New approaches to divorce with children: A problem of public health

Abstract

This broad review elaborates on the most up-to-date knowledge on biochemical and psychobiological aspects of parental loss and other childhood adversities during divorce involving minor children. So far, divorce involving minor children was unfortunately considered by authorities only as a purely juridical problem, and this approach has often allowed a completely different approach according to the Courts. Now, scientific research, also making use of animal models, is demonstrating the biological basis of the problem and the indisputable consequences on the well-being and health of children. The innovative conclusion of this review is that this argument (because of its frequency and gravity) is primarily a question of public health and that it is necessary to further harmonize practices in this area.

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Introduction
Science has demonstrated direct effects on infants and
young adult health caused by childhood adversity. This
damage can be classified into two different categories: the
effects caused by chronic stressors and, on the other hand,
the effects caused by traumatic experiences. Many of them
belong to divorce-correlated situations.
The definition of childhood adversity includes the
following:
1. Chronic stressors. Parental loss (and parental
lack), parental separation with long-term family
conflict, neglect, parental education, parental mental
health, poverty, and drug use in the family.
2. Traumatic experiences. Physical abuse, verbal
abuse, mental abuse, witnessing violence within the
home, and severe childhood illness.
Although it is not always possible to demonstrate a
causal effect (as it is for animal models), it is important to
highlight some psychobiological damage associated with
parental loss and other childhood adversities as they touch
on so far unsuspected fields and because the consequences
can become apparent after 10, 20, or 30 years.
The problem is significant as parental separation con-
cerns more than 10 million minors in Europe, and more
than one million children experience every year the divorce
of their parents in United States, making divorce involving
children a question of public health. Parental separation is
in fact the first cause of parental loss in Western countries
(it occurs in more than 40% of divorces in some countries)
and is often linked to other childhood adversities like, for
example, parental conflict or witnessing violence. In fact, it
is noteworthy that until a few years ago, the research in this
area focused on effects of divorce “tout court” without con-
sidering whether after divorce the child could have still fre-
quent, satisfying, and regular contact with both parents
because shared parenting was rare.
The need for very large data sets to make solid infer-
ences about very small subgroups of the population severely
restricted the possibility to statistically validate research on
children living in a shared-parenting situation. The bias was
New approaches to divorce with
children: A problem of public health
Vittorio Carlo Vezzetti
Abstract
This broad review elaborates on the most up-to-date knowledge on biochemical and psychobiological aspects of parental
loss and other childhood adversities during divorce involving minor children. So far, divorce involving minor children
was unfortunately considered by authorities only as a purely juridical problem, and this approach has often allowed a
completely different approach according to the Courts. Now, scientific research, also making use of animal models, is
demonstrating the biological basis of the problem and the indisputable consequences on the well-being and health of
children. The innovative conclusion of this review is that this argument (because of its frequency and gravity) is primarily
a question of public health and that it is necessary to further harmonize practices in this area.
Keywords
adolescence, children, community health promotion, divorce, family, inequalities, psychological distress, public health
psychology, risk factors, risk reduction
ATS Insubria, Italy
Corresponding author:
Vittorio Carlo Vezzetti, Via Uponne 6 Ranco 21020, Italy.
Email: vittorio.vezzetti@crs.lombardia.it
678105HPO0010.1177/2055102916678105Health Psychology OpenVezzetti
research-article2016
Critical Review

2 Health Psychology Open
(and often still is) to attribute to divorce consequences
regarding, for instance, parental loss or family conflict.
Only in recent years, the diffusion, especially in Nordic
countries, of shared parenting allowed wide comparative
research to take place (those forming part of the ELVIS
Project was significant and widespread, in Sweden), and to
see that this type of parenting could have a huge influence
on the consequences of divorce for child well-being. This
topic will be discussed further in this article.
The research cited in this review was published almost
entirely in international peer-reviewed journals or govern-
mental reports, found in databases in PubMed, PsycINFO,
Social Science Research Index, MedSciNet, preferring
research—where it was possible—as broad as possible
and considered able to give a meaningful contribution to
five areas: (1) biological effects on animal models health
linked to parental separation, (2) psychobiological effects
on infant health linked to parental separation and other
childhood adversities, (3) biological consequences of
parental loss and childhood adversities, (4) social effects
of parental loss and stress, and (5) comparison between
possible effects of shared and sole parenting on child and
young adult health.
Knowledge on biological effects on
animal models of health linked to
parental separation
We must not be surprised: we have in fact a lot of evidence
in several species of animals of the organic effects of child-
hood adversity, especially parental loss and parental sepa-
ration. Many more studies have addressed the effects of
maternal loss, but also the studies on the effects of paternal
loss are increasing rapidly. Usually, this research concerns
animals with co-parental care of the offspring and which
are frequently monogamous: examples include birds, mam-
mals, and also primates. Among a multitude of research, we
will cite just three examples.
In this area, Hoffman et al. (1995) found that in titi mon-
keys, separation from the mother for 1 hour did not elicit an
adrenocortical response from the infant unless the father
was also removed. Separation from the father elicited a sig-
nificant elevation in adrenocortical activity even when the
mother remained with the infant during the separation
period. Infants showed highest cortisol levels and vocaliza-
tion rates when both parents were removed and the infant
remained alone in the living cage for 1 hour. As in previous
research, infants maintained higher levels of contact with
the father than with the mother.
Bambico et al. (2013) showed that father absence in the
monogamous California mouse impairs social behavior and
modifies dopamine and glutamate synapses in the medial
prefrontal cortex.
Finally, we recall that exposure to enriched or impover-
ished environmental conditions, experience, and learning
are factors which influence brain development, and it has
been shown that neonatal emotional experience signifi-
cantly interferes with the synaptic development of higher
associative forebrain areas. Ovtscharoff et al. (2006) ana-
lyzed the impact of paternal care, that is, the father’s emo-
tional contribution toward his offspring, on the synaptic
development of the anterior cingulate cortex. The light and
electron microscopic comparison of biparentally raised
control animals, and animals which were raised in single-
mother families revealed no significant differences in spine
densities on the apical dendrites of layer II/III pyramidal
neurons and of asymmetric and symmetric spine synapses.
However, significantly reduced densities (−33%) of sym-
metric shaft synapses were found in layer II of the father-
less animals compared to controls. This finding indicates an
imbalance between excitatory and inhibitory synapses in
the anterior cingulate cortex of father-deprived animals.
Results query the general assumption that a father has less
impact on the synaptic maturation of his offspring’s brain
than the mother.
Psychobiological effects on infant
health linked to parental separation
and other childhood adversities
Although the most known effects of the divorce process are
commonly evident in the behavioral and emotional fields,
physical morbidity of the children was also described in
situations of parental loss and often correlated childhood
adversities. For example, a study from Taiwan (Juang et al.,
2004) found a clear link between parental divorce and chil-
dren’s daily headache (chronic daily headache-CDH).
Various studies have, moreover, described increased
prevalence of attention deficit and hyperactivity disorder
(ADHD) in children in situations of divorce and abuse (and
not always for a selection effect); for example, (Cohen
et al., 2002) interactional effects of marital disruption and
abuse were found for risk for lifetime ADHD, with parental
marital disruption and having been physically abused com-
bining to increase the risk indeed 15 times for diagnosis of
lifetime ADHD. In this study, parental marital status alone
was not a significant risk factor for adolescent psychopa-
thology, but a childhood adversity as physical abuse was a
significant risk factor for several diagnostic categories.
Much research (but all conducted in monoparental coun-
tries, where shared parenting is uncommon and divorce is
often linked to the increasing adverse effect of parental
loss, high rates of family conflict, etc.) found a correlation
between parental divorce and eating disorders and exces-
sive weight (Igoin-Apfelbaum, 1985; Johnson et al., 2002;
Yannakoulia et al., 2008).
Another study from France (Roustit et al., 2011) examined
the relationship between adverse family environments during
childhood and self-perceived health in adulthood. It was
found that exposure to separation and divorce in childhood

Vezzetti 3
was associated with worse health perception in older age. The
study referred to mental health as well as to physical status.
Moreover, a study of almost 1 million children in Sweden
observed that children growing up with single parents were
more than twice as likely to experience a serious psychiatric
disorder, commit or attempt suicide, or develop an alcohol
addiction (Ringsback-Weitoft et al., 2003).
Similarly, Hailey Maier and Lachman (2000) found in a
sample of 4242 adults who responded to the survey of
Midlife Development in the United States that loss or sepa-
ration from parents in childhood does have a negative
impact on health problems and psychological adjustment in
midlife, and that the effects are more pronounced for
divorce. It appears that parental divorce leads to lower edu-
cation and income attainment, an increase in drug use, and
lower levels of family support which may result in a greater
number of health problems later in life, while parental death
was also related to lower educational attainment but showed
no relationship with adult health.
Although both experiences (parental loss as conse-
quence of divorce and as consequence of parental death)
can impact economic resources, social resources may be
more affected by parental divorce, but parental divorce can
result in changes in the child’s relationship with both par-
ents, whereas parental death is less likely to disrupt the
child’s relationship with the remaining parent.
In further research, Tyrka et al. (2008) found that partici-
pants with separation/desertion and those with parental
death were significantly more likely than the control sub-
jects to report the subsequent onset of symptoms of a
depressive or anxiety disorder but Otowa et al. (2014) went
beyond finding that early parental separation has stronger
and wider effects on adult psychopathology than parental
death. Going into details, parental separation was associ-
ated with a wide range of adult psychopathology, whereas
parental death was specifically associated with phobia and
alcohol dependence. Maternal and paternal separations
were almost equally associated with most forms of psycho-
pathology. Structural equation modeling suggested that
parental loss accounted for about 10 percent of the variance
of adult psychopathology, of which parental separation had
the strongest impacts on risk for depression and drug abuse/
dependence (11% of the total variance).
Finally, a key body of research in Israel (Agid et al.,
1999) has drawn several conclusions:
1. Increased overall rates of early parental loss are
observed in major depression, bipolar disorder, and
schizophrenia, but the finding is most striking in
major depression followed by schizophrenia. The
finding in regard to major depression is consistent
with the majority of published studies in which loss
is not broken down into categories, while the litera-
ture on bipolar disorder and schizophrenia is insuf-
ficient for comparison.
2. Patients with major depression manifest a signifi-
cantly increased rate of early parental loss due to
permanent separation but not due to death, as
observed by a number of methodologically rigorous
case–control and epidemiological studies.
3. Loss of mother may be more significant than loss of
father; although in this analysis, this observation
was at a trend level only.
4. Loss at an early age (less than 9 years) is of greater
significance than later loss, as previously observed
by several researchers.
5. A specific sensitivity of females rather than males
to loss in major depression and bipolar disorder is
suggested by this research but cannot be regarded as
definitive because of sample size.
6. Genetic predisposition may influence the degree
of susceptibility of the individual to the effects of
early environmental stress and may also determine
the psychopathological entity to which the indi-
vidual is rendered vulnerable as a consequence of
the stress.
Biological consequences of parental
loss and other childhood adversities:
latest knowledge
By a more biological point of view, we have a lot of evi-
dence too; for instance, Nicolson (2004) showed that corti-
sol levels in adult men are increased if in their childhood
they were subject to parental loss or other adversities.
Similarly, Luecken (1998) found that both childhood
loss of a parent and poor quality of care are associated with
long-term increases in blood pressure and altered neuro-
hormonal responses to stress. More in detail, repeated-
measures analysis of covariance revealed significant main
effects on blood pressure of both parental loss and low
quality of family relationships (all p values < 0.05) such that
subjects who lost a parent or reported poor-quality family
relationships (FR) showed higher blood pressure across all
periods. The loss by FR by period interaction was not sig-
nificant. An FR by period interaction was found for cortisol
during the trial, in which poor-quality FR subjects showed
increased cortisol, whereas all others showed decreases. A
loss by period interaction was found for cortisol during the
speech, in which cortisol increased in loss subjects and
decreased in non-loss subjects.
We must highlight that chronic augmentation of cortisol
due to influence on hypothalamo–hypophysis–adrenocorti-
cal axis is linked to several disease in adulthood and senes-
cence like psychopathology (e.g. depression), diabetes II,
obesity, and osteoporosis.
It is noteworthy that through the action of glucocorti-
coids on the central nervous system, repeated or chronical
psychological stress can inhibit the thyroid-stimulating
hormone (TSH) secretion (Helmreich et al., 2005).

4 Health Psychology Open
In psychological stress, conversely, growth hormone
(GH) responses are rarely seen. Rather, there is GH secre-
tory defect with prolonged psychosocial stress causing a
wide pattern of clinical situations toward the rare condition
called psychosocial dwarfism (PD) (Delitala et al., 1987;
Magner et al., 1984; Skuse et al., 1996)
PD is a term describing severe childhood or adolescent
short stature and/or delayed puberty due to emotional depri-
vation, inadequate parenting, or psychological harassment.
Decreased GH secretion, that is reversible after separation of
the child from the responsible environment, is a characteristic
finding in this condition (Albanese et al., 1994). The treat-
ment with GH is not usually of benefit until the psychosocial
situation is improved. PD is also associated with a variety of
behavioral abnormalities, such as depression and bizarre eat-
ing PD were first studied in infants in foundling homes or
orphanages who failed to thrive, had decreased growth, and
even died. It was hypothesized that this failure to thrive
resulted from lack of attention and stimulation and/or defi-
cient nutrition. Later, it was shown that weight gain was inde-
pendent of food intake, whereas with a caring and attentive
environment, growth advanced and the psychological profile
improved. In addition to low GH secretion, these patients had
a dysfunctional thyroid axis, resembling the “euthyroid sick”
syndrome (Dom et al., 1993; Green et al., 1984).
Battaglia et al. (2009) showed that childhood separa-
tion anxiety can cause, in genetically prepared people,
panic disorders.
More in detail shared genetic determinants appeared to
be the major underlying cause of the developmental conti-
nuity of childhood separation anxiety disorder into adult
panic disorder and the association of both disorders with
heightened sensitivity to CO(2). Inasmuch as childhood
parental loss is a truly environmental risk factor, it can
account for a significant additional proportion of the covar-
iation of these three developmentally related phenotypes.
In the area of childhood adversities, Lacey et al. (2013)
found (but in the United Kingdom, a monoparental country
where parental loss after divorce is common: it would be
interesting to know whether the researchers would have
obtained the same outcome in a biparental country such as
Sweden, where shared parenting is common and parental loss
rare) that parental separation increases C Reactive Protein
(CRP) levels (correlated with type II diabetes, coronary heart
disease, depression, inflammatory diseases, etc.) in adult-
hood via chains of disadvantage across the life course.
Hartwell et al. (2013) found an important association of
elevated basal cytokines with childhood adversity in a sample
of healthy adults demonstrating the long-term impact of
childhood trauma and stress on homeostatic systems.
Importantly, this association was found in healthy adults, sug-
gesting that these alterations may precede the development of
significant stress-related psychiatric disorder or disease.
Moreover, Kiecolt-Glaser et al. (2011) demonstrated
that childhood adversity heightens the impact of later-life
caregiving stress on telomere length and inflammation and
are so related to continued vulnerability among older adults
enhancing the impact of chronic stress factors: it means
more psychiatric disorders (for abuse has been demon-
strated to lead to an increase in metabolic diseases, cancers,
and lung diseases).
This new epigenetic approach allowed the authors to
observe that presence of multiple childhood adversities was
related to both heightened interleukine-6 (IL-6) and shorter
telomeres compared with the absence of adversity; the authors
observed that the telomere difference could translate into a
7- to 15-year difference in life span. Abuse was associated
with heightened IL-6 and tumor necrosis factor-alpha (TNF-α)
levels; for TNF-α, this relationship was magnified in caregiv-
ers compared with controls. Moreover, abuse and caregiving
status were associated significantly and independently with
higher levels of depressive symptoms. Dysregulation of TNF
production has been implicated in a variety of human diseases
including Alzheimer’s disease, cancer, major depression, pso-
riasis, and inflammatory bowel disease (IBD) (Brynskov et al.,
2002; Dowlati et al., 2010; Locksley et al., 2001; Swardfager
et al., 2010; Victor and Gottlieb, 2002).
IL-6 stimulates the inflammatory and auto-immune
processes in many diseases such as diabetes, atherosclero-
sis, depression, Alzheimer’s disease, systemic lupus ery-
thematosus, multiple myeloma, prostate cancer, Behçet’s
disease, and rheumatoid arthritis (Gadó et al., 2000;
Hirohata and Kikuchi, 2012; Nishimoto, 2006; Smith
et al., 2001; Tackey et al., 2004).
Opacka-Juffry and Mohiyeddini (2012) contributed with
interesting research which showed evidence that adverse
experience in early life (such as but not exclusively paren-
tal loss) is negatively associated with oxytocin system
activity in adulthood (correlated with depression and anx-
ious disorders) and offer further insight into mediator and
moderator effects on this link. Gunther Meinlschmidt and
Christine Heim (2007) found altered central sensitivity to
the effects of oxytocin after early parental separation and
suggest that future studies should replicate these results and
scrutinize the role of oxytocin in mediating risk versus
resilience to psychopathology after early social adversity.
A new topic is the possible correlation between height
and familial disruption: Sheppard et al. (2015) argue that
familial disruption during early childhood has far-reaching
repercussions for the health of both men and women. Their
study assesses adult height as one such health-relevant out-
come. For men, parental death and divorce during early
childhood were associated with later puberty. Later puberty
was associated with shorter adult height. Path analyses dem-
onstrated that the relationship between parental divorce and
height was completely mediated by age at puberty, although
parental death was only partially mediated by age at puberty.
Among women, it was found that the father’s death dur-
ing early childhood was associated with earlier puberty,
which was in turn associated with shorter adult stature. The

Vezzetti 5
relationship between paternal death and height is entirely
mediated by age at puberty; no evidence of a direct relation-
ship between childhood family disruption and adult height.
Another link between parenting and human biology was
found by Human Lauren et al. (2014). They observed that
adolescents whose daily experiences were perceived more
accurately by their parents reported better psychological
adjustment (lower stress and depression) and a greater sen-
sitivity of their immune cells to anti-inflammatory signals
from cortisol (i.e. diminished production of inflammatory
proteins when cells were stimulated with the combination
of a bacterial product (lipopolysaccharide) and cortisol;
|β| range, 0.38–0.53, all p values < 0.041).
The authors argued that more attentive parental care
regarding adolescents’ daily experiences is associated with
better adolescent psychological adjustment and a more sen-
sitive anti-inflammatory response to cortisol. These results
provide preliminary evidence that more attentive parental
care regarding their adolescent’s daily experiences may be
one specific daily parent factor that plays a role in adoles-
cent health and well-being.
It is also noteworthy that Scott et al. (2008) found that
childhood adversities predicted adult-onset asthma with risk
increasing with the number of adversities experienced.
Another body of research found that all childhood adver-
sity was associated with elevated markers of inflammation
in breast cancer survivors, with potential negative implica-
tions for health and well-being. In particular, chaotic home
environment showed unique links with inflammatory out-
comes (Crosswell et al., 2014).
Finally, we recall that it is commonly known that adverse
life events increase vulnerability to affective disorders later
in life, possibly mediated by methylation of the serotonin
transporter gene methylation. All that granted, Van der
Knaap et al. (2014) demonstrate a higher level of serotonin
transporter gene methylation after stressful life events in
adolescents, with a more pronounced association for stress-
ful events during adolescence than during childhood.
Social effects of parental loss and
other childhood adversities
Much evidence on this issue has existed for a long time: for
more than 20 years, several research projects were con-
ducted on this topic (Metzler et al., 1994). In 1994, a study
of 700 adolescents, found that “compared to families with
two natural parents living in the home, adolescents from
single-parent families have been found to engage in greater
and earlier sexual activity.”
In wide and authoritative statistics in the United States,
researchers have found that fatherless children are at a dra-
matically greater risk of drug and alcohol abuse, mental ill-
ness, suicide, poor educational performance, teen
pregnancy, and criminality (US Department of Health and
Human Services, 1993).
At the same time, Duncan et al. (1994) found that teen-
agers living in single-parent households are more likely to
abuse alcohol and at an earlier age compared to children
reared in two-parent households.
Also, in the United States, a study of 156 victims of
child sexual abuse found that the majority of the children
came from disrupted or single-parent homes; only 31 per-
cent of the children lived with both biological parents.
Although stepfamilies make up only about 10 percent of all
families, 27 percent of the abused children lived with either
a stepfather or the mother’s boyfriend (Gomes-Schwartz
et al., 1988). Similarly, it was found by Deane Scott Berman
(1995) that absence of the father in the home affects signifi-
cantly the behavior of adolescents and results in the greater
use of alcohol and marijuana.
Finally, a more recent study from the Netherlands
(Houben-van Herten et al., 2015) aimed to confirm poten-
tial determinants of health-related quality of life in children
aged 4–11 years in the general population in the Netherlands.
As part of a population-based cross-sectional study, the
Child Health Questionnaire (CHQ) Parental Form 28 was
used to measure health-related quality of life in school-
aged children in a general population sample, and parents
of 10,651 children aged 4–11 years were interviewed from
January 2001 to December 2009. Multivariate and regres-
sion analyses demonstrated a lower CHQ psychosocial
summary score for children who had >1 conditions: disor-
ders or acute health complaints, boys, obese children, and,
finally, children of single parents.
Is shared parenting preventive of
childhood adversities and parental
loss? Does it have a positive influence
on well-being? How?
Most studies indicated that divorce has a negative impact on
children, but there are many different interpretations about
the consequences of this situation on children, whether the
negative impact arises from the divorce itself or more likely
from the process, the long-term conflict, the inadequate par-
enting, the parental loss (very frequent in most countries)
and whether this process can actually sometimes be good
for the children involved in some situations.
But, as we saw earlier, today, we have a lot of evidence
showing that separation with minor children is mainly a
question of public health and it should be treated first with
a scientific approach, following the experiences that have
demonstrated reduction in the risks of parental loss and
other childhood adversities.
Parental loss
The preventive effect of shared parenting on parental loss is
clear and indisputable. There is a tight inverse correlation
between shared parenting and parental loss: in countries

6 Health Psychology Open
where shared parenting has become common parental loss
decreased significantly, while in countries where shared
parenting is rare, childhood adversity such as parental loss
is higher in each case: in Denmark, parental loss after
parental separation has actually decreased to 12 percent; in
Sweden, it has quickly decreased to 13 percent; in Germany,
it is 20 percent; and in Italy and Greece, it is steady on about
30 percent (Bergström, 2015; Lohse, 2015; Paparigopoulos,
2016; Schiratzki, 2009; Suenderhauf, 2015; Vezzetti,
2009).
Some French research (Régnier-Loilier, 2013) observes
that the probability of losing contact with the father is 1 per-
cent when the judge ordered joint physical custody at least
in the first 6 months of judicial trial, but it increased up to
21 percent if the judge ordered the traditional arrangement.
Yet, in the same study, the researcher observes that the dis-
tance between the two parental homes (a parameter on
which the judiciary system can have a huge influence
allowing the emigration of one parent with the child) has a
significant influence. The study shows that the probability
of losing contact with the father is 12 percent if the father
and child live close to each other (15 minutes apart), but it
increases up to 33 percent if they live more than 4 hours
distance from each other and up to 81 percent if they are so
far apart that the father is not able to quantify the necessary
travel time.
Conflict
Extensive research has confirmed the positive effects of
shared parenting on several issues correlated with child-
hood adversity (like minimizing parental conflict and other
trauma separation-correlated) also if this aspect is more
controversial. The Australian experience seems to show
that the conflict is reduced by the new law on shared par-
enting (2006). In 2003/2004, the claims brought before the
Family Court were 45,004; in 2006/2007, were just 27,313;
and in 2008/2009, were 18,633. At the same time, the gen-
eral unrest was increased by the Federal Magistrates Court:
here, the claims were 70,261 in 2003/2004; 76,807 in
2006/2007; and 79,441 in 2008/2009 (Vezzetti, 2009).
In Spain, the presumption of Joint Physical Custody
(JPC) was introduced only in some regions and at different
times. In Catalonia, the law was approved in 2010 when the
claims for gender violence were 6155. In 2013, they were
5403 (−12.22%). In Corte Valencia, the law on JPC was
approved in 2011, and the claims for gender violence were
4712. In 2013, they were reduced to 4056 (−13.92%). In
Aragon, the law on JPC was introduced in 2010 when
claims were 603. In 2013, the situation was steady (617
claims, +2.3%) (Data from Spanish “Consejo general del
poder judicial,” 2014).
Therefore, it is not possible to argue about the negative
effect of shared parenting on family conflict as conversely
the global number of allegations has decreased.
In addition, we recall that in Sweden and Denmark, the
judicial trials have decreased as the shared parenting has
increased: actually, only 2 percent of divorcing couples in
Sweden enter a Court and about the same happens in
Denmark (Bergström, 2015; Lohse, 2015).
Nevertheless, in many jurisdictions, there is a legal pre-
sumption against shared parenting in high-conflict cases,
but, conversely, shared parenting provides an incentive for
parental cooperation, negotiation, mediation, and the devel-
opment of parenting plans.
In fact, a wide body of literature (Buchanan and Maccoby,
1996; Cashmore and Parkinson, 2010; Fabricius et al., 2012;
Kline et al., 1989; Melli and Brown, 2008; Sodermans et al.,
2013; Warshak, 2016) showed that there is no significant
difference between conflict between families in joint physi-
cal custody arrangement and families in sole custody.
Moreover, Fabricius and Luecken (2007) observed in
a sample of 266 university students, whose parents
divorced before they were 16 years old, that there is no
interaction between time with father and exposure to par-
ent conflict; thus, more time with the father was benefi-
cial in both high- and low-conflict families, and more
exposure to parental conflict was detrimental at both high
and low levels of time with father.
The Stanford Child Custody Study found that children
in joint physical custody (living at least one-third of the
time with their fathers) compared with children in sole
physical custody were most satisfied with the custody
plan and showed the best long-term adjustments, even
after controlling for factors that might predispose parents
to select joint physical custody (such as education,
income, and initial levels of parental hostility). In fact, in
80 percent of the joint physical custody families, one or
both parents initially did not want and did not agree to the
arrangement (Maccoby et al., 1993).
That explains why the Conference of International
Council on Shared Parenting in 2014 stated that
shared parenting is recognized as the most effective means for
both reducing high parental conflict and preventing first-time
family violence, there is consensus that legal and psycho-
social implementation of shared parenting as a presumption
should proceed with the goal of reducing parental conflict after
separation.
General well-being
Concerning other childhood adversities and the best
arrangements for children from separated couples, the out-
comes of the scientific literature are represented by 74
comparative studies published in peer-reviewed papers or
governmental reports between 1977 and 2014. They were
subject to two meta-analyses which compared sole and
shared custody between 1977 and 2014. The most notewor-
thy meta-analysis (2014) was written by Linda Nielsen
(Wake Forest University).

Vezzetti 7
This article addresses this question by summarizing the
40 studies that have compared children in joint physical
custody (at least 35% of time spent by each parent) and
children in sole custody during the past 25 years.
The 40 studies were identified by searching the data-
bases in PsycINFO and Social Science.
Research index. The keywords used in the search were
“shared parenting,” “shared care,” “joint” or “shared physi-
cal custody,” “shared” or “dual residence,” and “parenting
plans.” Although 85 percent of the studies were published
in peer-reviewed academic journals, the remainder was
reported in government sponsored reports. The findings of
the studies were grouped into five broad categories of child
well-being: (1) academic or cognitive outcomes, which
include school grades and scores on tests of cognitive
development such as language skills; (2) emotional or psy-
chological outcomes, which include feeling depressed,
anxious, or dissatisfied with their lives; (3) behavioral
problems, which include aggression or delinquency, diffi-
cult or unmanageable behavior at home or school, hyperac-
tivity, and drug or alcohol use; (4) physical health and
smoking, which also include stress-related illnesses such as
stomach aches and sleep disturbances; and (5) quality of
father–child relationships, which includes how well they
communicate and how close they feel to one another. The
following four final conclusions were textually made:
First, shared parenting was linked to a better outcome
for children of all ages across a wide range of emotional,
behavioral, and physical health measures.
Second, there was no convincing evidence that over-
nighting or shared parenting was linked to negative out-
comes for infants or toddlers.
Third, the outcomes are not positive when there is a his-
tory of violence or when the children do not like or
get along with their father.
Fourth, even though shared-parenting couples tend to
have somewhat higher incomes and somewhat less ver-
bal conflict than other parents, these two factors alone
do not explain the better outcomes for the children.
A second meta-analysis by Professor Hildegunde
Suenderhauf (2013) analyzes 50 comparative pieces of
research between 1977 and 2013. In this review, the cut-off
between sole custody and joint physical custody is at 25 per-
cent of the time spent by each parent (thus, with a lower limit
than in the study by Professor Nielsen). In 37 studies (74%),
the outcomes were favorable for joint physical custody; in 11
studies (22%), the outcomes included positive effects bal-
anced by some other negative effects; and only in two studies
(4%), the outcomes were negative (but further investigations
highlighted in this research some important bias).
A corollary to the meta-analysis cited above is another
meta-analysis by Professor Richard Warshak, published in
2014 with the endorsement of 110 internationally recog-
nized scientists, focused only on revision of international
literature related to shared care for babies aged under
4 years; this meta-analysis grounds on 13 papers published
between 1987 and 2010 and concludes literally with these
words: “There is no evidence to support postponing the
introduction of regular and frequent involvement, including
overnights, of both parents with their babies and toddlers”
and “In general the results of the studies reviewed in this
document are favorable to parenting plans that more evenly
balance young children’s time between two homes.”
Actually, we do not have much research on this topic
(shared parenting for toddlers), but new broad and thor-
ough research on shared-parenting and pre-school children
(focused on 3- to 4-year-old children) is in progress in
Sweden within the context of the ELVIS Project (coordi-
nated by the Centre for Health Equity Studies) and the first
preliminary outcomes would seem to confirm that pre-
school children in shared parenting are far better than chil-
dren in monoparental care (Bergström, 2015).
Between the literature published between 1977 and
2014, we find very few bodies of research apparently
against shared parenting. Essentially three: “Ongoing
Postdivorce Conflict: Effects on Children of Joint Custody
and Frequent Access” (Johnston et al., 1989), “Child-
focused and child-inclusive divorce mediation: compara-
tive outcomes from a prospective study of postseparation
adjustment” (McIntosh et al., 2008), and “Overnight
Custody Arrangements, Attachment, and Adjustment
Among Very Young Children” (Tornello et al., 2013). All
these studies are burdened by huge bias and important
methodological mistakes (Millar and Kruk, 2014; Nielsen,
2014; Poussin, 2016; Warshak, 2014, 2016).
Wide research on the topic of life satisfaction (linked to
childhood adversity) was run by seven researchers from
seven universities of Sweden, Greenland, Finland, Iceland,
the United States, and Denmark. The paper examines differ-
ences in life satisfaction among children in different family
structures in 36 Western, industrialized countries (n = 184,496).
Analyses were based on data from the 2005/2006 Health
Behavior in School-Aged Children (HBSC) study, a World
Health Organization collaborative cross-national study
children living with both biological parents reported higher
levels of life satisfaction than children living with a single
parent or parent–step-parent.
Children in joint physical custody reported significantly
higher levels of life satisfaction than their counterparts in
other types of non-intact families.
Controlling perceived family affluence, the difference
between joint physical custody families and single mother
or mother–stepfather families became non-significant.
Difficulties in communicating with parents were strongly
associated with lower life satisfaction but did not mediate
the relation between family structure and life satisfaction.
Children in the Nordic countries characterized by strong
welfare systems reported significantly higher levels of life

8 Health Psychology Open
satisfaction in all living arrangements except in single-
father households. Differences in economic inequality
between countries moderated the association between cer-
tain family structures, perceived family affluence, and life
satisfaction (Bjarnason et al., 2012).
In the same sample, impaired communication with both
mother and father was significantly less likely in joint
physical custody than in other non-intact families. Indeed,
impaired communication with the mother was equally
prevalent in intact families and joint physical custody fami-
lies, while impaired communication with the father was in
fact less prevalent in joint physical custody than intact fam-
ilies (Bjarnason and Arnarsson, 2011).
Further wide research wanted to examine children’s
health-related quality of life after parental separation, by
comparing children living with both parents in nuclear fam-
ilies to those living in joint physical custody and other
forms of domestic arrangements (Bergström et al., 2013).
Investigating a sample from a national Swedish class-
room study of 164,580 children aged 12 and 15 years old,
the researchers found that living in a nuclear family was
positively associated with almost all aspects of well-being
in comparison with the children with separated parents.
Children in joint physical custody experienced more posi-
tive outcomes, in terms of subjective well-being, family
life, and peer relations, than children living mostly or only
with one parent. For the 12-year-olds, beta coefficients for
moods and emotions ranged from −0.20 to −0.33 and peer
relations from −0.11 to −0.20 for children in joint physical
custody and living mostly or only with one parent. The cor-
responding estimates for the 15-year-olds varied from
−0.08 to −0.28 and from −0.03 to −0.13 on these subscales.
The 15-year-olds in joint physical custody were more likely
than the 12-year-olds to report similar well-being levels on
most outcomes to the children in nuclear families.
Other Swedish research shows that children with non-
cohabitant parents experience more psychosomatic prob-
lems than those in nuclear families. Those in joint physical
custody do, however, report better psychosomatic health
than children living mostly or only with one parent
(Bergström et al., 2015).
Finally, I recall the Turunen paper published in 2015: the
data for this study were from the Surveys of Living
Conditions (ULF) from 2001 to 2003, the first years when
the survey was accompanied by a child supplement.
The cross-sectional surveys consisted of a nationally
representative sample of the Swedish population aged 18–
84 years and child supplements with data collected from
children aged 10–18 years living in the household of the
main respondent. Like other recent studies of emotional
outcomes of shared physical custody, this study observed
that sharing residence equally after a parental union dis-
ruption may not be harmful for children. On the contrary,
children in 50/50 shared residence have markedly lower
likelihood of experiencing high levels of stress confirming
positive findings on other aspects of emotional
well-being.
These findings were then confirmed by the conclusion
of another important study where data on 15-year-old ado-
lescents from the 2005/2006 to 2009/2010 Swedish HBSC
survey were analyzed using logistic regression: here, the
authors found that shared physical custody after marriage
breakup seems to constitute a health protective factor for
adolescents’ health and problem behavior (Åsa et al., 2012).
Concluding note. The causal effect of shared parenting
on general wellbeing is more controversial: differently
from conflict and parental loss areas, in this field, it may be
more difficult to distinguish between selection effect and
causal effect of different parenting (shared, sole, etc.) on
individual well-being. However, even if it is not completely
clear how much the outcomes depend on selection effect
(where parents opting for “shared parenting” would be
more collaborative, non conflictual, and better care provid-
ers than “sole-parenting parents”) or on causal effect
(shared parenting really would lead to better outcomes for
the children), the sudden and huge increase in shared par-
enting in Sweden (where joint physical custody increased
from 4 percent in 1998 to 28 percent in 2006 and up to
40 percent in 2014, Bergström, 2015) and the observations
reported earlier (Buchanan and Maccoby, 1996; Cashmore
and Parkinson, 2010; Fabricius et al., 2012; Kline et al.,
1989; Melli and Brown, 2008; Nielsen, 2014; Sodermans
et al., 2013; Warshak, 2016) that there is no difference
between conflict between families in joint physical custody
arrangement and families in sole custody and leads us to
think that the positive outcomes of shared parenting cannot
depend just on selection effect.
The revolutionary dilemma: is divorce
with minor children a juridical, a
political or finally a public health
problem?
There is much evidence of significant biomedical conse-
quences of divorce on child health. The effects can appear
after 10, 20, or 30 years and, from a biological and bio-
chemical point of view, also in apparently healthy adults.
This issue indicates that this problem should be primarily
faced not from a juridical but from a public health point of
view. Unfortunately, in most countries, divorce involving
minor children is still considered a simple family law
problem, and in most European Union Member States, it
is the Ministry of Justice (and not Ministry for Childhood
or for Health!) that usually manages this kind of topic. As
an example of this approach, we recall the answer given
by Viviane Reding, at that time European Union (EU)
Justice Commissioner, on behalf of the European
Commission to European Parliament Vice President Hon.
Angelilli:

Vezzetti 9
The definition of joint custody belongs to substantive family law.
As such, it does not fall within the EU’s competence but remains
under the sole responsibility of the Member States. This explains
why there may be differences in the national systems as regards
the definition of joint custody and how it works in practice.
(Parliamentary Questions, 2013, E 000713/2013)
Similarly and unfortunately, also the Head of Unit of
Civil Justice Policy, on behalf of European Commissioner,
answered a question of Vittorio Vezzetti, President of
European Platform for Joint Custody Colibri that
The Commission is aware of differences in the national
systems and diverging practices when it comes to granting and
exercising these rights, where often cultural and societal
aspects play an important role. It is nevertheless of the opinion
that in decisions concerning children the primary consideration
shall be the best interests of the individual child assessed on a
case-by-case basis, in line with General Comment No 14
(2013) of the UN Committee on the rights of the child to have
his or her best interests taken as a primary consideration. The
legal base enshrined in the Treaty2 on which the Brussels IIa
Regulation is based, gives the Commission the powers to
propose measures to “develop judicial cooperation in civil
matters having cross-border implications, based on the
principle of mutual recognition of judgments and of decisions
in extrajudicial cases.” The objective of the reform of the
Regulation is therefore to enhance mutual trust in the fairness
of parental responsibility proceedings in the Member States
and thereby to ensure the smooth functioning of the Brussels
IIa Regulation to the benefit of parents and their children. In
this context, the Commission does not intend to unify the
definition of the best interests of the child. (Official Question
to European Commissioner for Justice, 2016)
This wrong and sectionalist approach leads to significant
and unjustifiable differences between the Member States,
and so the “paramount interest of the child” changes when
simply crossing a border as Vittorio Vezzetti has claimed by
Office of High Commissioner for Human Rights, European
Commissioner for Justice, European Commissioner for
Health, European Parliament, and Council of Europe
(International Council on Shared Parenting (ICSP), 2016;
Official Question to European Commissioner for Health,
2016; Official Question to European Commissioner for
Justice, 2016; Parliamentary Questions, 2014, E-005595-
14; Vezzetti, 2014; Vezzetti, 2015, 2016; see Tables 1 and 2
and Figure 1).
Conclusion
This review confirms that judgments of Family Courts
can have a huge influence on human health as they have
a huge influence on the probabilities of parental loss (var-
ied according different jurisprudences) and other child-
hood adversities (like inadequate parenting and long-term
conflict). The opinion of the author is that it is necessary
to make practices more harmonized such as in the medi-
cal world where shared and common guidelines usually
exist (inside which the operator can work according to a
case-by-case method). Considering the consequences on
children’s psychological and physical health, this might
be possible only by replacing the dominant “sectionalist”
legal language with a more universal scientific language
allowing all children to have an equal or adequate right to
health (as requested by most national Constitutions and
by EU’s Charter of Fundamental Rights) and overpassing
the Cartesian wall between Science and Right (Vezzetti,
2010).
Finally, the consequences of loss of contact between one
of the parents and the child/children will result in a heavy
burden for future worldwide generations.
Table 1. Protection of children’s right to co-parenting in case of divorce in different European countries by exact time division.
Section 1 Sweden Exact time division, >30%
Section 2 Belgium Exact time division, >20%
Section 3 France, Denmark, Spain Exact time division, 8%–20%
Section 4 UK, Germany Exact time division, 3%–8%
Section 5 Romania, Austria, Czech Republic, Slovakia,
Italy, Greece, Switzerland, Portugal
Exact time division, <3%
Table 2. Protection of children’s right to co-parenting in case of divorce in different European countries by physical shared
custody (excluded exact time division).
Physical shared custody <15% Physical shared custody <30% Physical shared custody >30%
Italy, Switzerland, Greece, Austria, Germany France, Spain Sweden, Belgium, Denmark
Czech Republic, Slovakia
UK, Romania
Portugal

10 Health Psychology Open
Acknowledgements
The author would like to thank Prof. Edward Kruk, British
Columbia University, President of International Council on Shared
Parenting, Canada; Med. Dr Ned Holstein, President of National
Parents Organization, USA; Prof. Hildegunde Suenderhauf,
Luteran University of Nurnberg, Germany; Dr Catalin Bogdan,
Vice President of European Platform for Joint Custody “Colibri,”
Romania; Prof. Alessando Salvatoni, Insubria University, Italy; and
Mrs Marcelle Holloway, European Commission, Ispra, Italy.
Declaration of Conflicting interests
PThe author(s) declared the following potential conflicts of inter-
est with respect to the research, authorship, and/or publication of
this article: This research was not done as part of official duties
with ATS Insubria or under its auspices-.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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