2000). Child custody evaluation: Law, ethics, and prac- tice. Tampa, FL: Louis de la Parte Florida Mental Health Institute. Otto, R. K., Edens, J. F., & Barcus, E. (2000a, August). The family bar’s perception of mental health professionals in the context of child custody. In M. Ackerman (Chair), What judges expect from psychologists in child custody evaluations. Symposium conducted at the annual meeting of the American Psychological Association, Washington, DC. Otto, R. K., Edens, J. F., & Barcus, E. (2000b). The use of psycho- logical testing in child custody evaluations. Family and Concili- ation Courts Review, 38, 312–340. Oyserman, D., Mowbray, C. T., Meares, P. A., & Firminger, K. B. (2000). Parenting among mothers with a serious mental illness. American Journal of Orthopsychiatry, 70, 296–315. Patterson, C. (1995). Lesbian and gay parenthood. In M. Bornstein (Ed.), Handbook of parenting (Vol. 3, pp. 255–276). Mahwah, NJ: Erlbaum. Paulhus, D. L. (1999). Manual for the Paulhus Deception Scales. North Tonawanda, NY: Multi-Health Systems. Paulhus, D. L. (1999). Paulhus Deception Scales (PDS): The Bal- anced Inventory of Desirable Responding—7. North Tonawanda, NY: MHS/Multi-Health Systems. Pruett, M. K., & Pruett, K. D. (1998). Fathers, divorce, and their children. Child and Adolescent Psychiatric Clinics of North America, 7, 389–407. Quinnell, F. A., & Bow, J. N. (2001). Psychological tests used in child custody evaluations. Behavioral Sciences and the Law, 19, 491–501. Reidy, T., Silver, R., & Carlson, A. (1989). Child custody decisions: A survey of judges. Family Law Quarterly, 23, 75–87. Reitman, D., & Gross, A. M. (1995). Familial determinants. In M. Hersen & R. T. Ammerman (Eds.), Advanced abnormal child psychology (pp. 87–104). Hillsdale, NJ: Erlbaum. 208 Child Custody Evaluation Renken, B., Egeland, B., Marvinney, D., Mangelsdorf, S., & Sroufe, L. A. (1989). Early childhood antecedents of aggression and passive-withdrawal in early elementary school. Journal of Per- sonality, 57, 257–281. Robins, L., West, P., & Herjanic, B. (1975). Arrests and delinquency in two generations: A study of Black urban families and their children. Journal of Child Psychology and Psychiatry, 16, 125–140. Rogers, R., Bagby, R. M., & Dickens, S. E. (1992). Structured Interview of Reported Symptoms . Odessa, FL: Psychological Assessment Resources. Rogers, R., & Webster, C. (1989). Assessing treatability in mentally disordered offenders. Law and Human Behavior, 13, 19–29. Rogosch, F. A., Mowbray, C. T., & Bogat, G. A. (1992). Determi- nants of parenting attitudes in mothers with severe psycho- pathology. Development and Psychopathology, 4, 469–487. Rohman, L., Sales, B., & Lou, M. (1987). The best interests of the child in custody disputes. In L. Weithorn (Ed.), Psychology and child custody determinations (pp. 59–105). Lincoln: University of Nebraska Press. Rorschach, H. (1942). Rorschach Inkblot Test . Los Angeles, CA: Western Psychological Services. Rowe, D. (1994). The limits of family inﬂuence: Genes, experience, and behavior. New York: Guilford Press. Schutz, B., Dixon, E., Lindenberger, J., & Ruther, N. (1989). Solomon’s sword: A practical guide to conducting child custody evaluations. San Francisco: Jossey-Bass. Settle, S. A., & Lowery, C. R. (1982). Child custody decisions: Content analysis of a judicial survey. Journal of Divorce, 6, 125–138. Shaffer, M. B. (1992). Bricklin Perceptual Scales. In J. L. Conoley & J. C. Impara (Eds.), The twelfth mental measurements yearbook (pp. 118–119). Lincoln, NE: Buros Institute of Mental Measure- ments. Shaw, D. S., & Winslow, E. B. (1997). Precursors and correlates of antisocial behavior from infancy to preschool. In D. M. Stoff, J. Breiling, & J. D. Maser (Eds.), Handbook of antisocial behavior (pp. 148–158). New York: Wiley. Solomon, J., George, C., & DeJong, A. (1995). Children classiﬁed as controlling at age six: Evidence of disorganized representa- tional strategies and aggression at home and at school. Develop- ment and Psychopathology, 7, 447–463. Stahl, P. (1994). Conducting child custody evaluations: A compre- hensive guide. Thousand Oaks, CA: Sage. Steinhausen, H. C. (1995). Children of alcoholic parents: A review. European Child and Adolescent Psychiatry, 4, 419–432. Sun, Y. (2001). Family environment and adolescents’ well-being before and after parents’ marital disruption: A longitudinal analysis. Journal of Marriage and Family, 63, 697–713. Swaim, R. C. (1991). Childhood risk factors and adolescent drug and alcohol abuse. Educational Psychology Review, 3, 363–398. Tombaugh, T. N. (1996). Test of Memory Malingering . Tonawanda, NY: Multi-Health Systems. U.S. Bureau of the Census. (1989). Statistical abstract of the United States. Washington, DC: Author. Wallerstein, J. S., & Lewis, J. (1998). The long-term impact of divorce on children. Family and Conciliation Courts Review, 36, 363–383. Wechsler, D. (1981). Wechsler Adult Intelligence Scale—Revised (WAIS-R). San Antonio, TX: Psychological Corporation. Wechsler, D. (1997). Wechsler Adult Intelligence Scale – Third Edition . San Antonio, TX: The Psychological Corporation. Wechsler, D., & Stone, C. P. (1955). Wechsler Adult Intelligence Scale (WAIS). San Antonio, TX: Psychological Corporation. Weintraub, S. (1987). Risk factors in schizophrenia: The Stony Brook High Risk Project. Schizophrenia Bulletin, 13, 439–450. Weisz, V. G. (1999). Commentary on conceptual and empirical issues in child custody evaluations. Clinical Psychology: Science and Practice, 6, 328–331. Weithorn, L. (1987). Psychological evaluations in divorce and cus- tody: Problems, principles, and procedures. In L. Weithorn (Ed.), Psychology and child custody determinations (pp. 158–181). Lincoln: University of Nebraska Press. Weitzman, L. J. (1985). The divorce revolution: The unexpected so- cial and economic consequences for women and children in America . New York: Macmillan. Wellman, M. M. (1994). Ackerman-Schoendorf Scales for Parent Evaluation of Custody. In D. Keyser & R. Sweetwater (Eds.), Test critiques (Vol. 10, pp. 13–19). Austin, TX: ProEd. West, M. O., & Prinz, R. J. (1987). Parental alcoholism and child- hood psychopathology. Psychological Bulletin, 102, 204–218. Wolchik, S. A., Wilcox, K. L., Tein, J., & Sandler, I. N. (2000). Maternal acceptance and consistency of discipline as buffers of divorce stressors on children’s psychological adjustment problems. Journal of Abnormal Child Psychology, 28, 87–102. Wyer, M., Gaylord, S., & Grove, E. (1987). The legal context of child custody evaluations. In L. Weithorn (Ed.), Psychology and child custody determinations (pp. 4–22). Lincoln: University of Nebraska Press. Zill, N., Morrison, D., & Coiro, M. (1993). Long-term effects of parental divorce on parent-child relationships, adjustment, and achievement in young adulthood. Journal of Family Psychology, 7, 91–103. Zusman, J., & Simon, J. (1983). Differences in repeated psychiatric examinations of litigants to a lawsuit. American Journal of Psychiatry, 140, 1300–1304. CHAPTER 12 Assessment of Childhood Trauma STEVEN N. SPARTA 209 DEFINITIONS OF TRAUMA 209 Classes of Psychological Trauma 210 DSM Diagnoses Related to Childhood Trauma 211 Differential Symptomatology of Posttraumatic and Anxiety States 211 Phase-Related Trauma Symptomatology 212 Determinants of Traumatic Effects 212 Understanding Trauma as Developmental Psychopathology 212 Biological Reactions to Trauma 213 Comorbidity and Preexisting Dysfunction 213 Factors Mediating Traumatic Response 213 COMPETENCY, RECALL, AND CREDIBILITY OF CHILDREN’S STATEMENTS 214 EVALUATION OF TRAUMA 214 Psychological-Legal Contexts for Evaluating Trauma 214 Forensic Expert Qualiﬁcation in Child Trauma Assessment 216 Trauma Assessment or Treatment of Trauma? 217 Situational Factors Affecting Trauma Evaluation 217 Developmental Factors and Personality 217 Traumatic Reminders and Secondary Adversities 218 Childhood Trauma Case Examples 218 Interviewing and Testing Issues When Evaluating Trauma Effects 219 Interview Preparation, Phase-Related Trauma Responses, Follow-Up Clariﬁcations 221 Arrangements with Legal Representatives and Informed Consent from Guardians 221 Sample Evaluation Protocol 222 Traditional Clinical and Speciﬁc Trauma Assessment Techniques and Instruments 224 SUMMARY 227 REFERENCES 227 Over the past two decades, there has been increased attention paid around the world to the causes and effects of traumatic stress on children. Along with this has been an increasing recognition that children may experience a variety of psycho- logical reactions, including posttraumatic stress disorder (Pynoos, Steinberg, & Goenjian, 1996; Shannon, Lonigan, Finch, & Taylor, 1994). These developments, and the nature and consequences of psychological trauma, are of particular interest to both psychologists and attorneys addressing issues related to a variety psycholegal applications involving children. DEFINITIONS OF TRAUMA Trauma is discussed in the literature in various ways. Psycho- logical trauma has sometimes been described as an overwhelming experience that can result in a continuum of posttrauma adaptations and/or speciﬁc symptoms. At other times, psychologists and lawyers have interchangeably de- ﬁned trauma as a qualitative degree of suffering within the child (an effect) or as a psychological consequence related to a forensically relevant event (a cause). The forensic psychol- ogist asked to evaluate children in such matters should be careful to avoid assumptions about the nature, extent, and causality of psychological functioning based solely on the ex- istence of a legally contested event and its presumed magni- tude of psychological disruption. Whether a child has suffered the effects of trauma that is proximally related to a legally re- lated event can be determined only after a careful analysis of multimodal data gathered within an objective forensic evalu- ation context. Melton, Petrila, Poythress, and Slobogin (1997) note that a variety of terms have been used to describe the mental effects associated with emotional distress legal cases, but the trauma-based diagnosis most likely to be involved in mental injury cases is posttraumatic stress disorder (PTSD). Impair- ment and diagnosis are both relevant to clinical treatment and prognosis. In assessing childhood trauma, concepts of I wish to thank Marc R. Stein, Esquire, and Robert Kinscherff, PhD, JD, for their very helpful review of the chapter. 210 Assessment of Childhood Trauma damage or disability should include evaluations of whether the child’s psychological problems were proximately caused by a legally relevant event. Evaluation of childhood trauma need not be limited to traditional psychiatric diagnostic clas- siﬁcations systems, such as the Diagnostic and Statistical Manual of Mental Disorders, fourth edition ( DSM-IV; Amer- ican Psychiatric Association [APA], 1994). The DSM-IV states that the essential feature of PTSD is the development of characteristic symptoms following exposure to a situation experienced as stressful. The stressful event can involve direct personal experience that involves actual or threatened death or serious injury or other threat to one’s “physical integrity,” as well as “witnessing an event that in- volves death, injury, or a threat to the physical integrity of an- other person; or learning about unexpected or violent death, serious harm or threat of death or injury experienced by a fam- ily member or other close associate” (APA, 1994, p. 424). Historical accounts of trauma appear early in literature and are varied. For example, as cited in Pynoos et al. (1996), accounts of an adolescent’s reactions to the eruption of Mount Vesuvius are reported as early as A . D . 100–113 in the letters of Pliny the Younger (1931). Andreasen (1985) notes that the term post-traumatic stress disorder ﬁrst appeared in DSM-III, but that the concept is considerably older, often found in histories of early warfare. Andreasen describes a stress syndrome in soldiers during the U.S. Civil War that was originally believed to be due to functional cardiac distur- bance. The condition of “shell-shock” during World War I was once believed to be due to organic brain syndrome sec- ondary to carbon monoxide gas. World War II gave rise to a great number of “combat neuroses” or “traumatic war neu- roses,” which led to an increased interest in PTSD, eventually resulting in a category of “gross stress reaction” in the International Classiﬁcation of Diseases ( ICD; World Health Organization, 1977). The Web site of the National Institute of Mental Health Public Inquires notes that PTSD is a debilitating condition that follows a terrifying event and can occur at any age, including childhood. About 4% of the population will experience symptoms in a given year. Symptoms typically begin within three months following a traumatic event, al- though occasionally symptoms do not begin until years later. Once PTSD develops, the duration of the illness varies. The DSM-IV reports prevalence ranges from 1% to 14% because of the variability of the methods of ascertainment and sam- pling of populations. The public information Web site for the American Psychiatric Association (1999) reports that 10% of the population has been affected at some point by clini- cally diagnosable PTSD. The DSM-IV notes that duration of symptoms varies, with complete recovery occurring within three months in approximately half of cases. Andreasen (1985) notes that chronic PTSD is less common than acute, with symptoms of six months or longer. The foregoing statis- tics are not speciﬁc to children. Therefore, evaluators should appreciate that a given referral involving child trauma may represent a problem with signiﬁcantly different base rates. In his manual for the Trauma Symptom Checklist for Children, Briere (1996) notes that researchers have docu- mented a wide variety of psychological effects associated with trauma.As cited by Briere, some of the effects include the mur- der of a parent (Malmquist, 1986), war (Baker, 1990; Sack, Aangel, Kinzie, & Rath, 1986; Ziv, Kruglanski, & Shulman, 1974), natural disasters such as earthquakes or hurricanes (Green et al., 1991), physical and sexual abuse (Browne & Finkelhor, 1986; Kiser, Heston, Millsap, & Pruitt, 1991; Kolko, Moser, & Weldy, 1988; Lanktree, Briere, & Zaidi, 1991), witnessing spousal abuse (Jaffe, Wolfe, & Wilson, 1990; Kashani, Daniel, Dandoy, & Holcomb, 1992), physical and sexual assaults by peers or caretakers (Boney-McCoy & Finkelhor, 1995; Freeman, Mokros, & Poznanski, 1993; Singer, Anglin, Song, & Lunghofer, 1995) as well as parental divorce or hospitalization of a family member (Evans, Briere, Boggiano, & Barrett, 1994). Studies suggest that half of all sexually abused children meet partial or full criteria for PTSD (McLeer, Deblinger, Atkins, Foa, & Ralphe, 1988; McLeer, Deblinger, Henry, & Orvashel, 1992). In addition to direct threats to children, posttraumatic stress can be experienced indirectly when children perceive threat to their major sources of psychological security. Motor vehicle accidents are considered the major cause of posttraumatic stress in the general population (Norris, 1992). Burns can result in pro- tracted and disﬁguring injuries; in pediatric cases, ﬁre and burn injuries are second only to motor vehicle accidents in children ages 1 and 4 years. Children may be traumatized not only by directly experi- encing traumatic experience, but by observing the event (Lyons, 1988). In the growing literature concerning domestic violence, children are described as being subject to serious psychological detriment from the observation or knowledge of violence in the household (Jaffe, 1995). Parent reports of the child’s history or their ratings of the child’s functioning can be distorted by downplaying the incidence of interper- sonal violence in the family or their noting the effects on the child. Classes of Psychological Trauma The range of forensically relevant referrals can be grouped into categories of noninterpersonal and interpersonal forms of trauma. Noninterpersonal forms of trauma can include burns, witnessing ﬁres, motor vehicle accidents, ﬂoods, earth- quakes, and hurricanes, and other forms of natural disaster. Deﬁnitions of Trauma 211 Interpersonal forms of trauma can include sexual/physical abuse, witness to domestic violence or spousal murder, chronic exposure to expressed hostility in divorce conﬂicts, kidnapping, or shootings in school settings. One case the writer reviewed involved the scalding death of a baby in the presence of multiple siblings. In this case, there were direct and secondary traumatic effects of interpersonal origin. Not only did the children witness the death of a sibling by a parent, but they were also being considered for trial testimony in the prosecution of a parent in a death penalty case.Although each case should be analyzed without preconceptions as to whether a child is necessarily affected or to what degree, DeBellis (1997) noted that when trauma is of interpersonal origin, the resulting disorders may lead to more lasting and/or severe symptoms. Terr (1991) suggested that two classes of trauma may lead to PTSD in children. The ﬁrst involves single, sudden and unexpected experiences, such as being the victim of a violent crime; the second involves repeated occurrences, often ex- pected by the victim, such as ongoing physical or sexual abuse. Repeated exposure to traumatic stressors may result in signiﬁcant psychological disruption for a variety of reasons, including the child’s inability to proﬁt from moderating vari- ables of resilience, social support, and positive coping mech- anisms. The assessment should be broad enough to examine variables beyond simply the magnitude of the stressor, as me- diating variables can signiﬁcantly affect the child’s reaction to a traumatic event. DSM Diagnoses Related to Childhood Trauma Relevant DSM diagnoses include, but are not limited to, PTSD, acute stress disorder, and adjustment disorder with anxious or depressed features. Careful differential diagnosis is needed, particularly concerning mood disorders and/or attention-deﬁcit/hyperactivity disorder (ADHD), whose clin- ical presentations can appear similar and may be comorbid with PTSD. Meyer (1993) has noted that it may be more appropriate at times to use the diagnosis of adjustment dis- order, qualiﬁed by possible features of anxious or depressed mood, disturbance of conduct, academic inhibition, mixed emotional features or mixed disturbance of emotions and conduct. This can occur when a stressor is more likely within the normal range of experience, with little in the way of a vivid reexperiencing of the event. Differential Symptomatology of Posttraumatic and Anxiety States PTSD is classiﬁed as one of the anxiety disorders. Although some features of some anxiety disorders can occur in posttraumatic states, there are a number of distinguishing characteristics. Knowledge of these differences can be im- portant when formulating opinions as to whether the symp- toms documented in the forensic evaluation are proximately caused by a legally related event or are related to a preexist- ing or coexisting disorder. For example, panic attacks can be associated features of other anxiety and psychotic disorders. Panic attacks in PTSD are cued by stimuli recalling the stres- sor, whereas panic attacks that occur in the context of other anxiety disorders are situationally bound, predisposed, or more generalized. Panic attacks in PTSD can generalize to other situations but should originate in stimuli reminiscent of the trauma before generalization. In social phobia, the panic attack is cued by social situations; in speciﬁc phobia, by a particular object or situation; and in obsessive-compulsive disorder, by exposure to the object of an obsession ( DSM-IV, APA, 1994). Anxiety as a trait has a familial association. Generalized Anxiety Disorder, which includes Overanxious Disorder of Childhood, consists of a variety of anxiety symptoms exclusive of the distinguishing posttraumatic characteristics. Acute stress disorder is a closely related diagnosis, but is appropriate only for symptoms that occur within one month of an extreme stressor. For symptoms that persist longer than one month, PTSD should be considered. For those children who experience an extreme stressor but do not meet the PTSD criteria of dissociative symptoms, persistent reexperi- ence of the traumatic event, marked avoidance of stimuli associated with the traumatic event, anxiety, or arousal, a di- agnosis of adjustment disorder should be considered. When attempting to describe the results of one’s forensic evaluation using DSM classiﬁcations, it is important to keep in mind that each descriptive term may represent connotations to judges or attorneys not consistent with their meanings and implica- tions understood by mental health professionals. For exam- ple, the term acute stress disorder may be understood to be synonymous with PTSD in terms of the severity of symptoms or how long symptoms persist. Therefore, diagnoses de- scribed in reports or during testimony should be carefully characterized and distinguished from one another. Dissociative amnesia is characterized by a difﬁculty in re- calling important personal information, whereas depersonal- ization can include persistent or recurrent feelings of being detached from one’s mental processes or body ( DSM-IV, APA, 1994). Dissociative amnesia can occur in PTSD and is not diagnosed when it does. Forensic evaluation of children who have experienced chronic sexual or physical abuse should consider the possibility of dissociative reactions as part of a PTSD. Evaluation of these children requires addi- tional evaluation competencies to ensure defensible inter- viewing techniques and the reliability of one’s opinions. 212 Assessment of Childhood Trauma The range of symptomatology with children is not deﬁned by stage of development or the severity of the disorder. Eval- uators should be alert to the widest possible spectrum of man- ifestations that can differ from those found in the diagnostic criteria for PTSD. The evaluator should be knowledgeable about traumatic reactions in children and carefully assess the possible presence of such problems. Doing so not only increases the evaluator’s conﬁdence in the conclusions, but also anticipates possible cross-examination challenges to forensic opinions. Communicating Trauma in Forensically Relevant Terms Evaluators should not rely solely on DSM diagnostic formula- tions to deﬁne forensically relevant issues. This diagnostic classiﬁcation system was not developed to address legally rel- evant questions such as proximate cause in civil cases, the best interests of children in custody disputes, or whether children require the protection of the Juvenile Court in child abuse cases. Although trauma assessment can be undertaken in any of the psycholegal contexts described above, if the forensic psychologist uses only the DSM classiﬁcation system, impor- tant areas of legally relevant information related to the child’s response to traumatic events may be overlooked. Some chil- dren experience problems not detectable on standardized tests. Some have few symptoms; those who do not reach thresholds of clinical concern may yet be at risk for “sleeper” effects, experiencing signiﬁcant problems later in the developmental sequence. The American Academy of Child and Adolescent Psychiatry (1998) noted that PTSD in children may be under- diagnosed, possibly because the diagnostic criteria are not developmentally sensitive or because available methods for assessment make it difﬁcult to detect these effects. Phase-Related Trauma Symptomatology Forensic evaluators of trauma should recognize that the acute, chronic, and delayed-onset phases of the disorder may pro- duce different symptoms of different intensity or frequency in children at different developmental stages. Children in the acute phase may have nightmares, distressing dreams, hyper- vigilance, difﬁculty falling asleep, generalized anxiety, and an exaggerated startle response. A different symptom pattern among children whose PTSD had moved into a chronic form was noted by Famularo, Kinscherff, and Fenton (1990) for children suffering long-standing difﬁculties with detachment, restricted range of affect, sadness, dissociative episodes, es- trangement from others, and a future expectation that life will be difﬁcult. Determinants of Traumatic Effects How a child reacts to a stressful event is a function of a com- plex biopsychosocial process, including, but not limited to, the level of stress; the nature of the traumatic event; the indi- vidual’s coping ability, predisposition for autonomic arousal, and personality; the constructive support available from care- takers following the trauma; and comorbid or premorbid de- velopmental/psychological conditions. The impact of any potentially traumatic experience depends not only on the characteristics of the event, but also on the child’s tempera- ment, neurodevelopmental reactivity, attachment status, and a variety of risk-protective factors (e.g., family functioning and emotional resources; Saywitz, Mannarino, Berliner, & Cohen, 2000). Briere (1997) summarized the determiners of posttraumatic responses. He includes such factors as the characteristics of the stress, variables speciﬁc to the victim, subjective response to the stress, and the response of others to the victim. These factors can account for signiﬁcant vari- ability among children who experience what appears to be equivalent stresses. These ﬁndings underscore why it is es- sential for forensic evaluators to view each child’s situation as unique. The developmental vulnerability of the child may increase the signiﬁcance of the response by caretakers or oth- ers toward that child, thus highlighting the need for a child forensic evaluation to carefully consider this factor. Understanding Trauma as Developmental Psychopathology It is essential that forensic evaluators of childhood trauma un- derstand developmental psychopathology. This provides an integrative framework for understanding the normal trajec- tory of changes in children in general, and how disruptions in childhood development can occur at later stages in the child’s life. Examined in this framework, the disruptive effects of traumatic experience can be understood to have consequences on the child’s future ability to process information, regulate affect, and adapt socially (Berliner, 1997). The potential for future developmental disruption to a child’s functioning is one distinguishing feature in assessing trauma in children as compared to adults. It is clear, however, that childhood trauma may have profound effects on all of adult functioning, to the extent that childhood trauma may be considered a mitigating factor in death penalty cases (Goldstein & Goldstein, in press). At times, a traumatic event can exacerbate a preexist- ing psychological condition, such as a child’s anxiety and loss following a conﬂictual divorce in his or her family. It is always important for the forensic evaluator to recog- nize that the presence of legitimate psychological symptoms Deﬁnitions of Trauma 213 does not necessarily mean that they represent legally relevant evidence of impairment. For example, and as described later, whether psychological impairments are proximately related to legally contested events is an essential consideration for psychological evaluation of damages in a personal injury civil litigation. Biological Reactions to Trauma Traumatic events can produce a complex interaction between behavioral and biological stress responses systems. DeBellis and Putnam (1994) noted that multiple, densely intercon- nected, neurobiological systems were likely to be impacted by acute and chronic stressors associated with the traumatic event. The dysregulation of stress response systems within the child may impact emerging neurodevelopment and thus be potentially more detrimental to a child than to an adult. These major systems can have signiﬁcant implications for the strength of mood dysregulation, including anxiety and depression. Evaluation should include an assessment of be- havioral manifestations of motor restlessness due to hyper- aroused stress systems and /or learning and memory deﬁcits that may be secondary to anxiety. In addition, DeBellis and Putnam suggest that it is important to note the biological role in understanding traumatic effects because of the potential use of pharmacological treatments for speciﬁc target symp- toms. Such treatment may represent an important element that determines the prognosis for the child’s recove

bundet

ry. The presence or absence of appropriate treatments after a trau- matic event may affect the ultimate settlement in assessing damages. Although the forensic evaluator may not be able to accurately project the response by the child to such recom- mended interventions, identifying the foregoing issues in an evaluation report can signiﬁcantly beneﬁt considerations for treatment or legal settlement. Comorbidity and Preexisting Dysfunction Traumatic effects with children can assume a variety of divergent symptomatic expressions, requiring a broad- spectrum assessment of major areas of developmental func- tioning. Broad assessment also can identify conditions that coexist and are not proximately related to a legally contested event. Children may be assessed years after a traumatic event following the appearance of a number of psychologically signiﬁcant symptoms independent of the initial trauma. Foren- sic evaluators familiar with trauma can conduct careful inter- views of children that increasingly focus evaluation questions to clarify the nature of a child’s psychological functioning. Pynoos et al. (1996) note that grief, depression, posttrau- matic stress, and separation anxiety are interrelated but can occur independently of one another. It is essential to have as complete a history as possible of the child’s functioning over the entire developmental life span up to the time of the trau- matic event. Frequently, evaluators focus on present function- ing without sufﬁcient inquiry concerning prior functioning. Questions about prior functioning should include inquiries about trauma that may have occurred before the legally con- tested event. Many children are victims of domestic violence, physical and/or sexual abuse, medical emergencies, or ﬁres or are witnesses to extreme violence. These children may have been experiencing symptoms before the legally contested event. The evaluator must, therefore, determine whether the prior trauma has contributed to increased impairment or the child’s functioning has been changed by the event. For exam- ple, some children who have been removed from their parents due to child protection concerns are subsequently maltreated while in substitute care. Other children evaluated for psycho- logical damages stemming from a ﬁre may have been victims of chronic sexual abuse prior to the legally contested event. Consequently, the evaluator may observe signiﬁcant sympto- matology not caused by a speciﬁc traumatic event that was the precipitant for the evaluation referral. Factors Mediating Traumatic Response As noted above, prior traumatization can be a factor affecting the duration or severity of the trauma response. The sudden- ness or severity of the stressor is an important component in predicting the impact on the child, but could increase or de- crease potential effects depending on other variables. It is helpful for evaluators to consider that current symptoms may not remain present in the near future. Conversely, positive functioning at the time of the evaluation should not be taken to indicate that the child could not have suffered signiﬁcant symptoms at an earlier time. Situational factors such as pro- tracted litigation can have a contributing effect at the time of evaluation (Weissman, 1990). Personality traits can create vulnerabilities that limit adaptation and foster chronic im- pairment. The presence or absence of social support can have a dramatic effect on children’s adaptation to traumatic stress. Shalev (1996) and Shalev, Bonne, and Eth (1996) noted various factors that may predict the likelihood of PTSD, including pretrauma vulnerability, the magnitude of the stres- sor, immediate responses to the event, and posttrauma re- sponses. Additional factors that can affect the duration or severity of posttraumatic responses include genetic predis- position, prior traumatization, preexisting personality, and the child’s stage of development at the time the trauma is 214 Assessment of Childhood Trauma experienced (van der Kolk, 1987). These factors provide use- ful criteria to consider in any forensic trauma assessment. COMPETENCY, RECALL, AND CREDIBILITY OF CHILDREN’S STATEMENTS Children’s statements during evaluation must be considered in terms of developmental competency to accurately report the experience, accurately recall the chain of events, and in terms of deception. The child’s reports should ordinarily be assessed against corroborating data, which usually are more persuasive than clinical observation alone. Kuehnle (1996) noted that in the context of assessing the veracity of state- ments from children suspected of having been sexually abused, information based on consistent observations by multiple experienced professionals has consensual validity. Reports of teachers, day care staff at preschools, and pediatri- cians, in addition to mental health professional consultation, can help establish consistency of statements and behavior across settings and time periods. Such methods can assist in the determination of the child’s accuracy of recall and devel- opmental competency or indications of deception. Forensic evaluators should never solely rely on subjective appraisals of a child’s credibility to answer psycholegal questions. Weissman (1991) reported that competency in reporting events involves the capacity to perceive facts accurately, to recall, to distinguish truth from falsehood, and to be able to communicate based on personal knowledge of the facts. Expert developmental knowledge of cognitive capacities is required to assess the child’s reports and to frame questions in developmentally appropriate language. Preschool children are particularly susceptible to suggestibility as well as to de- velopmentally different ways of expressing or experiencing time and sequence. Because of these developmental lim- itations, it is sometimes difﬁcult to determine whether an absence of reported symptoms is due to an absence of difﬁ- culty, developmental limitations in expression, or DSM-IV Cluster B symptoms associated with avoidance of thoughts or feelings caused by the trauma. When assessing young children’s reports about traumatic events, one must recognize the potential complications of recall/memory in adults and children. Accurate recall by chil- dren represents a complicated process affected by diverse variables, including ongoing reports by family members and a shifting developmental interpretation for the original expe- rience. As the child learns from others about the traumatic event and their reaction to it, the child can internalize a be- lief at variance with the actual event. Studies of memory show that events are not simply encoded and later replayed, analogous to a tape recorder. Accurate recall is malleable, subject to various factors, including suggestibility, the length of time delay until questioned, emotions that existed at the time of the event, and potential selective reinforcement for certain beliefs. In addition, children have a natural tendency to reach closure, which may lead them to construct a “story” explaining what happened. Such perceptions and beliefs reported by children during evaluation may or may not be factually accurate in whole or in part, but they are psycho- logically important to understanding children’s adaptation. Although these points need to be carefully considered, chil- dren should not be presumed incapable of accurate reporting of prior events, including child abuse. EVALUATION OF TRAUMA Psychological-Legal Contexts for Evaluating Trauma The nature of the legal proceeding determines the applicable psycholegal constructs to be considered in each case. Psycho- logical assessment involving childhood trauma can occur in a variety of legal proceedings, each with different purposes, court rules, rules of evidence, and culture among attorneys and judges. The forensic evaluation is different in scope, purpose, and method from a traditional clinical assessment. The selection of assessment instruments and interview formats should be consistent with the psycholegal requirements of the assess- ment. If traditional clinical instruments are selected, the eval- uator should use them with a complete understanding of their limited applicability to the ultimate legal questions. The purpose of the forensic assessment of trauma is to in- form the court with the use of objectively gathered, valid, and relevant information. To assist the court in making informed judgments, evaluators should be open to various alternative hypotheses. Psychological tests can complement interview data by providing standardized administration of various questions or tasks with normative data. Prior to the comple- tion of the report, the evaluator should challenge his or her own conclusions by formulating counterhypotheses to ex- plain the same ﬁndings. Melton et al. (1997) suggest that the interpretive results of tests are best considered as hypotheses subject to corroboration from other sources. Grisso (1986) has noted the problem of employing general psychological constructs as a conceptual basis for assess- ments related to psycholegal issues. He discussed the need to use, whenever possible, speciﬁc forensic formulations and instruments. As with all psychological assessment instru- ments, forensic assessment instruments operationally deﬁne Evaluation of Trauma 215 dimensions of behavior, attitude, or ability. Grisso notes that forensic assessment instruments resemble criterion- referenced tests, which can speciﬁcally deﬁne the legally rel- evant domain to be measured and formulate speciﬁc ways to deﬁne mastery of the domain skills or abilities. To address the causal question of whether measured deﬁcits are proximally related to a traumatic event, the eval- uation should address the domain of psychological constructs described in the theories and empirical ﬁndings related to the trauma literature. It is important for evaluators to perform this analysis consistent with the general developmental re- quirements for assessing children and the specialized trauma literature regarding children. The sample evaluation protocol described later in this chapter includes general psychological assessment techniques useful for generating hypotheses and identifying potential areas of subsequent assessment, in addi- tion to speciﬁc PTSD instruments. Because the concept of trauma is not limited to one partic- ular type of legal proceeding, there is no single domain or test for application in all legal proceedings. Discussions of trauma in a forensic context should inform the court, in reasonably supported probabilities, about deﬁcits and the potential for stability, change, and rehabilitation. Assessment strategies should be informed by empirical research about trauma effects in children, including those studies that establish links be- tween past traumatic events and current behavioral and psy- chological functioning. Relationships among trauma variables should be demonstrated. For example, the intensity of the trau- matic event combined with the duration of exposure can lead to increased risk for disability (van der Kolk, 1987). Other re- lationships may mitigate the potential for enduring impacts, such as mediating factors of effective social support, coping strategies, and personality traits involving resiliency. Grisso (1986) describes how assessment results can iden- tify certain psychological characteristics of the examinee, and that existing research can guide the evaluator’s infer- ences to reject or accept various causal explanations and pre- dictions. At a minimum, the forensic assessment can provide the court with an explanation of functional deﬁcits and strengths with a consideration of the relationship between the results and psychological theories or studies about speciﬁc areas of functioning. Psychological Trauma in Personal Injury Litigation Trauma often arises in the context of personal injury litigation. When this occurs, it should be viewed as one part of a broader set of psychological and legal issues related to tort law and personal injury. ( See the chapter by Greenberg in this volume for information regarding psychological evaluation in tort litigation). Other forensic applications potentially involving trauma include, but are not limited to, child abuse cases and child custody conﬂicts, including allegations of domestic violence and/or child abuse; special education eligibility de- terminations; and delinquency cases where PTSD may be rel- evant to the offense or to the potential for rehabilitation. Personal injury evaluations of children can occur in civil cases involving the adjudication of alleged wrongs. Tort law is designed to provide monetary compensation for certain types of injuries. In civil proceedings, psychologists are usu- ally involved in assessing alleged damages, not in the liabil- ity portion of the proceeding, which determines whether the defendant has responsibility for the plaintiff’s allegations. Damages in tort proceedings are set by juries, subject to judicial review. According to Melton et al. (1997), deﬁnitional criteria can vary for different types of torts, but usually, the follow- ing elements deﬁne whether an actionable event has been committed: (a) The defendant owes a “duty” to the plaintiff, (b) which is violated or “breached” by the defendant, © “proximately” causing the injury, and (d) the injury is recognized as compensable. Psychologists evaluating children for psychological trauma typically do not become involved in the question of whether a duty to the plaintiff existed and/or was breached. However, the concept of proximate cause is an important legal issue and must be understood by the forensic psycholo- gist. Whether conduct was intentional or negligent, it will not lead to liability unless it proximately causes the injury. Explanations of “proximate” include whether one can reason- ably foresee that one event causes another or that an unbroken sequence of events causes the injury. Weissman (1985) re- ported that proximate cause can represent the extent to which the cause of action constitutes a substantial factor in causing impairment or disorder. He described the importance of sepa- rating proximate from nonproximate factors in the causal nexus of impairment. When conducting forensic evaluations, psychologists are trained to respect the multiplicity of biolog- ical, social, psychological, environmental, and other factors that can inﬂuence behavior and functioning. To determine proximally caused impairments, the evaluator must assess the child in a comprehensive and rigorous manner. Isolating present functioning of a child to one or more legally relevant factors can be extremely complicated and, in some cases, may be impossible to do with conﬁdence. Partic- ularly because children’s developmental capabilities evolve at different rates over time, it is often difﬁcult to determine or quantify whether the child’s delayed functioning in some areas at the time of evaluation was proximately caused by the legally contested event or by some other factor. Also, 216 Assessment of Childhood Trauma comorbid disorders predating or subsequent to the traumatic event may account for some or all of the observed deﬁcits. At the time of evaluation, children may be susceptible to situa- tional events occurring in their home, the need to be evalu- ated, or possibly being interviewed by other strangers. Even when using standardized methods of assessment with norma- tive data, the evaluator must formulate by a preponderance of the evidence a logically persuasive opinion based on a care- ful analysis of historical and multimodal assessment data. Psychological Trauma in Other Legal Proceedings In contrast to the personal injury evaluation associated with tort litigation, allegations of traumatic effects of child abuse at the hands of a parent or from witnessing domestic vio- lence can occur during a contested divorce child custody dis- pute. The Uniform Marriage and Divorce Act (1973) served as a model code for various state statutes deﬁning elements of “the best interests of the child,” the primary judicial con- cern in such cases. Statutory deﬁnitions of a child’s best in- terests are usually broad enough to include psychological trauma as one of many potentially relevant evaluation fac- tors. The psycholegal standards are different for custody evaluations, personal injury assessments, special educational evaluations, and psychological evaluations for child protec- tion in a Juvenile Court, but all assessments require knowl- edge of trauma effects with children. Estimating Future Damages Forensic evaluators frequently are asked to estimate future damages of an impaired individual. Each case should be viewed as reﬂecting a unique constellation of factors, not amenable to easy generalizations about future functioning based on epidemiological statistics. Andreasen (1985) notes that most cases are acute, in that symptoms develop quite rapidly after the traumatic event, usually within hours or days. In many of these cases, the symptoms resolve sponta- neously without psychiatric treatment. Mediating factors, described later in this chapter, can have signiﬁcant inﬂuence on future functioning. Recognizing that precise estimates of future psychological impairment may not be possible, evalu- ation opinion can include whether the child’s problems are improving or worsening and what types of interventions are likely to improve functioning. Ultimate Opinion Issues in Trauma Assessment Melton et al. (1997) caution psychological evaluators that although courts frequently seek opinions about ultimate legal issues, evaluators should be careful not to exceed the limits of what can reasonably be supported on the basis of their specialized knowledge. Even if a court permits such an opinion, the professional should be careful not to exceed the limits of the data from the evaluation. Simon and Wettstein (1997) noted that questions could be asked about whether the traumatic stressor alleged to have caused PTSD is of sufﬁcient severity to produce the disorder. However, in a forensic context, answers to such direct questions could be contaminated by a variety of factors discussed in this chapter. Unless the evaluator can provide a reasonably sup- ported and relevant opinion, it would be ethically incum- bent on the evaluator to defer the ultimate judgment to the trier of fact. Instead, the evaluator could provide the trier of fact with speciﬁc results and analyses based on the evalua- tion that do not answer the ultimate questions before the court. Forensic Expert Qualiﬁcation in Child Trauma Assessment Who is an expert in childhood trauma assessment? Fed- eral Rule of Evidence 702 deﬁnes testimony by experts. Each state may have different statutes, but they generally parallel Rule 702: “If scientiﬁc, technical, or other specialized knowl- edge will assist the trier of fact to understand the evidence or determine a fact at issue, a witness qualiﬁed as an expert by knowledge, skill, experience, training or education, may tes- tify thereto in the form of an opinion or otherwise.” (For a more comprehensive discussion of this issue, see the chapter by Packer & Borum in this volume.) In performing evaluations of children and adolescents in legal proceedings, specialized knowledge and training requires specialized competence to assess general develop- mental functioning to differentiate normal childhood ex- perience from extraordinary, such as that experienced by traumatized children. Special knowledge in childhood psy- chopathology is required to differentiate traumatic effects from possible comorbid or premorbid conditions. The eval- uator must know how to properly interview, test, or other- wise evaluate children and have specialized forensic knowledge for the type of assessment being performed. The expert must be familiar with the requirements of the relevant law speciﬁc to the appropriate jurisdiction and the type of legal referral question when performing assessments involv- ing trauma. As suggested by the foregoing forensic examples involving childhood trauma, the evaluator may potentially be called on to examine a divergent range of highly speciﬁc childhood problems, each type requiring unique training and knowledge. Evaluation of Trauma 217 Trauma Assessment or Treatment of Trauma? Greenberg and Shuman (1997) discussed the signiﬁcant dif- ferences in roles between an evaluator and a psychotherapist. The evaluator strives for objectivity and to provide relevant, balanced information for the court, not to rehabilitate or cure the client’s problems. The treatment alliance includes a quasi- advocacy role for the stated preferences of the patient, whereas forensic psychologists can be said to advocate for the data instead of the person. This principle can be easily violated in assessing childhood trauma victims, who have suffered in their past and thereby elicit, within the evaluator, protective and empathetic identiﬁcations. Parents who accompany chil- dren for their appointments may ask for advice or information, more easily creating in the evaluator blurred boundaries of roles. In these situations, the writer does not believe it is ethi- cal to withhold potentially helpful information, but imparting information may be more suitably accomplished by directing the parents to appropriate resources. Situational Factors Affecting Trauma Evaluation Those working with children often note the potentially sig- niﬁcant effects that interviews or other procedures can exert on the child. Weissman (1990) noted that protracted litigation itself may have effects on litigants, referring to this effect as “jurisogenic” conditions. Applying this concept, the writer frequently has noted that parents involved in litigation may experience altered emotional reactions that can affect their children and the child’s response to the evaluation itself. Thus, evaluations should consider the potential inﬂuence of situational variables such as parental stress and the child’s understanding of his or her own role as related to the goals of litigation. Developmental Factors and Personality The failure to adequately factor into an assessment develop- mental knowledge of a child’s level of language and cognition can result in excluding important information. Communicat- ing in terms understandable to children and eliciting responses that can be reliably interpreted are essential elements of any child assessment. It is essential to elicit relevant symptoms and to make reliable estimates of the intensity of evaluated deﬁcits, particularly as an element of compensable injury. In child cus- tody assessments, formulating opinions about child protection risk can be compromised by evaluation interviewing that exceeds the child’s developmental capability to comprehend what is asked or due to the child’s inability to adequately ex- press signiﬁcant information. Evaluations of trauma-related issues in special education cases may be compromised by comorbid factors of developmental delays in language or com- munication. Children may lack the language and cognitive competence to adequately express the nature of their experience. Special attention should be given to reports by children so that attor- neys and evaluators do not prematurely accept erroneous in- formation or reject important data that the child is unable to express. For example, in determining the magnitude of psy- chological distress, attorneys and evaluators frequently ask children to estimate the degree of their distress (e.g., anxiety or depression) on a 10-point scale. Such a technique may per- mit a useful starting point for relative comparisons, but there may be signiﬁcant psychological scaling differences between number points within or among categories or time periods. What a child means in assigning a low number in one cate- gory and what verbal labels such as “a little” mean vary tremendously and can have important legal consequences. To clarify these issues, consensual validation in the interview is useful and can be achieved by examining the same issue from a variety of vantage points. For example, the use of a 10-point scale can be complemented by having the child determine “greater than” and “less than” responses in reference to im- portant life events as well as the traumatic incident. Temporal estimates can be assessed by reporting functioning in refer- ence to known events, such as the birth of a sibling or a major holiday. Similarly, asking the child to respond via visual representational aids, such as coloring in the correct num- ber of equal-size blocks on a bar graph, allows the evaluator to examine the child’s responses according to nonverbal quantiﬁcation. To differentiate affect regulation and psychological de- fenses related to traumatic injury from other factors, it is important for the evaluator to assess general personality/tem- perament functioning. For example, teacher and parent char- acterizations of the child as shy and withdrawn in a variety of situations predating the traumatic incident would temper interpretations that all of a child’s withdrawal or avoidance could be ascribed to the traumatic event. Collateral sources of information and the child interview should attempt to recon- struct the child’s functioning in general and his or her adapta- tion to stressful life events prior to the traumatic incident. The evaluator could inquire about the child’s reactions to hospi- talizations/medical treatments, the ﬁrst day of school, marital conﬂicts/separations, and other noteworthy events. DeBellis (1997) suggested that the potential impact of trauma may be associated with a delay or deﬁciency in developmental achievements. For example, DeBellis notes the following: The anxious toddler, age 2 or 3, may show regression in motor and verbal skills, bed-wetting, and 218 Assessment of Childhood Trauma deﬁciencies in ability to self-regulate emotions; the 3- to 6- year-old may exhibit psychomotor retardation or restlessness or possible guilt; between 7 and 11 years, androgens are as- sociated with increased aggressive behaviors and inability to regulate emotions; and during adolescence, trauma may im- pact identity formation, separation-individuation, future goals, and intimate relationships. Pynoos et al. (1996) sug- gest that children be examined in the context of traumatic stress interacting with the acquisition of developmental com- petencies. That is, the manner in which a child shows the effects of trauma is partly dependent on what is developmen- tally characteristic for the child’s age, recognizing that the child is continuing to evolve developmental capabilities. Considering the impact of trauma on development gives rise to issues of future difﬁculties that have not yet emerged and that may have signiﬁcant implications for estimating damages. Traumatic Reminders and Secondary Adversities Assessment should consider that reminders of the trauma may trigger chronic or phasic recurrence of fears or other symp- toms. Berkovitz, Wang, Pynoos, James, and Wong (1994) studied children who experienced the 1994 Northridge, Cali- fornia earthquake. They found that reactivity to reminders and an inability to feel calm were predictive of chronic PTSD. Assessment interviews should focus on children’s reactions to family discussions, television news reports, and school subjects. Traumatic reminders need not be direct. For exam- ple, in one case involving a wildﬁre that destroyed an entire community, a child had to evacuate his home and described emotional reactions of fear and anticipatory dread while on his school bus going home. These reports were not provided in response to direct questions about PTSD symptoms but, rather, in the course of describing his daily experiences. After a careful interview about this experience, he revealed that he would look to the sky and see cloud formations, reminding him of how he saw smoke gradually accumulating in the sky. When he saw treetops from his school bus window, he thought of how the trees could easily catch ﬁre. Evaluators should be careful to distinguish the above reactions from sim- ple questions by the evaluator that cause recollections of past traumatic events. During litigation, it is not uncommon for parents, other family members, or attorneys to create recol- lections based on their questions. Answers to direct questions about past experience is not an intrusive recollection. Pynoos et al. (1996) note that secondary adversities can accompany traumatic suffering of children, including med- ical and surgical procedures. One such example was a child burn victim who required an ongoing series of surgeries to treat skin contractures. As the child recovered from the dis- ruption of school and family, along with the pain associated with surgery, he had to endure additional treatments. The continued surgeries, daily pain, and physical disﬁgurement constituted chronic secondary reminders of the traumatic event. Melton et al. (1997) have noted that symptoms contained in DSM or in suggested checklists, such as one described by Wilkinson (1983), need not be present for compensation if the requisite causation element is met. Although PTSD receives the predominant attention in terms of traumatic events, grief and sorrow (Smith, 1982) and changes in self-perception or “body image” in the aftermath of physical injury have also been found to be compensable (Roberts & Wilkinson, 1983). Children’s grief or sorrow can be considerable when there is loss associated with major psychological attachment ﬁgures on whom the child has depended for security and stability. In traumatic situations, the magnitude of the threat can be used to estimate the degree of psychological distress. Some studies have examined the subjective perception of threat with children (Schwartz & Kowalski, 1991), and evaluators should always inquire into the meaning of the experience to the child being psychologically assessed. Pynoos et al. (1996) note that a contributing factor to the child’s experience of external threat is the unavailability or ineffectiveness of contemplated or actual protective actions. Sparta (1982) noted children’s re- actions of learned helplessness following traumatically in- duced neurological impairment. Children with hemiplegia/ quadriplegia following sudden traumatic impairment can suf- fer pervasive disruption to major life activities, in functions not physiologically impaired, because of generalized cogni- tive attributions or beliefs about their abilities. Assessment of childhood trauma should always include inquiry about the child’s subjective experience, the role or expectation, and in- terpretations of traumatic experience. Childhood Trauma Case Examples In child trauma cases, the exposure to trauma can be more in- tense due to developmental context because children have a greater dependency on caretakers. Social supports are neces- sary to maintain even normal functioning in addition to rep- resenting a potential mediating factor and facilitating healthy adaptation. Secondary gain can be unconscious, shaped by the child’s desire to respond to the needs of parents or other attachment ﬁgures. The forensic evaluator should avoid rigid categorizations or preconceptions when determining how events can result in potential trauma in children. Consider the following exam- ple: An 8-year-old child and his younger brother in a rural Evaluation of Trauma 219 setting wander to a grain elevator. While playing, one of the brothers falls into a large grain tower and begins to sink deeper and deeper. As the child becomes more desperate to free himself, his anxious brother is holding one of his arms, attempting to pull him free. The child’s brother eventually disappears beneath the grain. After running for help, the sur- viving brother learns that it is too late to save the victim from asphyxiation. There is tremendous loss, which is vicariously reexperienced in the secondary reminders promoted by his mother’s grief. The interview revealed pervasive references to survivor guilt and a burden of responsibility and guilt for his failure to save his brother. Intrusive recollections were actively avoided by the child and not known to the child’s mother. Initially, the child denied any intrusive recollections. Later in the evaluation, feelings of loss and fear were sug- gested in drawings. The content of the drawings provided an opportunity for follow-up questions, yielding elaborate explanations for speciﬁc emotional distress associated with the traumatic event, triggered by speciﬁc situations. The child’s potential for developing autonomy and indepen- dence was compromised by his perception of his mother’s separation anxiety if he was not in close proximity. No psy- chological treatment had been provided. The child experi- enced multiple disruptions in a variety of areas, including learning due to intrusive thoughts, increased anxiety when away from his mother or home, increasing withdrawal of ef- fort in response to challenges previously mastered, and sad mood and/or anhedonic experience during much of his daily routine. Consider another example: Two children are driving with their father in his truck. When it swerves to avoid debris on the highway, the truck overturns, falling into an adjacent canal ﬁlled with water. The father is unconscious and trapped, as are the two children, who remain conscious. As the water continues to ﬁll the cab, the oldest child recognizes that she and her family are being increasingly submerged but is un- able to free herself. Eventually, a passerby runs to help all the victims, discovers all submerged below water, and reaches below the surface, successfully pulling one of the children to safety. The second child, who was very young, also survived, but the father died. In this case, the mother provided tremen- dous support, continuity, and reassurance to the surviving children. There were many extended family members who also provided the children with a continuing sense of stability, maintaining preexisting school relationships and routines. Personality traits of the child being evaluated found her to be resilient, with excellent coping skills. The acute effects of the traumatic experience were greatly mediated by other factors. Although the traumatic events are serious in both examples, the psychological outcomes could be signiﬁcantly different because of a number of mediating factors. Interviewing and Testing Issues When Evaluating Trauma Effects Considerations When Interviewing Sattler (1998) has proposed the following techniques as use- ful for interviewing children: Use appropriate intonation and do not lead; ask for examples; be open to what children tell you; rephrase children’s answers for conﬁrmation; give praise frequently for talking about their experience, but avoid selective reinforcement for only certain topics or responses; consider the child’s age in setting the tempo and length of the interview; and use simple questions and, where appropriate, concrete referents. A concrete referent can be line drawings depicting emotional expressions on faces to create affect la- bels or concrete representations of the strength of the child’s psychological experience. Sattler (1998) has also suggested avoiding yes-no ques- tions unless a speciﬁc fact is being veriﬁed. Questions should avoid compound elements within the same question, in which the child is confronted with two persons or situations at once. The child may be confused and interpret the question in a manner completely different from that intended, or respond to selective elements in a manner that is not clearly understood by the interviewer. When conducting interviews, the evaluator should be care- ful not to offer suggestions, distort the meaning of child com- munications, or follow misleading avenues of questioning due to the examiner’s prior expectancies. Possible contamination in a trauma assessment could result from an evaluator’s start- ing the evaluation by asking the child questions with speciﬁc content reﬂecting the DSM criteria. Instead, the examiner might begin asking open-ended questions that elicit the child’s descriptions. This is especially important when work- ing with preschool children, who may be deferential to older/authority ﬁgures. Additionally, because recall may be a function of a malleable and reconstructive process subject to various contaminating inﬂuences, the interviewer may wish to inquire about how many prior occasions the child was inter- viewed and under what conditions. An interesting analogy may be drawn to techniques used by a recognized sketch artist who consults with the FBI and other law enforcement agencies (Boylan, 2000). The artist recog- nized the potential contamination caused by conventional police techniques of showing children photos and asking them multiple questions about a criminal suspect before the chil- dren have had an opportunity to spontaneously report their 220 Assessment of Childhood Trauma own experiences in their own words and at their own pace. Interviewing children should begin by establishing rapport. When the child is relaxed and talking, the interviewer care- fully introduces selected elements. Only after a thorough re- construction of the child’s account does the interviewer ask speciﬁc conﬁrmatory questions. Similarly, when conducting trauma interviews, the mental health professional must be alert to such effects. Ceci and Bruck (1995) have described various potential examiner effects on children interviewed in the context of child sexual abuse investigation. Such cautions are relevant to trauma assessments. Other commentators have addressed similar issues in the forensic context (e.g., Faust, Ziskin, & Hiers, 1991), recog- nizing that examinee responses may be affected by the char- acteristics or behavior of the examiner. Ware (1998) noted that direct observation is an effective complement to parent and /or self-report. When observing the child in various settings, the evaluator should consider the timing of the observation in relation to when the trauma occurred. There are a number of structured and semistruc- tured tools for assessment, ranging from generalized behav- ior to speciﬁc quantiﬁcation within particular populations. The examiner’s choice of instrument should be guided by the ﬁndings that emerge as the evaluation proceeds. Considerations When Conducting Psychological Testing When using psychological tests, it is important to recognize that most were developed for traditional psychotherapeutic needs rather than for forensic evaluation of speciﬁc traumatic effects. Therefore, caution must be exercised in interpreting the results from such instruments. Briere (1997) noted that results obtained on traditional tests can be misinterpreted by confusing intrusive recollections caused by PTSD with hallu- cinations or obsessions, dissociative avoidance related to trauma with fragmented thinking, or hypervigilance with paranoid processes. Checklists or structured interviews that speciﬁcally parallel posttraumatic symptomatology can pro- vide an opportunity to more precisely differentiate the causes of various symptoms. Trauma effects can vary in frequency of symptoms and their respective intensity and duration. Therefore, the evalua- tor should be open to consider the broadest range of possible effects. Because the type of psychological testing instrument used can produce different information about the same child, the evaluator should consider a range of different types of assessment techniques or instruments. Rating scales vary in their format and type of information revealed. Some scales ask whether a symptom is present, the degree to which it is experienced by the child, and the frequency and/or intensity with which it is experienced. Nader (1997) noted that some- times just asking about symptoms can produce them tem- porarily in a traumatized child, and that speciﬁc symptoms may occur with a relatively healthy child. Kuehnle (1996) noted that dissociation has been reported as a common consequence of trauma and speciﬁcally sexual abuse. ( See Chapter 22 for more information regarding this topic.) Dissociation is a complex psychophysiological process, representing, on the severe end of the continuum, a signiﬁcant disruption in the child’s everyday life. This process needs to be differentiated from common developmental expe- rience related to daydreaming, forgetfulness, or changes in at- tention (Hornstein & Putnam, 1992). Among the instruments that assess dissociation are the Child Dissociative Checklist (Putnam, 1990) and the PTSD Reaction Index (Pynoos et al., 1987). Concordance in reporting between child and parent can provide corroboration regarding the validity of some test ﬁnd- ings. However, some parents may not wish to recognize their child’s suffering (Sternberg et al., 1993). This may depress es- timates on rating scales for frequency or intensity of symp- toms. Nader (1997) has noted some indications that long-term and ongoing trauma may produce greater reexperiencing and avoidance, creating more challenges for accurate assessment. Third-Party Interviews Information from parents, teachers, and other care providers can provide important information about the child’s reactions to a traumatic event. Prior to weighing the relative impor- tance of such information, the forensic evaluator should assess whether the third-party respondent is minimizing or otherwise distorting the impact of events. For example, one study noted that after a tornado, parents attempted to control their own anxiety by minimization or denial of the event’s impact (Bloch, Silber, & Perry, 1956). In personal injury evaluations, where monetary gain or loss is possible depend- ing on the outcome of the evaluation, respondents can per- ceive or report exaggerated disability. As part of a comprehensive evaluation, parental history is sought regarding the child’s family, educational, social, and health history. Educational, medical, and other professionals who have observed the child should ordinarily be included as collateral sources of information. Parents are also potential sources of important information as to the child’s functioning both before and after the traumatic event. Interview questions may begin assessing general cate- gories of developmental functioning, including, but not limited to, questions related to the child’s behavior in learning situations, social relationships, mood, academic functioning, Evaluation of Trauma 221 family relationships, mastery of activities of daily living, motivation in completing tasks, and health status. More speciﬁc questions may include symptoms described in DSM-IV (APA, 1994), such as sleep disturbance, dimin- ished interest or participation in activities, deliberate at- tempts to avoid certain situations or thoughts, or statements suggesting a foreshortened future (e.g., not expecting a nor- mal life span or a career). The evaluator should be alert to probe when reports suggest altered behavioral or emotional reactions representing different functioning compared to pretrauma functioning. As the interview continues, the evalu- ator should inquire about possible symptoms, traumatic reminders, and secondary effects. Later sections of this chap- ter provide references for various instruments that survey childhood reactions to trauma. (For further information on third-party interviews, see the chapter by Heilbrun and Warren in this volume.) Interview Preparation, Phase-Related Trauma Responses, Follow-Up Clariﬁcations The forensic evaluator must be familiar with all known as- pects of the traumatic event(s), including the sequence of events, the reported reactions of the child and/or family, and all external source of information, such as police reports, wit- ness statements, news accounts, and other collateral sources. Forensic evaluations are typically undertaken signiﬁcantly after the traumatic event has occurred, resulting in an assess- ment conducted considerably later in the child’s reaction to the trauma. Children can make a successful adaptation to an acute traumatic response within six months. Andreasen (1985) noted that most cases of PTSD are acute, involving symptoms within hours or days of the event, and that in many of these cases, symptoms resolve without treatment. How- ever, children may continue to experience intense psychic numbing and avoidance, which can mask psychological difﬁ- culty, and there can be a risk to underestimate the complexity of children’s traumatic experiences (Pynoos et al., 1996). The DSM-IV (APA, 1994) notes that complete recovery occurs within three months in approximately half of the cases, whereas many other cases reﬂect persisting symptoms of experience of the trauma, avoidance, and hyperarousal longer than 12 months. Following the completion of assessment instruments in the standardized fashion, a follow-up interview with the child is essential. As Nader (1997) noted, children and ado- lescents more accurately convey their true psychological ex- perience when they can comfortably ask questions of a skilled interviewer, one who can probe when necessary while avoid- ing leading questions. Because of age-related variables in comprehension and expression, possible limitation in item construction, and possible avoidance features of posttrau- matic response, follow-up validation is important. For exam- ple, a 9-year-old child who survived a sniper shooting that killed her sibling and wounded her mother reported on the Children’s Depression Inventory (Kovacs, 1992), “I’m tired all the time.” This raised questions about possible lethargy, anhedonia, and withdrawal from activities of daily living. Subsequent interviews revealed that her answer was actually quite benign, as the child explained that in the morning she “likes to sleep in all the time.” Particularly with younger chil- dren, adults can frequently infer meanings that are not ac- curate reﬂections of the child’s experience. In the same protocol, the child denied mood disturbance, but a follow-up interview revealed dysphoric mood, intrusive recollections of the event, and an acute grief reaction that immediately fol- lowed the trauma and her mother’s bouts of depression asso- ciated with the trauma. A follow-up interview is also important because sec- ondary trauma can cause effects that would not be predicted from a logical understanding of the traumatic event itself. For example, a child of 2 years of age at the time of a sniper shooting would not likely be able to fully comprehend the seriousness of the presence of emergency response vehicles, smoke accumulating in the residence complex, or fearful ex- pectations about future threats. However, the child’s depen- dence on the quality of attachment with her primary caregiver could lead to signiﬁcant disruption because of the adverse impact on the child’s mother. The child’s vicarious identiﬁca- tion with the mother’s fears and depression or the mother’s withdrawal behavior can secondarily produce signiﬁcant impact on the child’s functioning. Arrangements with Legal Representatives and Informed Consent from Guardians Evaluators should explain to the minor’s legal guardian, in terms that are understandable and noncoercive, what their role will be. A separate explanation should also be provided to the minor in developmentally appropriate terms. The agreement should make clear to the legal guardian that you are assessing the child for purposes of formulating general psychological opinions and, to the extent possible, speciﬁc psychological opinions related to the child’s psychological functioning rela- tive to the legal case. Because all states have some form of legally mandated child-abuse reporting laws, the evaluator should inform the appropriate parties about these responsibil- ities. The possibility of child abuse is a potentially signiﬁcant factor in differentiating whether symptoms preexisted trau- matic events. 222 Assessment of Childhood Trauma A letter of engagement from the attorney or court that retained the expert should memorialize his or her role prior to assessment. This letter should include fees and how they are to be paid and clearly state that a contingency agreement does not exist.Any payment contingency creates an actual or perceived contamination inﬂuence on the objectivity of the evaluator’s opinions and is speciﬁcally prohibited in the “Specialty Guidelines for Forensic Psychologists” (Committee on Ethi- cal Guidelines for Forensic Psychologists, 1991). Evaluators should explain who retained them, that they may be communi- cating directly to the retaining party any information they may gather or opinion they may form, and that interpretation and opinion may be used in the case. Evaluators may be asked to audiorecord the session, particularly during personal-injury-related cases. Some eval- uators decline participation of an evaluation under such conditions because it is believed to violate standardized assessment protocol. Regarding audiotaping the session, fre- quently, one machine records for the requesting party, and another machine simultaneously records for the examiner/ retaining party. In general, this writer does not consent to requests to videorecord, as he considers it too intrusive to the evaluation process when compared to an audiorecording that can preserve an accurate record of the examination. The expert may be asked to allow legal counsel to be pre- sent during the examination. This writer will not agree to conducting an evaluation under this condition, as it violates the standardized nature of the assessment process, with po- tential effects on subject and/or examiner. Some states have legal cases supporting the exclusion of legal counsel during psychological evaluation. Ragge v. MCA (1995) resulted in a court ruling that the plaintiff’s attorney was not entitled to disclosure of the spe- ciﬁc psychological tests that would be used in the evaluation and declined to allow a third-party observer to be present dur- ing the psychological examination. In evaluations of trauma with children, it is common to request from parents behavior rating forms, such as the Achenbach Child Behavior Check- list (Achenbach, 1992). Prior release of such forms to parents and legal representative(s), outside of the evaluator’s ofﬁce, results in a situation whereby the evaluator does not know the conditions under which the forms were discussed and poten- tially inﬂuenced by others. If the expert was retained by a defense attorney involving a personal injury matter, the family’s lawyer frequently will prohibit the parent from being drawn into the evaluation process in any way. If this cannot be resolved by the evaluator, it should be referred to the attorneys for resolution. If the parent does not provide information, evaluators should note in the report possible limitations of the ﬁndings. Sample Evaluation Protocol Identifying Information and Reason for Referral The evaluator should describe who was seen and whether they were seen individually and/or conjointly. Report how many sessions occurred and the total amount of time spent with each person. Report who retained the expert and for what purpose. Describe the nature and date of the legal event and/or alleged psychological injury. Describe the fact pattern that gave rise to the cause of action, describing the events and reactions of the child and the child’s family. Report whether the evaluation was recorded and, if so, by whom. Personal, Family, Educational, and Medical History The evaluator should describe the child’s educational experi- ence, including reports of teacher concerns and student successes, special education assessments, and any type of edu- cational remediation. Describe the child’s family history, including household composition, divorce and custody ar- rangements, and conﬂicts associated with child custody. Char- acterize family relationships, including any problems that required police responses, social service interventions, or re- locations, and special health problems of family members. Report the developmental history of the child, including any speciﬁc delays, birth complications, including causes of anoxia/hypoxia, and any history of accidents/injuries. For older children and adolescents, review any past alcohol or drug use. Report health status and the reasons for past medica- tion. Inquire about possible mental health treatment or school counseling, and report the results of the review of records of these interventions and interviewees of providers or parents. Review of Records and Other Data Sources List all sources of information reviewed in formulating opin- ions, including testing previously administered. List all eval- uation procedures, including all psychometric instruments, clinical interviews, mental status examinations, developmen- tal history, and observations of the child during conjoint meetings. Interviewing Protocol Create the proper interview environment. Build rapport by showing interest, being attentive, offering encouragement and compliments when appropriate, encouraging sponta- neous discussion, and inviting discussions presumed to be nonthreatening and enjoyable to the child. Inquire about gen- eral interests and past experiences. During the interview, Evaluation of Trauma 223 invite projective responses for which there are no clear an- swers, such as: “What do want to be when you grow up?”; “Tell me about your favorite books, movies, or TV pro- grams”; “Tell me about your happiest memory”; “What was so special about it?”; “If you had three wishes, what would you wish for? Why?” The forensic evaluator should be alert to responses in the context of the psycholegal questions related to trauma. For example, what the child wants to be when he or she becomes an adult may reveal whether the child has a fore- shortened sense of the future or has speciﬁc fears, or may sug- gest whether the child has positive expectations for the future. When the evaluator is ready to transition to more formal questioning, the content of the forensic interview can include the following. General Psychological Functioning. This includes major developmental/psychological areas of functioning. In- quire about family and other interpersonal relationships and academic and behavioral functioning in school. Examine ac- tivities of daily living, but with the perspective of what is known from the trauma literature. Examples to consider when reviewing the child’s general experience include dis- turbed sleep and the time course for its existence, possible acting or feeling as if the traumatic event were recurring, and intrusive recollections of the traumatic event. When ques- tioning the child about everyday experience or past history, the evaluator should be alert to probe areas suggesting altered emotional responses during the interview. Having the beneﬁt of prior records review or interview data from third parties, the evaluator can identify potential areas of differential func- tioning compared to pretrauma functioning. It is not uncom- mon to begin questioning about general experience and then refocus inquiry in speciﬁc areas of trauma-related symptoms. Speciﬁc Interview about the Legal Cause of Action. This includes questions about precipitating events and the child’s narrative of what occurred. The child should be ques- tioned about his or her reactions to reported events as well as reactions to potential intervening factors or events that may have exaggerated or moderated the child’s reaction. The eval- uator should ask the child to describe his or her functioning over time, up to the time of evaluation. Question subjective symptoms, including their onset, frequency, and intensity, and whether the child reports feeling different in any way since the legally relevant event. Interview the parents for their observations and impressions about these areas. Medical/Health History. This should include inquiries about all medications that are being taken and for what pur- pose, emergency room consultations, and consultations with physicians or other health care professionals. The child’s reports should be compared to those of the parent and the medical record. Inconsistencies should be investigated for possible distortions by the child and/or parent or possible signs of avoidance or inability to recall important aspects of the trauma. Family History. Ask the child and the family about the trauma’s impact on various family members. Inquire about possible preexisting/coexisting sources of trauma, including questions designed to rule out all forms of prior child abuse, exposure to domestic violence, alcohol/drug abuse in the child’s environment, divorce conﬂicts, and frequent disloca- tions of home and school environments. In some cases, col- lateral sources of information may have to be interviewed about these factors. Interviews Speciﬁc to Traumatic Events The Diagnostic Interview Schedule for Children, Version IV, PTSD Subscale. The highly structured Diag- nostic Interview Schedule for Children (Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000) has been in develop- ment since 1979, and the current version is based on the DSM-IV . The schedule also includes a PTSD subscale. Sepa- rate questionnaires are used for children ages 6 to 12 and for adolescents ages 13 to 17. The interview is available in English and Spanish and can be used by nonprofessionals. This interview schedule will guide the evaluator asking ques- tions sufﬁcient to address the nature of the traumatic experi- ence and DSM-IV symptomatology including reexperiencing symptoms, numbing/avoidance, and hyperarousal. Mental Status Exam. The evaluator may perform a clinical assessment of the child according to the traditional criteria of a mental status exam, enabling the evaluator to make comparisons of the child with other children previously evaluated. Mental status examination criteria may focus on areas of functioning found in the literature on childhood trauma. Assessment of orientation and alertness could in- clude questions regarding physiological reactivity to internal cues that resemble or symbolize an aspect of the traumatic event. When assessing the child’s range of emotional expression and predominant mood, the evaluator should note altered states of emotional functioning, intense psychological dis- tress, the presence of a foreshortened future, and diminished interests. In assessing the child’s thinking process, the evalu- ator may include questions about possible anticipatory fears for future events and anxious beliefs related to the traumatic 224 Assessment of Childhood Trauma event. The child’s responses should be analyzed for possible perceptual distortions associated with sensory cues and other events. An assessment of the child’s thought content may include questions about intrusive thoughts and persistent reexperience of the traumatic event. Evaluation of cognition may include questions about al- terations of attention and concentration. The evaluator should inquire about possible hypervigilance. Questions about the child’s insight and judgment may include the child’s under- standing of the relationship between the traumatic event and present functioning. Motor functioning, including exagger- ated startle response, hyperactivity, and psychomotor retarda- tion should be assessed and differentiated from possible preexisting disorders, such as ADHD. Psychological Testing The evaluator may administer a broad battery of testing sufﬁ- cient to assess the general emotional, cognitive, and educa- tional functioning of the child, combined with speciﬁc interview instruments or techniques related to childhood trauma. Standardized testing for cognitive/neuropsychologi- cal functioning may include a full intelligence test battery. Assessment of personality traits, emotional states, with- drawal tendencies, reports of somatic symptoms, distur- bances of mood, and interpersonal conﬂicts can be evaluated with a variety of standardized measures, some of which are described later in this chapter. Standardized testing instru- ments using developmental norms assist the evaluator in making comparisons among different test scores with the same child. This can potentially reveal inconsistencies in re- porting, useful for determining possible exaggeration or min- imization of symptoms. Standardized measures of aptitude and achievement could potentially reveal signiﬁcant decre- ments in functioning compared to pretrauma functioning. The evaluator should note differential responsiveness to di- rect versus indirect questioning of trauma so that the in- terview process can be adjusted to comport with the child’s ability to proceed. Traditional Clinical and S

bundet

peciﬁc Trauma Assessment Techniques and Instruments The forensic evaluator may consider using the traditional clinical instruments described below, recognizing that those developed for traditional clinical purposes may suffer con- siderably in accurately generalizing results to addressing psycholegal issues. Because there are severe limitations in methodology in assessing emotional states in young chil- dren, the following traditional clinical procedures may be considered for purposes of generating hypotheses subject to corroboration. Additionally, as children may experience a wide range of reactions that are not directly PTSD-related, it is important to use instruments that can assess a broad spec- trum of symptoms (Ruggiero, Morris, & Scotti, 2001). In- formation generated from such instruments may lead the examiner to inquire in areas that may not have been appar- ent. Evaluators should guard against formulating unsup- ported opinions, which can be helped by examining results in the context of standardized protocols reﬂecting the cur- rent research about traumatic effects in children. Traditional Clinical Assessment Techniques and Instruments The Children’s Depression Inventory. For use with children between 7 and 17 years of age, the Children’s Depression Inventory (Kovacs, 1992) quantiﬁes a range of depressive symptoms, including disturbed mood, hedonic capacity, vegetative functions, self-evaluation, and interper- sonal behaviors. Items from this instrument can help identify possible intrusive ideation and attentional inconsistencies, isolating or withdrawing behaviors as possible defenses against unresolved psychic trauma. Body image distortions, which can be particularly important in cases involving actual or feared disﬁgurement, such as from ﬁre/burns, physical trauma secondary to motor vehicle accident, dog bite attacks, and physical assaults, can be revealed on items pertaining to self-image and self-esteem. The Draw-a-Person and Kinetic Family Drawing Techniques. Although among the weakest in terms of empirical validation, these instruments, when used in a lim- ited fashion, can facilitate communication and hypotheses about the child’s psychological experience (Pihl & Nimrod, 1976). The examiner should recognize that such tech- niques do not meet deﬁnitions of formal tests with manuals describing standardized procedures, reliability/validity stud- ies, and descriptions of their development in reference to the population being studied. However, when used in a child assessment as a basis for generating hypotheses or facilitating the child’s expression of past experiences or psychological states, the use of drawings can be an intrinsi- cally rewarding opportunity for the child to overcome avoidant defenses. Systematic scoring techniques have been developed for childhood cancer victims as one example of preserving the intrinsic interest by children for drawing while maintaining methodological standardization for ad- ministration and interpretation (Spinetta, McLaren, Fox, & Sparta, 1981). Evaluation of Trauma 225 Sentence Completion Techniques. These techniques do not qualify as tests, but can facilitate expression, generat- ing associations within the child about trauma-related experi- ence. Follow-up interview concerning the child’s responses can yield important information not previously disclosed dur- ing any other portion of the evaluation, or can provide addi- tional information about subjects reported at another time. Thematic Apperception Test/Children’s Apperception Test and Roberts Apperception Test. The child’s story constructions can help reveal the child’s perceptions of the environment, defense mechanisms for resolving conﬂicts, predominant moods, and relationships with others. Using the Thematic/Children’s Apperception Test (Bellak, 1993) or Roberts Apperception Test (McArthur & Roberts, 1990), children who have experienced traumatic effects may elabo- rate on threats of harm, hypervigilance, or avoidance toward particular elements of the traumatic event. In the context of such discussions, where the secondary gain for exaggerating symptoms is less obvious, such data can provide a corrobo- rating source of evaluation ﬁndings. Behavior Rating Scales. These scales can be completed by teachers and parents, providing important data comple- menting self-reports by the child or collateral information contributed by sources independent of litigation. The Child Behavior Checklist (Achenbach, 1992) includes scales of at- tentional difﬁculties, depression/anxiety, and speciﬁc items within each scale potentially relevant to the assessment of trauma effects. Information can be immediately scanned for signiﬁcant items on the day of the child’s examination. Con- sistency among items endorsed by parents and problem areas elicited from the child during the forensic interview provides convergent validity or suggestions for over/underreporting. Assessment of a broad spectrum of developmental function- ing is helpful for examining the potential presence of comor- bid or preexisting problems. Teachers can provide valuable information in helping to establish diagnoses regarding the spectrum of childhood psychopathology. Parents can report changes in behaviors in the home and with peers (Reich & Earls, 1987). Ratings of children should consider source vari- ance (consisting of rater biases), setting variances (consisting of differences in the child’s functioning by environment), and temporal variance (referring to changes in behavior over time; Martin, Hooper, & Snow, 1986). The Children’s Attributions and Perceptions Scale. This brief 18-item scale was designed to measure children’s attributions and perceptions of self in a sexual abuse context (Mannarino, Cohen, & Berman, 1994). This scale includes questions assessing feeling different from peers, reduced interpersonal trust, and personal attributions for negative events. In the context of trauma assessment, information from this scale may yield information about guilt and help- lessness following sudden traumatic experience or sexual abuse. Two of the subscales were reported to correspond to the stigmatization and betrayal factors described by Finkelhor (1987). Speciﬁc Trauma Assessment Techniques and Instruments The instruments described below more closely follow the theory and empirical research regarding the trauma literature related to children. Many of the instruments are focused on PTSD or other trauma-related conditions and should be con- sidered as part of a comprehensive assessment of trauma. Nader (1997) provides excellent critiques on reliability, va- lidity, training, and issues related to the use of these scales. The Trauma Symptom Checklist for Children. Briere’s (1996) instrument is one of the most psychometri- cally developed in terms of item relevance and empirical in- vestigation. It is a self-report measure of posttraumatic stress and related psychological symptomatology, for use with children between 8 and 16 years of age. Because the child provides direct responses to the items, it is an excellent com- plement to rating data completed by parents or teachers. The range of posttraumatic symptomatology is broad, including items concerning sexual victimization. Two validity scales are included along with six clinical scales. After the standard- ized completion of the instrument, the evaluator can inter- view the child about items that contain signiﬁcant answers. This posttest interviewing can provide important clariﬁcation regarding the underlying psychological experience of the child, often including essential clariﬁcations related to proxi- mate cause, secondary traumatic effects and comorbid or pre- morbid factors. Promising preliminary psychometric support has been established for a version of the instrument for chil- dren younger than 8 years (Briere et al., 2000). The Clinician-Administered PTSD Scale for Children. Developed by Nader, Kriegler, Blake, and Pynoos (1994), this instrument has more direct relevance to forensic assess- ment as compared to more traditional assessment tools. Fre- quency and intensity of PTSD symptoms are evaluated, as well as their impacts on social functioning. Symptoms in- clude those reported in DSM-IV and from the literature con- cerning childhood trauma. This is a relatively new instrument without extensive validity or reliability data. 226 Assessment of Childhood Trauma The Child Dissociative Checklist. This instrument (Putnam, 1990; Putnam & Peterson, 1994) is completed by someone familiar with the child’s functioning during the pre- vious 12-month period. It is short and can be completed in a brief amount of time. The items were derived from profes- sional experience with dissociative disorders, including am- nesia, rapid shifts in demeanor, access to information, ability and age-appropriateness of behavior, spontaneous trance states, alteration in identity, aggressive or sexual behavior, and hallucinations. Because of the brevity of the instrument, it is possible to easily perform repeated assessments during different times and circumstances in the child’s life, although this often is not possible in forensic assessment. The Child Posttraumatic Stress Reaction Index. This 20-item scale developed by Frederick, Pynoos, and Nader (1992) considers the main symptoms of DSM-IV, including questions related to reexperiencing trauma, numbing/avoid- ance, and physiological arousal. Items are scored on a 5-point Likert scale ranging from “none” to “most of the time.” Realmuto et al. (1992) note some inconsistency between the items on the scale and symptoms listed in the DSM-III-R and DSM-IV, including some items asked more than once and some symptoms not addressed by the scale. In using this scale and others related to forensic assessment of trauma, it is par- ticularly important to conduct posttesting interviews about symptom duration, frequency, and intensity (Nader, 1997). The Children’s Impact of Traumatic Events Scale. First developed by Wolfe, Wolfe, Gentile, and Larose (1986), the scale was revised based on factor analysis of the original 54-item instrument (Wolfe & Gentile, 1991). Dimensions in- clude PTSD (intrusive thoughts, avoidance, hyperarousal, and sexual anxiety); social reactions (negative reactions from oth- ers and social support); abuse attributions (self-blame/guilt, empowerment, vulnerability, and dangerous world); and eroticism (particularly relevant to trauma caused by sexual abuse). The scale can be used for noninterpersonal types of traumatic experiences as well as interpersonal trauma result- ing from sexual abuse. The sexual anxiety scale was patterned after the traumagenic factors described by Finkelhor and Browne (1985), consisting of helplessness, stigmatization, betrayal, and traumatic sexualization. Child Rating Scales of Exposure to Interpersonal Abuse. Nader (1997) reports that the Child Rating Scales of Exposure to Interpersonal Abuse (Praver, 1994) assesses both the frequency and severity of children’s exposure to interper- sonal abuse. This instrument can be used for children 6 to 11 years of age. A version of this instrument, the Angie/Andy Child Rating Scale (Praver, Pelcovitz, & DiGiuseppe, 1994), uses an illustrated format based on cartoon characters. The child is asked whether a character has been exposed to sexual abuse, physical abuse, witnessing family violence, and com- munity violence. An earlier scale by Richters and Martinez (1990), called Things I Have Seen and Heard, is described as a structured interview for assessing young children’s violence exposure and also uses a cartoon character. These scales may be useful in trauma assessment for young and/or develop- mentally delayed children who have experienced interper- sonal forms of trauma. When Bad Things Happen Scale. Similar to the Trauma Symptom Checklist for Children, this scale (Fletcher, 1991) is completed by the child. The scale can be used for chil- dren age 8 and older and assesses PTSD symptoms and other trauma-related items. An additional scale, Dimensions of Stressful Events, measures trauma-exposure variables and results. Examples of what is assessed include number of traumas and whether there is a sense of stigmatization. This scale and many others focused on trauma assessment are continually being revised and undergoing psychometric validation. The Child’s Reaction to Traumatic Events Scale. Jones’s (1994) 15-item self-report measure assesses the child’s reactions to stressful events. Item content focuses on DSM criteria of PTSD and from reported reactions to people following traumatic experiences using a 4-point rating scale from “not at all” to “often.” Particular attention is given to items related to intrusions and avoidance. March (1999) provided an excellent review of assessment instruments related to childhood trauma. Additional instru- ments related to PTSD criteria include the Kiddie Post- Traumatic Symptomatology Scale (March & Amaya-Jackson, 1999, as cited in March, 1999) and the Children’s PTSD Inventory (Saigh, 1997). As Ruggiero et al. (2001) note, trauma researchers typi- cally distinguish among various distinct events. For example, sexual abuse represents a distinct form of interpersonal vio- lence. Consistent with Grisso’s (1986) recommendations, assessment instruments used for forensic purposes should match the psycholegal dimensions of behavior, attitude, and ability. The Trauma Symptom Checklist for Children (Briere, 1996) contains items related to sexual abuse in a separate subscale. The Child Sexual Behavior Inventory (Freidrich, 1997) assesses a wide variety of sexual behaviors by children and provides normative behavior for abused and nonabused child populations. It provides a greater amount of psychome- tric information regarding its development and validation References 227 relative to many PTSD surveys. The Child Rating Scales of Exposure to Interpersonal Violence (Praver, 1994) are emerg- ing measures concerned with children’s exposure to interper- sonal violence, including frequency and severity. Enns et al. (1988) reported a number of trauma-related assessment tech- niques in connection with adults who may have experienced sexual abuse as children. Kuehnle (1996) provides an excel- lent review of assessment techniques of child sexual abuse (see also the chapter by Kuehnle in this volume). Strategies for assessment should include measures reﬂecting the unique nature of each type of trauma, not simply generalized PTSD responses. SUMMARY Concerns about violence underscore the need for accurate as- sessment of how traumatic events affect children. The in- creased attention in the trauma literature improves the ability of experts to provide effective treatment and answer forensic questions. Legally contested issues involving children may include a variety of traumatic events. Forensic referrals differ in pur- pose, including, but not limited to, those associated with per- sonal injury litigation, child abuse cases, child custody conﬂicts (including allegations of child abuse or domestic violence), special education eligibility, and delinquency cases in which PTSD may be relevant to the offense or to the potential for rehabilitation. Each type of referral demands knowledge of the speciﬁcally relevant law of the applicable jurisdiction. Forensic evaluation of trauma with children in- volves developmentally appropriate and empirically sup- ported methods, and must focus on the relevant psycholegal questions. Evaluations that are objectively performed use multimodal traditional clinical and forensic methods, and in- tegrate specialized knowledge about trauma and its effects can provide the trier of fact with valuable information neces- sary to a verdict. As Melton et al. (1997) note, the ultimate practical useful- ness of a forensic report, or testimony based on that report, is a persuasive message to the referral source about the ﬁndings and opinions resulting from the evaluation. To facilitate the understanding of legal consumers, several areas are worthy of further investigation. Forensic evaluations of young chil- dren are particularly challenging because of the limitations in methodology in assessing the potentially broad range of emo- tional states associated with childhood trauma. Traditional assessment methods may be used to generate hypotheses sub- ject to other validation, but such instruments can have serious limitations. One reason forensic assessment instruments are usually superior to traditional forms of techniques in forensic pro- ceedings is that they more directly sample and measure the speciﬁc legal application appropriate to the referral. When the inferential components between assessment procedure and forensic conclusion are reduced, the forensic evaluator has a better chance of more accurately addressing the domain of psycholegal issues and to clearly communicate with the legal consumers of trauma evaluations. Future specialized assessment methods, more sensitive and speciﬁc to trauma issues, will address Briere’s (1997) cautions about the risks of misinterpretation based on the use of only traditional clinical assessment methods. For example, in a personal injury case involving a child burn victim, assessment could go beyond questions that mir- ror the PTSD diagnostic criteria. Questions regarding the na- ture and extent of pain, whether there is anticipatory fear for repeated medical procedures or surgery, and psychological identity issues resulting from disﬁgurement may yield impor- tant data not elicited by other PTSD or dissociation in- struments. The potential identiﬁcation of these issues may increase the likelihood for determining secondary adversities not typically associated with the traumatic event. Each type of childhood trauma represents a relatively unique and impor- tant area deserving specialized investigation. It may be par- ticularly difﬁcult for the forensic evaluator to appropriately transpose broad categories of PTSD symptomatology into relevant psychological experience among the many different types of childhood trauma. Given the developmental factors that make accurate un- derstanding of a child’s psychological experience sometimes difﬁcult, more specialized assessment methods may make it easier for children to communicate their experience. The PTSD symptom of avoidance against revealing traumatic experience emphasizes the need for developmentally sensi- tive and specialized assessment. The literature has described problems that arise when questioning children. These difﬁcul- ties may be due to the child’s perception of the interviewer, the wording of questions, and the absence of concrete refer- ents in eliciting or cross-validating answers. The development of solidly conceptualized and rigorously validated instru- ments speciﬁc to each type of trauma experience would greatly enhance forensic assessment conclusions. REFERENCES Achenbach, T. M. (1992). Manual for the Child Behavior Checklist/2–3 and 1992 proﬁle. Burlington: University of Vermont, Department of Psychiatry. 228 Assessment of Childhood Trauma American Academy of Child and Adolescent Psychiatry. (1998). Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 4S–26S. American Psychiatric Association. (1994). Diagnostic and statisti- cal manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (1999). Public information on- line, post-traumatic stress disorder. (Available from 1400 K Street, N.W. Washington, DC; www.psych.org) Andreasen, N. C. (1985). Posttraumatic stress disorder. In H. Kaplan & B. Sadock (Eds.), Comprehensive textbook of psychiatry/IV. Baltimore: Williams & Wilkins. Baker, A. (1990). The psychological impact of the Intifada on Palestinian children in the occupied West Bank and Gaza: An exploratory study. American Journal of Orthopsychiatry, 60, 496–505. Bellak, L. (1993). The T.A.T., & C.A.T., & S.A.T. in clinical use (5th ed.). Needham Heights, MA: Allyn & Bacon. Bellak, L., & Bellak, S. (1949). Children’s Apperception Test. Larchmont, NY: C.P.S. Berkovitz, I. H., Wang, A., Pynoos, R., James, Q., & Wong, M. (1994, October). Los Angeles earthquake, 1994: School district reduction of trauma effects. Symposium presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry, New York. Berliner, L. (1997). Intervention with children who experience trauma. In D. Cicchetti & S. Toth (Eds.), Developmental perspectives on trauma: Theory, research and intervention. Rochester, NY: University of Rochester Press. Bloch, D., Silber, E., & Perry, S. (1956). Some factors in the emo- tional reaction of children to disaster. American Journal of Psychiatry, 113, 416–422. Boney-McCoy, S., & Finklehor, D. (1995). Psychosocial sequelae of violent victimization in a national youth sample. Journal of Consulting and Clinical Psychology, 63, 726–736. Boylan, J. (2000). Portraits of guilt: The woman who proﬁles the faces of America’s deadliest criminals. New York: Pocket Books. Briere, J. (1996). Trauma symptom checklist for children: Profes- sional manual. Odessa, FL: Psychological Assessment Resources. Briere, J. (1997). Psychological assessment of adult posttraumatic states. Washington, DC: American Psychological Association. Briere, J., Johnson, K., Damon, L., Bissada, A., Crouch, J., Gil, E., et al. (2000, January). The Trauma Symptom Checklist for Young Children: Reliability and predictive data from a multi-site study. Paper presented at the San Diego Conference on Responding to Maltreatment, San Diego, CA. Browne, A., & Finklehor, D. (1986). Impact of child sexual abuse: A review of the research. Psychological Bulletin, 99, 66–77. Ceci, S. J., & Bruck, M. (1995). Jeopardy in the courtroom: A scientiﬁc analysis of children’s testimony. Washington, DC: American Psychological Association. Committee on Ethical Guidelines for Forensic Psychologists. (1991). Specialty guidelines for forensic psychologists. Law and Human Behavior, 15, 655–665. Crandall, V., Crandall, V., & Katkovsky, W. (1965). A children’s social desirability questionnaire. Journal of Consulting Psychol- ogy, 29, 27–36. DeBellis, M. D. (1997). Posttraumatic stress disorder and acute stress disorder. In R. T. Ammerman & M. Hersen (Eds.), Hand- book of prevention and treatment with children and adolescents: Intervention in the real world context. New York: Guilford Press. DeBellis, M. D., & Putnam, F. W. (1994). The psychobiology of childhood maltreatment. Child and Adolescent Clinics of North America, 3, 663–677. Enns, C. Z., Courtois, C. A., Lese, K. P., Campbell, J., Gottlieb, M. C., Gilbert, M. S., et al. (1988). Working with adults who may have experienced childhood abuse. Professional Psychology: Research and Practice, 29 (3), 245–256. Evans, J., Briere, J., Boggiano, A., & Barrett, M. (1994, January). Re- liability and validity of the Trauma Symptom Checklist for chil- dren in a normal sample. Paper presented at the San Diego Conference on Responding to Maltreatment, San Diego, CA. Famularo, R. A., Kinscherff, R. T., & Fenton, T. (1990). Symptom differences in acute and chronic presentation of childhood posttraumatic stress disorder. Child Abuse and Neglect, 14, 439–444. Faust, D., Ziskin, J., & Hiers, J. B. (1991). Brain damage claims: Coping with neurological evidence. Los Angeles: Law and Psychology Press. Federal Rule of Evidence, Section 702, 28 U.S.C. 539–605 (1976). Finkelhor, D. (1987). The trauma of sexual abuse: Two models. Journal of Interpersonal Violence, 2, 348–366. Finkelhor, D., & Browne, A. (1985). The traumatic impact of child sexual abuse: A conceptualization. American Journal of Ortho- psychiatry, 55, 530–541. Fletcher, K. (1991). When Bad Things Happen Scale. (Available from the author, University of Massachusetts Medical Center, Dept. of Psychiatry, 55 Lake Ave. North, Worcester, MA 01655) Frederick, C., Pynoos, R., & Nader, K. (1992). Childhood PTSD Re- action Index. (Available from Frederick and Pynoos, 760 Westwood Plaza, Los Angeles, CA 90024) Freeman, L. Mokros, H., & Poznanski, E. (1993). Violent events reported by normal school-aged children: Characteristics and depression correlates. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 419–423. Freidrich, W. N. (1997). The Child Sexual-Behavior Inventory manual [Mayo Clinic Foundation]. Odessa, FL: Psychological Assessment Resources. References 229 Freidrich, W. N., Grambsch, P., Damon, L., Hewitt, S., Koverola, C., Lang, R., et al. (1992). Child Sexual Behavior Inventory: Normative and clinical comparisons. Psychological Assessment, 4, 303–311. Goldstein, A. M., & Goldstein, N. E. (in press). Relevance of child- hood trauma and childhood developmental factors to juvenile and adult death penalty cases. In S. N. Sparta & G. P. Koocher (Eds.), Forensic assessment of children and adolescents: Issues and applications. New York: Oxford University Press. Green, B. L., Korol, M., Grace, M. C., Vary, M. G., Leonard, A. C., Glesser, G. C., et al. (1991). Children and disaster: Age, gender, and parental effects on PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 945–951. Greenberg, S. A., & Shuman, D. W. (1997). Irreconcilable conﬂict between therapeutic and forensic roles. Professional Psychol- ogy: Research and Practice, 28, 50–57. Grisso, T. (1986). Evaluating competencies: Forensic assessments and instruments. New York: Plenum Press. Hornstein, N. L., & Putnam, F. W. (1992). Clinical phenomenology of child and adolescent dissociative disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 1077–1085. Jaffe, P. G. (1995). Children of domestic violence: Special chal- lenges in child custody and visitation dispute resolution. In J. Carter, B. Hart, & C. Hostler (Eds.), Domestic violence and children: Resolving custody and visitation disputes, a national judicial curriculum (pp. 19–30). San Francisco: Family Violence Prevention Fund. Jaffe, P. G., Wolfe, D. A., & Wilson, S. K. (1990). Children of battered women. Newbury Park, CA: Sage. Jones, R. T. (1994). Child’s Reaction to Traumatic Events Scale (CRTES): A self report traumatic stress measure. (Available from the author, Dept. of Psychology, Virginia Polytechnic Insti- tute and State University, 4102 Derring Hall, Blacksburg, VA 24060) Kashani, J. H., Daniel, A. E., Dandoy, A. C., & Holcomb, W. R. (1992). Family violence: Impact on the child. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 181–189. Kiser, L. J., Heston, J., Millsap, P. A., & Pruitt, D. (1991). Physical and sexual abuse in childhood: Relationship with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 776–783. Kolko, D. J., Moser, J. T., & Weldy, S. R. (1988). Behavioral/ emotional indications of sexual abuse in child psychiatric inpa- tients: A controlled comparison with physical abuse. Child Abuse and Neglect, 12, 529–542. Kovacs, M. (1992). Children’s Depression Inventory. New York: Multi-Health Systems. Kuehnle, K. (1996). Assessing allegations of child sexual abuse. Sarasota, FL: Professional Resource Press. Lanktree, C. B., Briere, J., & Zaidi, L. Y. (1991). Incidence and im- pacts of sexual abuse in a child outpatient sample: The role of direct inquiry. Child Abuse and Neglect, 15, 447–453. Lyons, J. (1988). Posttraumatic stress disorder in children and ado- lescents: A review of the literature. Journal of Developmental and Behavioral Pediatrics, 8, 349–356. Malmquist, C. P. (1986). Children who witness parental murder: Post-traumatic aspects. Journal of the American Academy of Child and Adolescent Psychiatry, 25, 320–325. Mannarino, A. P., Cohen, J. A., & Berman, S. R. (1994). The Chil- dren’s Attributions and Perceptions Scale: A new measure of sexual-abuse related factors. Journal of Clinical Child Psychol- ogy, 23, 204–211. March, J. S. (1999). Assessment of pediatric posttraumatic stress disorder. In P. A. Saigh & J. D. Bremner (Eds.), Posttraumatic stress disorder: A comprehensive text (pp. 199–218). Needham Heights, MA: Allyn & Bacon. Martin, R. P., Hooper, S., & Snow, J. (1986). Behavior rating scale approaches to personality assessment in children and adoles- cents. In H. Knoff (Ed.), The assessment of child and adolescent personality (pp. 309–351). New York: Guilford Press. McArthur, D. S., & Roberts, G. E. (1990). Roberts Apperception Test for Children. Los Angeles: Western Psychological Services. McLeer, S. V., Deblinger, E., Atkins, M. S., Foa, E., & Ralphe, D. (1988). Posttraumatic stress disorder in sexually abused chil- dren. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 650–654. McLeer, S. V., Deblinger, E., Henry, D., & Orvashel, H. (1992). Sexually abused children at high risk for PTSD. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 875–879. Melton, G. B., Petrila, J., Poythress, N. G., & Slobogin, C. (1997). Psychological evaluations for the courts: A handbook for mental health professionals and lawyers (2nd ed.). New York: Guilford Press. Meyer, R. G. (1993). The clinician’s handbook: Integrated diagnos- tics, assessment and intervention in adult and adolescent psy- chopathology. Boston: Allyn & Bacon. Nader, K. O. (1997). Assessing traumatic experiences in children. In J. P. Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD. New York: Guilford Press. Nader, K. O., Kriegler, J. A., Blake, D. D., & Pynoos, R. S. (1994). Clinician administered PTSD Scale: Child and adolescent version (CAPS-C). White River Junction, VT: National Center for PTSD. National Institute of Mental Health Public Inquires. (2000). Anxiety disorders, post-traumatic stress disorder. (Available from 6001 Executive Blvd. Rm 8184 MSC 9663, Bethesda, MD, www.nimh.nih.gov) Norris, F. (1992). Epidemiology of trauma: Frequency and impact of different potentially traumatic events on different demo- graphic groups. Journal of Consulting and Clinical Psychology, 60, 409–418.