Supporting the mental health of children and youth of separating parents
Posted: Sep 3 2013 | Reaffirmed: Feb 1 2016
The Canadian Paediatric Society gives permission to print single copies of this document from our website. For permission to reprint or reproduce multiple copies, please see our copyright policy.
Brenda Clark; Canadian Paediatric Society, Mental Health and Developmental Disabilities Committee
Paediatr Child Health 2013;18(7):373-7
The rising international trend in the number of parents who separate or divorce is raising concerns about long-term consequences for child and youth well-being and adjustment to adulthood. Separation and divorce may increase risks for negative outcomes in physical, mental, educational and psychosocial well-being during childhood and later, as youth transition to adulthood. Most children of separated and divorced families do not have significant or diagnosable impairments. Family processes that have a positive mediating effect on child well-being after parental divorce or separation include improving the quality of parenting, improving the quality of parent–child relationships and controlling hostile conflict. Physicians can offer support and guidance to separating parents by helping them to identify risk factors, strengthen protective factors and enhance children’s capacity to cope with family changes.
Key Words: Divorce; Mental health; Outcome; Separating parents
In Canada, the family structure has been changing over the past 20 years, with the proportion of married-couple families declining and common-law and lone-parent families increasing. According to the 2011 Canadian census, the total number of census families (those who completed the census that year) rose by 5.5%, while the proportion of married-couple families decreased slightly to 67.0%. The proportion of common-law couple families increased 13.9%, more than four times the rate for married couples over the same five-year period. For the first time, the number of common-law couple families (16.7%) surpassed lone-parent families (16.3%), and the number of same-sex couples nearly tripled between 2006 and 2011. Despite these trends, the number of married couples remains greater than the number of common-law couples in Canada, although their proportion has been steadily decreasing.
There were 5,587,165 children 14 years of age and younger living in private households in 2011. Most of these children lived with married (63.6%), common-law (16.3%) or lone (19.3%) parents, while 0.8% of children lived with other relatives or nonrelatives. Of these, 29,590 (0.5%) were reported as foster children and 30,005 (0.5%) lived in ‘skip-generation families’, usually with grandparents. In 2006, for the first time, census families without children (42.7%) outnumbered those with children (41.4%) and, by 2011, the number of couples with children had decreased to 39.2%.
According to Statistics Canada, and based on statistics from the six reporting provinces and territories, the number of new divorce cases (ie, the legal dissolution of a marriage) between 2006/2007 and 2010/2011 declined steadily by a total of 8%. Still, it was estimated in 2008 that 41% of marriages will end in divorce before their 30th year, an increase from 36% in 1998. The high rates of divorce and separation continue to have a significant impact on the physical, academic, economic and mental health of Canadian children and youth. Primary care physicians and paediatricians need to be aware of their role in advocating and supporting the mental health of children and youth of separating parents.-
Consequences of separation and divorce
Separation or divorce is usually the end result of a discordant marriage with ongoing tensions, family conflict and, in some cases, violence. Divorce is a process, not a single event, and so the child’s adjustment occurs in stages. Ongoing parental conflict or violence can lead to stress and the onset of mental health concerns long before the time of actual separation. Most children and youth experience initial painful emotions including sadness, confusion, fear of abandonment, anger, guilt, grief and conflicts related to loyalty and misconceptions.- Many children experience feelings of loss when one parent leaves the family, but some also feel a sense of relief because domestic violence or abuse stops. Nearly all children will experience confusion and concern about what is going to happen to them.- If there is a high level of conflict, children appear to be better off if the marriage ends and separation occurs. If the child perceives little conflict, the parental separation may be unexpected and children can appear to be worse off following the separation. In either case, there is likely to be a decline in household income, loss of contact with one parent and multiple changes involving home, school and friends.-
Although many children and youth of separating or divorcing parents experience distressing thoughts and emotions, the overwhelming majority do not experience serious outcomes.- However, even small negative effects constitute a serious public health problem when multiplied by the millions of individuals who experience separation or divorce. According to research conducted in the 1990s, children of divorced parents scored significantly lower than children of continuously married parents on measures of academic achievement, conduct, psychological adjustment, self-concept and social relations.- More recent research continues to suggest an ongoing gap between children of divorced parents and continuously married parents. The negative impact of divorce can reach into adulthood and even later in adult married life, with potential increases in poverty, educational failure, risky sexual behaviour, unplanned pregnancies, earlier marriage or cohabitation, marital discord and divorce.-
Research has attempted to answer key questions related to the magnitude of effects of separation/divorce as well as co-occurring risk factors. Are the negative associations due to the process or experience of separation/divorce? Are they causal or due to factors that caused marital disruption in the first place? What are the specific environmental factors that mediate these associations?
Children’s experience of divorce can manifest in various ways. The way children react to the consequences of divorce may vary among siblings, and parents need to be mindful of each child’s level of development and temperament. There is increased risk for short-term stress as children and youth face the disruption and emotional turmoil arising from decisions that affect their personal lives. Research suggests that although there is increased risk for negative outcomes in children of divorced families compared with children of continuously married families, there is significant variability. Most children do not experience short- and long-term negative outcomes, and there are many factors that can reduce risk and promote resilience.-
Family risk factors
Family protective factors
Ongoing conflict between parents (especially if it is abusive and/or focused on children)
Protection from conflict between parents
Diminished capacity to parent or poor parenting
Cooperative parenting (except in cases of domestic violence)
Lack of monitoring children’s activities
Healthy relationships between child and parents
Multiple family transitions
Parents’ psychological well being
Parent mental health problems
Quality, authoritative parenting
Chaotic, unstable household
Household structure and stability
Impaired parent-child relationships
Supportive sibling relationships and extended family relationships
Adapted from reference 
Family processes account for most of the increased risk associated with parental divorce. The three most significant factors that impact children’s well-being during the process of parental separation or divorce are: the quality of parenting; the quality of parent–child interaction; and the degree, frequency, intensity and duration of hostile conflict.- Targeting these processes may improve outcomes for children. Parents have the potential to change the course of children’s outcomes by learning to manage conflict, parent effectively, and nurture warm and loving relationships with their children. Many will need guidance and support over time to accomplish these goals. Much can be done to foster children’s resilience, and prevention is largely in the hands of parents. Physicians can offer support and guidance to separating parents by helping them to identify risk factors, strengthen protective factors and enhance children’s capacity to cope with family changes. The paediatrician’s role also involves assessing risk factors and anticipatory guidance to decrease the morbidity associated with separation and divorce.-
The following sections review in detail the three main factors affecting child and youth resilience, and list parenting recommendations that physicians can use to counsel parents in office practice.
Research has shown that the quality of parenting, as defined by warmth and nurturance along with effective discipline and limit-setting, is a powerful protective and resilience-promoting factor for children experiencing parental separation or divorce.- Parents need to communicate well and frequently with children and youth, openly expressing their love and devotion. However, the other side of parenting, discipline, is equally important and characterized by clear guidelines, limits and developmentally appropriate expectations. Effective discipline helps children and youth adapt to change by increasing the predictability of their environment and fostering their sense of control. Children need to understand that it is normal to have many feelings about their own experience of divorce or separation. Learning to cope with different emotions and the behaviours that sometimes follow can be a challenge for both parent and child.
Most of the literature has focused on mother–child relationships, with only a few studies reporting on parent–child and custodial–child relationships. It is the expert opinion of most authors that their comments probably apply to the child or youth’s relationships with either parent. Therefore, we have chosen to use the term ‘parent–child relationships’. The quality of parent–child relationships is an important protective factor that predicts the long-term impact of separation and divorce on children.- Parent–child relationships characterized by warmth, supportiveness, effective problem-solving skills, positive communication, and low levels of conflict and negativity are consistently associated with fewer negative outcomes related to mental health and with more positive outcomes related to social adaptation following a separation or divorce. Developing strong parent–child relationships depends on communicating effectively and often with children. Parenting through a separation or divorce presents many challenges. Most children do not speak with their parents about divorce, so it may be difficult to know what they really think or feel about their new circumstances. Parents need to learn to listen without judgment, reflect understanding, allow silence and respond with empathy. Establishing family routines, sharing activities and increasing one-on-one time with each child can help to strengthen the bonds between parents and children, ultimately reinforcing the most important parental message of enduring, unconditional love for their children.-
Ongoing interparent conflict is one of the most damaging aspects of divorce.- Exposures to violence and abusive behaviour are especially toxic to children, and parents must learn to control verbal and physical conflict. Frequent, intense verbal and/or physical hostility, especially when it is directed toward children, is very damaging and must be prevented.- Developing a respectful, businesslike relationship between parents, with clear boundaries and ground rules for interacting and a common commitment to the children’s best interests and well-being is a protective step.
Mediation is an effective way to resolve conflict and an alternative to litigation alone. Parents who seek mediation are often better able to co-parent, resolve conflict and stay actively involved compared with parents who seek litigation alone.- When parents are having great difficulty sharing responsibilities, or are experiencing high levels of conflict, legal and mental health professionals can help draft a parenting plan. This document will structure and decrease interaction time between parents while allowing the child’s developmental needs to be met.
Preventive interventions have shown positive outcomes for social and emotional adjustment, school engagement, and reducing anxiety and physical complaints.- Group support helps reduce children’s sense of isolation, clarifies misconceptions, and teaches how to problem-solve and communicate more effectively with parents. Interventions provide critical information to help parents understand the risk and resilience factors that will affect their child’s outcomes, and can help divorced parents reframe their relationship as a respectful, businesslike parenting relationship. Positive messaging empowers parents, helping them to understand what aspects they control and what they do not. An intervention can re-emphasize the benefits of quality parenting and positively reinforce parent–child relationships.
The feelings and emotions surrounding a separation are often complex and difficult for parents to mediate due to their own levels of stress, emotional turmoil, hostility and sense of loss. There may be ongoing conflicts with the ex-partner or battles in court that negatively affect parent–child relationships and parenting, making it difficult for either parent to focus on the children’s priorities.
The stress of separation or divorce may cause changes in sleep patterns, appetite and lifestyle, which can result in physical changes and decrease general health. These issues compound the effects of stress, thereby reducing parenting capacity and emotional availability. Parents need to look after their own health and set aside time to care for themselves. Entering a new relationship too quickly can increase a child’s sense of loss and the fear of being ‘replaced’ as a parent shifts the focus of his or her affection to a new partner. New relationships need to be introduced slowly and handled with care, especially when they involve other children.
Children whose parents effectively share joint custody tend to be better adjusted after separation or divorce than children with one custodial parent.- In one long-term study, a good relationship with the custodial parent predicted fewer child behaviour problems, better communication skills, better grades and higher ratings of adjustment. The amount of parenting time should not be emphasized as much as a parenting plan that allows both parents to feel engaged and responsible. The importance of valuing one another’s contributions to child-rearing and what each parent brings to the task cannot be overemphasized. This effect is synergistic and creates a team working for the child’s best interests.
The period of separation or divorce is marked by confusion, disorganization, stress and conflict. Parents usually want to do what is best for their children but often need support and guidance to make the best choices and decisions. There are many factors involved, and many different plans and decisions can work well. The principle to follow is that, when decisions are being made, the resulting arrangements must preserve and strengthen the child’s relationship with both parents whenever possible.
Three major areas of concern have been raised by researchers and need to be considered when supporting young children of separating parents: the direct effects of parental conflict and violence; the effects of diminished quality in parenting; and the effects of repeated separations between the infant and primary attachment figures.-
The developmental stage and temperament of each child needs to be considered. Attachment to a parent usually starts to develop at a cognitive age of seven to nine months. Infants, toddlers and preschool children develop attachments as their primary caregivers respond to their needs in a consistent and sensitive way. They do best with predictable schedules and responsive parenting that takes their individual temperaments into account. Frequent access to both parents helps them to build a memory of the absent parent and supports parental cooperation around feeding, sleep and other daily routines.
Children younger than five years of age need special consideration, given the developmental vulnerability related to rapid physical, cognitive, language, social and emotional growth in this period. The brain’s development continues after birth and depends on quality care and experiences to reach maximum potential. The years between birth and five years of age are also the period of peak attachment formation.
Quality parenting in the early years of life is very important to psychological and emotional development and to the child’s subsequent ability to regulate stress and emotional arousal. Young children need a predictable and safe environment with consistent access to caregivers who are emotionally available and able to respond to their needs in a consistent and sensitive way. Repeated or prolonged separation from a primary attachment figure because of shared-time parenting may compromise attachment formation and consolidation if the baby or young child does not have a consistent, reliable experience with either parent.- Comprehensive reviews have recommended that principles of attachment theory and well-validated measures of attachment security can help to inform custody evaluations.
Consistent, warm and responsive care is important for infants and young children. Infants and children younger than three years of age may reflect a caregiver’s distress and grief, and their observed behaviours may include irritability, poor sleep-wake rhythms, separation anxiety, feeding disturbances or even developmental regression. Extreme parental conflict or unsafe and overwhelming experiences may also threaten an infant’s ability to form organized attachments and subsequent capacities for self-regulation.- High-intensity conflict is linked to the development of insecure and disorganized attachment styles.- Chronic conflict, with ongoing disputes, unresolved grief and loss, and financial stressors impact parenting sensitivity and availability. The loss of patience and emotional energy decreases parenting sensitivity and can lead to harsher styles of discipline.
At four to five years of age, children often blame themselves for a separation and become increasingly ‘clingy’, with separation anxiety, externalizing behaviours and excessive fears of abandonment. School-age children have a strong sense of rules and fairness, and they are working toward mastery of cognitive, physical and social challenges. They are prone to loyalty conflicts and may take sides. Children at this age are learning right from wrong and have a strong desire to belong to a peer group. The involvement of both parents with school meetings, after-school activities and visits with peers needs to be considered in the scheduling of visits between parental homes. It is important for both parents to maintain respectful, businesslike behaviour and keep children out of parental conflicts. Being civil helps children to maintain a secure relationship with both parents and avoids complications when switching houses and routines. School-age children need to continue to develop peer relationships and participate in after-school activities.
During adolescence, personality and identity become consolidated and peers become the reference group for daily activities and many decisions. Teens are eager to be accepted and to belong. Parents remain important and have a strong influence in many areas including health, academic choices, activities and moral values. Youth at this stage need access to both parents, and often choose to move between homes according to their academic and social needs. Parents need to communicate effectively, provide consistent limit-setting and promote healthy teenage development.
The structure of the Canadian family is changing. Although the rate of divorce declined slightly between the 2006/2007 and 2010/2011 census years, by 2% per year, the number of separating and divorcing couples with children remains significant, raising concerns about long-lasting consequences for child and youth well-being and adjustment to adulthood. The impact of separation and divorce has been documented, along with an increase in risk for negative outcomes in physical, mental, educational and psychosocial well-being during childhood and later, as youth transition to adulthood. Although there is increased risk for various negative outcomes, most children and youth of separating and divorcing families do not have significant or diagnosable impairments. Family processes that have a significant mediating effect on child well-being after parental divorce or separation include improving the quality of parenting, improving the quality of parent–child relationships and controlling hostile conflict. Physicians can offer support and guidance to separating parents by helping them to identify risk factors, strengthen protective factors, and enhance children’s capacity to cope with family changes.
Recommendations for physicians
- Become familiar with the possible negative outcomes related to separating and divorcing parents.
- Provide information, advice and advocacy for children, youth and parents on issues related to separation and divorce. Inform them about the possible emotional and behavioural responses to separation and divorce. A parent handout titled ‘Helping children cope with separation and divorce’ is available.
- Maintain supportive and positive relationships with the children and both parents. Avoid taking sides and encourage open communication.
- Refer parents and/or children and youth to mental health services for treatment of associated mental health issues, if indicated, and provide information on supportive community programs.
- Encourage parents to look after their own physical and mental health.
- Recommend mediation in complex cases of separation and divorce.
- Encourage positive parenting and effective discipline. Refer parents to positive parenting programs and other appropriate supportive community services.
- Advocate for more research on the impact of parent–child relationships with parents of either sex.
- Advocate for research that answers questions related to the magnitude of effects of separation/divorce and co-occurring risk factors.
- Advocate for more research to answer the questions related to shared-time parenting and the effects on development in the young child.
- American Academy of Pediatrics: Bright Futures: www.brightfutures.aap.org
- Encyclopedia on Early Childhood Development: www.child-encyclopedia.com
- The Incredible Years: www.incredibleyears.com
- OSEP Technical Assistance Center on Positive Behavioral Interventions and Supports Effective Schoolwide Interventions: www.pbis.org
- National Center for Infants, Toddlers, and Families: www.zerotothree.org
- Triple P: Positive Parenting Program: www.triplep.net
This position statement has been reviewed by the Canadian Academy of Child and Adolescent Psychiatry, and by the Adolescent Health and Community Paediatrics Committees of the Canadian Paediatric Society.
CPS MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES COMMITTEE
Members: Stacey A Bélanger MD PhD (Chair); Brenda Clark MD; Johanne Harvey MD (Board Representative); Daphne J Korczak MD
Liaisons: Debra Andrews MD, CPS Mental Health Section; Clare Gray MD, Canadian Academy of Adolescent Psychiatry; Janet Kawchuk MD, CPS Developmental Paediatrics Section
Principal author: Brenda Clark MD
- Statistics Canada. 2007. 2006 Census: Family structure, 1981 and 2006 (percent). Catalogue no. 97-554-XCB2006007.
- Statistics Canada. 2012. Portrait of Families and Living Arrangements in Canada: Families, households and marital status, 2011 Census of Population. Statistics Canada Catalogue no. 98-312-X2011001.
- Kelly MB. Divorce cases in civil court, 2010/2011. Component of Statistics Canada Catalogue no. 85-002-X: http://statcan.gc.ca/pub/85-002-x/2012001/article/11634-eng.htm (Accessed April 22, 2013).
- D’Onofrio BM. Consequences of separation/divorce for children. Emery RE, topic ed. In: Tremblay RE, Boivin M, Peters RDeV, eds. Encyclopedia on Early Childhood Development. Montreal, Quebec: Center of Excellence for Early Childhood Development and Strategic Knowledge Cluster on Early Child Development; 2011:1-6. www.child-encyclopedia.com/pages/PDF/DOnofrioANGxp1-Divorce.pdf (Accessed April 22, 2013).
- Emery RE, topic ed. Divorce and separation – Synthesis. In: Tremblay RE, Boivin M, Peters RDeV, eds. Encyclopedia on Early Childhood Development. Montreal, Quebec: Centre of Excellence for Early Childhood Development and Strategic Knowledge Cluster on Early Childhood Development; 2011: i-iii: www.child-encyclopedia.com/pages/PDF/synthesis-divorce_and_separation.pdf (Accessed April 22, 2013).
- Amato PR, Keith B. Parental divorce and the well-being of children: A meta-analysis. Psychol Bull 1991;110(1):26-46.
- Amato PR. Children of divorce in the 1990s: An update of the Amato and Keith (1991) meta-analysis. J Fam Psychol 2001;15(3):355-70.
- Amato PR. Research on divorce: Continuing trends and new developments. J Marriage Fam 2010;72(3):650-66.
- Hetherington EH, Stanley-Hagan M. The adjustment of children with divorced parents: A risk and resiliency perspective. J Child Psychol Psychiatry 1999;40(1):129-40.
- Hetherington EM, Kelly J. For Better or for Worse: Divorce Reconsidered. New York: WW Norton, 2002.
- Averdijk M, Malti T, Elsner M, Ribeaud D. Parental separation and child aggressive and internalizing behavior: An event history calendar analysis. Child Psychiatry Hum Dev 2012;43(2):184-200.
- Arkes J. The temporal effects of parental divorce on youth substance use. Subst Use Misuse 2013;48(3):290-7.
- Donahue KL, D’Onofrio BM, Bates JE, et al. Early exposure to parents’ relationship instability: Implications for sexual behavior and depression in adolescence. J Adolesc Health 2010;47(6):547-54.
- Gibb SJ, Fergusson DM, Horwood JL. Relationship, separation and mental health problems: Findings from a 30-year longitudinal study. Aust N Z J Psychiatry 2011;45(2):163-9.
- Kelly JB, Emery RE. Children's adjustment following divorce: Risk and resilience perspectives. Fam Relat 2003;52(4):352-62.
- Kleinsorge C, Covitz LM. Impact of divorce on children: Developmental considerations. Pediatr Rev 2012;33(4):47-54.
- Pedro-Carroll J. Putting Children First: Proven Parenting Strategies for Helping Children Thrive through Divorce. New York: Penguin, 2010.
- Pedro-Carroll J. How parents can help children cope with separation/divorce. Emery RE, topic ed. In: Tremblay RE, Boivin M, Peters RDeV, eds. Encyclopedia on Early Child Development. Montreal, Quebec: Centre of Excellence for Early Childhood Development and Strategic Knowledge Cluster on Early Child Development, 2011:1-10. http://www.child-encyclopedia.com/pages/PDF/Pedro-CarrollANGxp1.pdf. (Accessed April 22, 2013)
- Wolchik SA, Schenck CE, Sandler IN. Promoting resilience in youth from divorced families: Lessons learned from experimental trials of the New Beginnings Program. J Pers 2009;77(6):1833-68.
- Zhou Q, Sandler IN, Millsap RE, Wolchik SA, Dawson-McClure SR. Mother-child relationship quality and effective discipline as mediators of the 6-year effects of the New Beginnings Program for children from divorced families. J Consult Clin Psychol 2008;76(4):579-94.
- Vélez CE, Wolchik SA, Tein JY, Sandler I. Protecting children from the consequences of divorce: A longitudinal study of the effects of parenting on children's coping processes. Child Dev 2011:82(1);244-57.
- Lamb ME, Lewis C. The development and significance of father-child relationships in two-parent families. In: Lamb, ed. The Role of the Father in Child Development, 2nd edn. Hoboken: John Wiley, 2010:94-153.
- Pruett K, Pruett MK. Partnership Parenting: How Men and Women Parent Differently – Why it Helps Your Kids and Can Strengthen Your Marriage. New York: De Capo, 2009.
- McIntosh JE. Enduring conflict in parental separation: Pathways of impact on child development. J Fam Stud 2003;9(1):63-80.
- Wallerstein J. The impact of divorce on infants and very young children. In: Haith MM, Benson JB, eds. Encyclopedia of Infant and Early Child Development, Vol 1. Elsevier. 2008;412-21. Accessed April 22, 2013.
- McIntosh JE. Special considerations for infants and toddlers in separation/divorce: Developmental issues in the family law context. Emery RE, topic ed. In: Tremblay RE, Boivin M, Peters RDeV, eds. Encyclopedia on Early Childhood Development. Montreal, Quebec: Centre of Excellence for Early Childhood Development and Strategic Knowledge Cluster on Early Child Development, 2011:1-6: http://www.child-encyclopedia.com/pages/PDF/McIntoshANGxp1.pdf (Accessed April 22, 2013).
- Emery RE. Renegotiating family relationships: Divorce, child custody, and mediation, 2nd edn. New York: Guilford Press, 2012.
- Kline Pruett M. Parenting plans following separation/ divorce: Developmental considerations. Emery RE, topic ed. In: Tremblay RE, Boivin M, Peters RDeV, eds. Encyclopedia on Early Childhood Development. Montreal, Quebec: Centre of Excellence for Early Childhood Development and Strategic Knowledge Cluster on Early Child Development, 2011:1-6. http://www.child-encyclopedia.com/pages/PDF/KlinePruettANGxp1.pdf (Accessed April 22, 2013).
- Backen Jones L. Divorce and separation: Commentary on Kline Pruett and McIntosh. Emery RE, topic ed. In: Tremblay RE, Boivin M, Peters RDeV, eds. Encyclopedia on Early Childhood Development. Montreal, Quebec: Centre of Excellence for Early Childhood Development and Strategic Knowledge Cluster on Early Child Development, 2011:1-6. http://www.child-encyclopedia.com/pages/PDF/BackenJonesANGxp1.pdf (Accessed April 22, 2013).
- Wolchik SA, Sandler IN, Millsap RE, et al. Six year follow-up of preventive interventions for children of divorce: A randomized controlled trial. JAMA 2002;288(15):1874-81.
- McIntosh JE, Smyth B. Shared-time parenting: An evidence-based matrix for evaluating risk. In: Kuehnle K, Drozd L, eds. Parenting Plan evaluations: Applied Research for the Family Court. New York: Oxford University Press, 2012.
- Zeanah CH, Berlin LJ, Boris NW. Practitioner review: Clinical applications of attachment theory and research for infants and young children. J Child Psychol Psychiatry 2011;52(8):819-33.
- Zeanah CH, Danis B, Hirshberg L, et al. Disorganized attachment associated with partner violence: A research note. Infant Mental Health J 1999;20(1):77-86.
- Calloway G, Erard RE. Introduction to the special issue on attachment and child custody. J Child Custody 2009;6(1-2):1-7.
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.