Protecting Children Beyond the Clinic

Introduction

Child maltreatment remains a detrimental public health crisis in the United States.¹ Approximately 1 in 7 children experience some form of maltreatment, and nearly 2,000 children die each year as a result.²˒³ An estimated 4.4 million children are reported to Child Protective Services (CPS) annually, though this figure underrepresents the true prevalence because many cases go unreported.⁴ Neglect is the most common form of maltreatment among CPS-confirmed cases, followed by physical abuse, sexual abuse, and emotional abuse.⁵ These are not merely statistics; they represent preventable suffering, disability, and death. 

Physicians are uniquely positioned to identify and report suspected maltreatment. Yet a physician’s responsibility to protect children does not necessarily end when a child leaves the clinical setting. In child custody proceedings, allegations of child maltreatment or intimate partner violence (IPV) may be inappropriately dismissed when claims of parental alienation (PA) are introduced into the courtroom. PA may be used to explain a child’s rejection of a parent without adequately considering whether maltreatment or exposure to IPV contributes to that rejection. Therefore, this commentary examines the intersection of child maltreatment, IPV, and custody proceedings, considers Kayden’s Law as a policy response, and explores the role of physicians in protecting children within and beyond the clinical setting.

The Biology of Child Maltreatment 

Research has shown that child maltreatment causes lasting biological harm.⁶ A dose-dependent relationship exists between adverse childhood experiences (ACE) and chronic conditions such as cardiovascular disease, hypertension, obesity, and type 2 diabetes mellitus.⁷⁻⁹ Each additional ACE is associated with a 12.9% increased risk of developing multiple chronic health conditions in adulthood.¹⁰ A longitudinal study published in 2022 of children aged three to five years found that abused and neglected children had significant impairments in cognitive, verbal, and motor development.¹¹ 

Furthermore, the American Academy of Pediatrics (AAP) affirms that early identification of children vulnerable to maltreatment can alter their developmental trajectory.¹² Findings from the Bucharest Early Intervention Project showed that early placement into foster care led to increased intelligence quotient scores relative to continued institutional care, with a difference of approximately nine points at age 18.¹³ This evidence demonstrates that although child maltreatment can have lasting effects, early interventions can improve outcomes. For physicians, identifying and reporting maltreatment can therefore not only protect a child in the short term, but also improve their health for years to come. 

The Intersection of Intimate Partner Violence and Child Maltreatment 

The relationship between IPV and child abuse is well-researched.¹⁴ Nearly 60% of children exposed to IPV in their lifetime experience child maltreatment.¹⁴˒¹⁵ IPV is also an established risk factor for child homicide.¹⁵ While the National Violent Death Reporting System has coded approximately 11% of child homicide victims as IPV-related, narrative review of case reports has identified about 20% as actually related to IPV.¹⁶ Further, U.S. foster care entry rates decreased approximately 29% while reported child maltreatment fatalities increased approximately 10% over the same five-year period,² and a considerable proportion of children who die from maltreatment are known by CPS.¹⁷ 

These findings represent an important limitation of reporting alone. Physicians are mandated reporters, but when they fulfill this obligation only for systems to inadequately protect the child, questions arise about whether existing systems are functioning effectively once abuse has been identified. Physicians may be among the few professionals able to recognize the connection between IPV and child maltreatment, particularly when children present with behavioral manifestations of exposure to violence.¹⁴ Yet recognition and reporting may not be sufficient if subsequent custody decisions fail to appropriately weigh evidence of abuse or violence. 

The Consequences of Parental Alienation 

Against this background, parents may report IPV and enter custody proceedings seeking to protect their children, yet the family court system may fail to provide adequate protection.¹⁸˒¹⁹ PA is a controversial concept originating from Parental Alienation Syndrome (PAS) described by psychiatrist Richard Gardner in 1985, a theory that has not been accepted as a formal diagnostic syndrome.²⁰ Proponents define PA as a mental condition in which a child strongly allies with one parent and rejects the other parent without justification as a result of alienating behaviors by the favored parent.²¹ However, the 2022 American Psychological Association Guidelines for Child Custody Evaluations note that there is a “plethora of reasons” why children may resist contact with a parent after separation, including maltreatment and exposure to IPV, and that it is not necessarily a result of vindictive influence.²² Indeed, allegations of PA have been misused in family courtrooms and criticized because they may be invoked to discount credible allegations of domestic violence or child abuse by framing a child’s fear or rejection of a parent as the result of manipulation by the other parent.¹⁹˒²² 

Both the American Psychological Association and the World Health Organization have rejected PAS as a valid diagnosis or scientific concept due to its limited evidence.²⁰˒²³˒²⁴ Neither PA nor PAS have been accepted in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders.²⁵ Further, the National Council of Juvenile and Family Court Judges has advised that family courts should not accept PAS or PA as testimony in custody cases under evidentiary standards.²⁶ Despite these rejections, PA continues to be invoked in custody proceedings. The persistence of PA in custody proceedings presents a particular challenge for the medical profession. Although the concept was introduced by a physician and subsequently rejected by these medical organizations, it continues to influence decisions affecting the health of children and families. This creates a professional responsibility for physicians to recognize when unsupported medical concepts continue to affect patients and families outside of the clinical setting. 

Although earlier research supported the integration of PA into custody proceedings with the well-intentioned goal of preventing an irrational rejection of one parent, the scientific foundation of PA remains contested.²² In cases of PAS, Gardner recommended custody be transferred from the favored parent to the rejected parent regardless of the child’s expressed fear or trauma.²⁷ This gave rise to court-ordered transfers of majority custody to the allegedly alienated parent as well as reunification treatments or camps that forcibly isolate children until they convincingly demonstrate affection for that parent.²⁸⁻³⁰ Research has reported adverse psychological outcomes among children who were placed into the custody of allegedly abusive parents following PA claims.³¹ High-quality evidence demonstrating the efficacy of reunification programs remains limited and raises ethical concerns regarding the psychological welfare and safety of the children subjected to them.³¹ Therefore, the physician’s ability to protect children through recognition and reporting may be undermined by decisions made after the child leaves the clinical setting. This creates a gap between medical recognition of risk and the systems responsible for acting on that evidence. 

Kayden’s Law 

These concerns illustrate the need for legal systems to incorporate credible evidence of child maltreatment and IPV into custody proceedings. In response to concerns regarding the handling of PA and abuse allegations in custody proceedings, several states have passed legislation in alignment with the federal Keeping Children Safe From Family Violence Act, commonly known as Kayden’s Law.³²⁻³⁸ The law was named after Kayden Mancuso, a 7-year-old girl killed by her father after he was granted unsupervised parenting time in Pennsylvania despite her mother’s repeated safety concerns.³⁹ Kayden’s father had been violent toward her mother but had also accused her of parental alienation, an allegation that was credited by the court, particularly since he had not previously physically harmed his daughter.³⁹ After Kayden’s Law was enacted federally in 2022, other states followed, with Pennsylvania naming its version after Kayden, Utah naming its version "Om’s Law," and California naming its version "Piqui’s Law" after children who experienced similar tragedies.³³⁻³⁵ 

The law states that "a court may not, in order to improve a deficient relationship with the other parent of a child, restrict contact between the child and a parent…who is competent, protective, and not physically or sexually abusive."³⁴ It further requires that any allegation of domestic violence or child abuse be considered in custody proceedings and mandates that judges and other professionals involved in child custody cases receive appropriate training in domestic violence, sexual violence, and child abuse—a requirement that does not yet exist in every state.³⁴ 

Critics of Kayden’s Law are concerned that limiting the use of parental alienation evidence in the courtroom may make it more difficult to recognize situations in which a child’s rejection of a parent is actually being reinforced by the other parent. When there is “verifiable evidence” that a parent is deliberately alienating a child, this may interfere with a child’s healthy relationship with either parent.²² However, these claims become problematic when there is no clear evidence of deliberate alienation, and they are instead used to redirect allegations of child maltreatment or IPV. Importantly, Kayden’s Law does not require courts to ignore evidence of interference in the parent-child relationship. Rather, it emphasizes consideration of such behavior within the broader context of child maltreatment and recognizes that a child’s rejection of a parent may reflect an effort by the child to protect themselves from harm. 

A Call to Action for the Medical Community 

Physicians play a critical role in keeping children safe. The AAP has emphasized that pediatricians are uniquely positioned to identify maltreatment, advocate for child safety, and influence public policy.⁴⁰ At the clinical level, physicians can meet concerned parents and children where they are and document, objectively, thoroughly, and verbatim, their stories and physical examination findings in the medical record, which may be used in the courtroom.⁴¹˒⁴² Children experiencing abuse often present with sleep disturbances, somatic complaints, behavioral problems, and mood symptoms.⁴³ Physicians can recognize that exposure to intimate partner violence in itself is harmful to children, and document this as well, as child abuse and domestic violence frequently coexist.¹⁴ Yet physicians underreport suspected maltreatment; one study found that clinicians reported only 6% of injuries to CPS for which there was any suspicion of maltreatment.⁴⁴ A lower threshold for reporting, however, is only one part of protecting children. Physicians should also recognize that their efforts in the clinic, including carefully documenting medical evidence, cannot protect a child if systems responsible for custody decisions fail to appropriately interpret or weigh that evidence. 

At the systems level, physicians can advocate for legislation like Kayden’s Law in their state that prioritizes child safety, such as meaningful consideration of prior abuse in custody proceedings and the requirement that judicial officials receive trauma-informed training, paralleling efforts to incorporate trauma-informed care into medical education.⁴⁵ Such advocacy is a natural extension of the physician’s responsibility to protect children. Physicians are trained to rely on evidence-based expertise and to continuously learn and relearn when a concept or fact has been discredited. They should advocate for systems that uphold the same principles and allow credible medical evidence to meaningfully inform decisions about child safety.

Conflicts of Interest/Disclosures

The authors did not receive support from any organization for the submitted work. The authors also have no relevant financial or non-financial interests to disclose. This commentary did not require Institutional Review Board (IRB) review.