When a parent is a prison inmate or has illnesses such as AIDS or a psychiatric disorder, issues of visitation or custody often arise. Diane Schetky, M.D., a child and adolescent forensic psychiatrist in private practice in Rockport, Maine, provided guidance on what to look for in these special situations to determine the child’s best interests.

Schetky was a panelist at the session "Children’s Rights in Separation and Divorce" in October at the American Academy of Child and Adolescent Psychiatry annual meeting in New York City.

Schetky described a case of an incarcerated father who petitioned for visitation rights to see his two daughters, ages 3 and 4. Because of their young age, Schetky was appointed by the judge to represent their interests. The father was in jail for murder.

His former wife opposed the petition claiming the children had no relationship with their father and did not want one. The wife had testified for the prosecution in the man’s murder trial and told Schetky that he was threatening and abusive toward her and the children. She divorced him and moved three hours away from the prison with the goal of starting her life over, said Schetky.

"When I examined the father’s relationship with his children, I found he had none with the youngest daughter who was born after he was incarcerated. There was also little evidence of bonding with the oldest daughter who had visited him a few times in prison and was terrified afterwards," said Schetky.

She also considered the nature of the father’s crime and duration of the sentence. When Schetky asked the man how he thought his daughters would react if they learned about his crime, he responded that "he didn’t think it would bother them because they hadn’t known the victim."

His reason for wanting to see his daughters was because "all his buddies got to see their kids, and he thought it was unfair that he was deprived of these visits," said Schetky.

He did not show any empathy for his children or concern about their welfare, she noted.

She also considered the location of the prison. The children lived three hours away, so visiting their father would require six hours of driving, most likely by the mother, who did not want to visit the father.

"After reviewing the relevant factors, I recommended to the judge that the father be denied visitation rights until the children reached school age, at which time they could express their wishes on the matter," said Schetky.

Visitation issues may also arise when a parent is dying of AIDS complications. The custodial parent may oppose visitation if he or she disapproves of the other parent’s lifestyle and believes that exposing the child to a parent with the illness would be too upsetting, said Schetky.

She described a case in which a father with AIDS filed a petition to enforce his visitation rights so he could see his children before he died. "The mother, who had full custody, responded that the visitation would be too upsetting for the children, ages 5, 7, and 10, and that they had no feeling for their father," said Schetky.

In this case, the child and adolescent psychiatrist should consider the child’s relationship to the dying parent, the child’s capacity to deal with death, the importance of the farewell visit, parental alienation caused by the mother’s homophobia and unresolved anger toward the father, the mother’s concern that the children could contract AIDS, the father’s capacity to meet the child’s physical and emotional needs, and the emotional support available for the visiting children, said Schetky.

The court ordered the mother and her children to attend family therapy. The father was allowed to have supervised visits with his children. "The children were not traumatized by seeing their father. Instead, they were able to prepare for his death and say their farewells," said Schetky.

Should a parent with a mental illness have custody of his or her children? The answer depends on several issues, Schetky suggested. Does the parent recognize that he or she has a mental illness? What is its course and chronicity? Does it affect the child? What impact does the illness have on parenting?

It is also critical to look at the parent’s prognosis and record of compliance with treatment. The risks the parent poses to the child vary according to the mental illness. For example, parental depression can result in decreased emotional involvement, inattention, and inability to supervise the child, said Schetky.

"Children may interpret a parent’s depression as rejection and feel unloved. Attachment problems can occur in young children. Discipline may be compromised, and older children may take on the role of the parent," said Schetky.

"It’s also common to see gaps in language and social skills and depression in these children," said Schetky.

Parents with psychosis are also often emotionally unavailable to the child. Their behavior may be disorganized, erratic, and even violent, said Schetky. They may have fixed delusions involving the child.

She described a case involving a mother with a 20-year history of psychosis and refusing medication. The mother was inattentive and frequently forgot to feed her infant. "She believes the child has special powers and could tell what she was thinking by just looking at her."

The social workers assigned to supervise the mother’s visits with her baby resigned because they were so uncomfortable with the way the mother interacted with the child, said Schetky.

"The social workers and I testified in court that the mother’s mental illness posed a significant risk to the child and that her prognosis was poor. However, the judge disagreed and ordered the visits to continue. The mother later relinquished her parental rights," she noted.

Determining the appropriateness of parental custody should also involve evaluating the child’s developmental level, relationship to the parent, response to the parent’s symptoms, ability to understand the parent’s mental illness, and the child’s wishes, said Schetky.

"If the mother is complying with treatment and I see evidence of bonding and good interactions with the child, I usually recommend a caseworker help obtain support services," said Schetky.

These include parenting classes, living in a partially supervised setting, home aids, and treatment services for children at risk of developing psychiatric symptoms, said Schetky.