Working with Children Whose Parents are Separated or Divorced

Vanessa is an occupational therapist (OT) who owns and operates a private pediatric practice. She received a referral to see Ethan, a 5-year-old boy who has autism spectrum disorder (ASD). The referral was initiated by Ethan’s mother Sharon, who requested occupational therapy services to work on fine and gross motor skills, sensory processing, and emotional regulation.

Ethan arrived for his first appointment at the clinic with his mother. Vanessa started the session by explaining her role as an occupational therapist, the type of service she can provide, and obtaining informed consent for the occupational therapy service.

Vanessa had previously read COTO’s resource on Obtaining Consent from Divorced or Separated Parents so she was aware that the consent of one parent is generally sufficient to proceed with occupational therapy service delivery, as both parents are equally ranked substitute decision makers (SDMs) for a child. In circumstances where there is information available to contradict this assumption, Vanessa understood that she should make appropriate inquiries to establish whether the other parent’s consent is needed.

With all this in mind, Vanessa asked Sharon if Ethan’s father is aware that they are accessing occupational therapy services. Sharon replied that she is separated (but not divorced) from the father. Sharon said that they are on “good terms” but that she manages all the appointments and makes the health care decisions because Ethan lives with her. When asked if there are any custody or decision-making arrangements with Ethan’s father, Sharon explained that he is not involved in Ethan’s day-to-day care, but he is aware of Ethan’s therapy needs and knew of their appointment today.

Vanessa decided based on the information she gathered that the father would not object to the occupational therapy service and proceeded based on Sharon’s consent.

About two months later, Vanessa receives a phone call from the father inquiring about Ethan’s occupational therapy sessions. He is upset that he was not consulted about his son’s care and wants more information. He is requesting a copy of the occupational therapy record. Vanessa calls Sharon who confirms he is indeed Ethan’s father. When Sharon is informed of the father’s request for a copy of the record she immediately refuses and says he does not “have a say” as he is not involved in Ethan’s caregiving. The next day, Sharon produces a letter that appears to be signed by a lawyer, stating that she has sole decision-making rights for Ethan. Vanessa has never seen these types of letters before in her practice. She is not familiar with the legal terms in the letter and is unsure how to proceed.

• Legislation: Under the Health Care Consent Act, both parents are equally ranked substitute decision makers (SDMs) to provide informed consent for their child’s health care services. Similarly, under the Personal Health Information Protection Act, both parents are equally ranked SDMs to provide consent to collect, use and disclose their child’s personal health information. Occupational therapists are expected to gather and use the information available to determine whether they need to obtain consent from one or both parents.
• Legal consultation: Legal counsel can assist occupational therapists in identifying authoritative legal documents to establish parental arrangements and consent authority, such as a court order or separation agreement.   
• Communication: Clear, respectful communication with both parents is key to reducing conflict and focusing on the care of the child.
• Professional Boundaries: Occupational therapists need to be mindful of any unconscious biases towards one or both parents and remain neutral throughout the process.
• Client’s best interest: The child is the focus of the occupational therapy service. The child’s best interests and timely access to care should remain central throughout the process.

• In order to gain insights and discuss experiences, Vanessa contacts one of her occupational therapy colleagues who also works in a pediatric clinic.
• Vanessa consults a lawyer to review the letter provided by Sharon about Sharon’s decision-making rights for the child and to clarify whether consent from the father is also required.
• A few days later, Vanessa is advised by legal counsel that the letter which appears to be signed by a lawyer is not sufficient evidence to confirm Sharon’s claim that she has sole decision-making rights regarding Ethan’s care. Legal counsel advises that Vanessa should obtain express consent from both parents and if she is not able to do so, she should request a copy of a court order or separation agreement which establishes how healthcare decisions regarding Ethan are to be made.
• Vanessa creates or modifies her practice’s consent policies and procedures to ensure appropriate consent is received in cases involving children whose parents are separated or divorced.
• Vanessa explains to Sharon that she has obligations to obtain consent from the father.
• Vanessa arranges a phone call with the father to describe her intake and consent processes. She explains that initially, she did not have information that would lead her to contact the other parent or question whether the other parent might object to the occupational therapy service. As new information has come to light, she has the professional responsibility to ensure that both parents are providing consent for the service, and that information can be shared with both parents.
• Vanessa proceeds to explain the purpose of occupational therapy, as well as the potential risks, benefits and alternatives. She answers the father’s questions about the service, but the father still wants some time to think about it.
• Vanessa informs both parents that she will not be able to proceed with services unless she has the consent of both of them or unless there is an order or agreement stating that one parent is able to provide consent without the other’s agreement.
• After 2 weeks, both parents provide consent for occupational therapy services and Vanessa is able to resume therapy sessions.
• Vanessa develops a plan to provide regular, short, written updates about Ethan’s progress to both parents. As a result, the father withdraws his request for a copy of the record.

Vanessa continues to have occupational therapy sessions with Ethan over the next 11 months. Ethan has been attending regularly, participating well, and making progress with his therapy goals. Sharon has been working on the occupational therapy recommendations at home and reports that Ethan is “calmer and doing better with his daily routines”.

During one session, Sharon approaches Vanessa and asks her to write a letter to support her divorce and custody case. She explains that she is preparing for court proceedings and says that a letter outlining Ethan’s progress in therapy will show that Ethan is doing well living with her. She offers to sign any consent form required. What should Vanessa do?

• Professional Boundaries: Will this be perceived (by the father or others) as a preferential bias towards Sharon? Will this compromise the professional objectivity and neutrality of the occupational therapist and undermine trust in the therapeutic relationship?
• Scope of Practice: Is this type of request a part of the occupational therapy service? The service is focused on clinical treatment of Ethan’s skills and abilities, not performing a custody evaluation or advocating in favor of one parent over the other.
• Competencies: In my role, do I have the competencies (knowledge, skill and judgement) to assess and opine on a parent’s legal case for custody?
• Standard for Record Keeping: Any letters provided to clients are part of the client record. Occupational therapists must document all relevant clinical information, and it may be viewed by anyone who has access to the record.

Vanessa wants to help Sharon and again consults a lawyer. Vanessa is advised to avoid getting drawn into a client’s legal disputes which are outside of her scope of practice and could breach her professional boundaries. She is informed that it would be appropriate for her to write a letter outlining Ethan’s progress in treatment. The letter should be provided to both parents as agreed above in Part 1, but it should not state that Ethan is doing well living with Sharon as requested, and should not suggest “support” of either parent’s custody case. Vanessa is reminded of her professional obligations to refrain from personal relationships with clients or their support persons, to recognize and manage any shifts in clients’ expectations of the boundaries of the client-therapist relationship, and to recognize and reflect on her desire to help Sharon beyond treating Ethan (see Standard for Professional Boundaries and the Prevention of Sexual Abuse, ss. 1.3, 3.1, 3.4, 3.5).

Therefore, Vanessa reviews the information she provided to Sharon during the intake process about her role as an occupational therapist and the type of service she can provide, and she reiterates that her engagement is to assist with Ethan’s fine and gross motor skills, sensory processing, and emotional regulation. Vanessa explains to Sharon that she cannot provide a letter to support either of Ethan’s parents’ custody cases as this falls outside of her role and the occupational therapy service, and to do so could constitute a violation of her professional boundaries.

Vanessa explains that if appropriate and with consent from both parents, she can provide a copy of the occupational therapy record or summary report if formally requested by Sharon or her legal representative.

Occupational therapists working with children with separated or divorced parents must be mindful not to get drawn into parental disagreements which can impact the occupational therapy service for the child. Occupational therapists should consider the following:

• Understand the legislative requirements around consent.
• Set up information gathering processes to ensure you are communicating with the appropriate parent(s) about consent for service and who you can collect, use and share information with.
• While obtaining one parent’s consent may be acceptable in some circumstances, it carries risk of future disputes, especially if the parents are separated and a court order or custody agreement is in place. It is generally recommended to obtain consent from both parents.
• Get legal advice when parents present forms and letters about custody and decision-making authority for the child’s health care. OTs may have access to some complementary legal consultation through their membership with professional associations.
• Stay focused on the clinical service and your role. Decline to provide services that are outside of the occupational therapy scope of practice, as providing such services may breach your obligation to maintain professional boundaries.
• Maintaining neutrality in communication and documentation helps protect the child, family and clinician.  
• The child’s best interest and access to care must remain central throughout the process.