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Attached are 2 documents:1) An article from a journal (Article for Analysis)2) guidelines to use when analyzing the article (Guide)Note: Use APA reference style.You can use the same references that are mentioned in the article, for example when referring to their literature review etc.Word count: between 1500-2000.Report to be prepared in a word document and a brief powerpoint presentation.Journ
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Journal of General Practice
ISSN: 2329-9126
Kacenelenbogen et al., J Gen Pract 2013, 1:4
DOI: 10.4172/2329-9126.1000133
Research
Article
Research
Article
Open
OpenAccess
Access
The General Practitioner and Children of Separated Parents in Belgium: A
Qualitative Study and its Implications
Kacenelenbogen N1*, Roland M1, Schetgen M2 and Dusart AF2
1
2
Department of General Practice/Family Medicine, Université Libre de Buxelles ULB, Belgium
Sociologist; School of Public Health, Politics and Services for Childhood, Université Libre de Bruxelles ULB, Belgium
Abstract
Background: Many children are experiencing their parents’ separation and General practitioners (GPs) often
have the responsibility to medically follow these young patients.
Objectives: The goals were to identify the main difficulties GPs are confronted with when following children
of separated (or divorced) parents and to find ways to improve the quality of these children’s continuous medical
monitoring.
Methods: Eight focus groups of GPs were organized in 2004 in the French-speaking Community of Belgium.
Each meeting focused on couples separated for less than three years, with children aged 0 to 15. The debates were
analysed with the QSR N5 software. Data saturation was obtained after four focus groups.
Results: The viewpoint of GPs is: 1. Divorce affects the working conditions of GPs. 2. Conflicts between the
parents cause difficulties for the GP, particularly the fact of being « exploited » by the parents. 3. All GPs do not
have the same attitude towards conflicts between the parents; only some of them will try to « manage » the conflicts
to improve the child’s situation. 4. Especially in the case of conflicts, parental separation brings a risk for the child:
psychological disorders, physical health problems. 5. The professional attitudes of GPs can have a positive influence
on the child’s development, including direct child-centred communication with the child. 6. Some actions, such as
producing sickness certificates or official reports of neglect, can aggravate these children’s situation, especially in
the case of conflicts between the parents.
Discussion: Parental separation could be an independent risk factor for the child’s health by inducing some
difficulties of tracking in primary care medicine. If this is confirmed, in case of a family breakdown, the GP should
adapt the practice of prevention and care, recognizing young patients as most at risk. In order to confirm the possible
impact of family status, cohort studies must be conducted either transverse observational targeting unselected
paediatric populations of different ages, or even better in prospective research. Given the high prevalence of parental
separation in Belgium, the influence of these situations should be measured in terms of public health.
Keywords: Parental separation; Child; Primary care; Psychological
repercussions; Physical health
Introduction
Belgium has a population of 11 million and from the 45,000
marriages per year, 30,000 divorces occur after an average period of
15 years. Three quarters of these legal separations affect young people
under 18, approximately 600,000 children [1]. For the last two decades,
American and European literature has described how such separationsof married or unmarried couples-affected children regarding their
school performances, social behaviour, psychological adaptation, selfimage, as well as the quality of the family’s interpersonal relationship
[2,3]. These difficulties seem to last until adulthood, thus potentially
influencing the following generations [4,5]. In 2008, 70% of children
aged 0-18 in Belgium consulted their family doctor 4 to 5 times per
year [6], which means that GPs are inevitably concerned with children
experiencing a parental separation. It is within this context that from
2004 until late 2005, the General Medicine Department (DMG) of
the University of Brussels (ULB) organized a study whose goal was
Our definition of continuous medical monitoring involves both the follow-up of
a specific pathology and the long-term general medical support and/or care to a
patient by the GP
b
http://www.ordomedic.be/fr/avis/conseil/le-m%E9decin-et-les-enfants-de-parentsnon-cohabitants
c
These groups of medical evaluation (GLEM) are organised following article
36bis of the coordinated law of 14 July 1994; they are part of a larger program of
continuing education for general practitioners and specialists, within the framework
of the accreditation system, whose goal is the increase the quality and economy of
medical care (National medico-mutualist agreement of 13 December 1993).
a
J Gen Pract
ISSN: 2329-9126 JGPR, an open access journal
to understand how the continuous medical monitoringa of children
from separated parents worked in general practice. Since 1996, the
National Board of Physiciansb highlights the difficulties faced by GPs
in the case of a parental separation, so that extreme caution is advised
when issuing certificates or reports relating to children. The Board also
emphasizes how important it is that a single physician oversees a child’s
monitoring.
Therefore the purpose of this research was to test hypotheses about
possible difficulties encountered by GPs in these situations for which
no study was found in the literature at the time:
 The GPs experience greater interpersonal difficulties with parents
after a separation.
 Parental separation increases the risks of a fragmentation of the
*Corresponding author: Nadine Kacenelenbogen, MD, Department of General
Practice, Université Libre de Buxelles ULB, Belgium, Tel: 00 32 475 770 433, 00 32
2 343 18 06; Fax 00 32 2 347 11 00; E-mail: nkacenel@ulb.ac.be
Received July 22, 2013; Accepted November 04, 2013; Published November
10, 2013
Citation: Kacenelenbogen N, Roland M, Schetgen M, Dusart AF (2013) The
General Practitioner and Children of Separated Parents in Belgium: A Qualitative
Study and its Implications. J Gen Pract 1: 133. doi: 10.4172/2329-9126.1000133
Copyright: © 2013 Kacenelenbogen N, et al. This is an open-access article
distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided
the original author and source are credited.
Volume 1 • Isue 4 • 1000133
Citation: Kacenelenbogen N, Roland M, Schetgen M, Dusart AF (2013) The General Practitioner and Children of Separated Parents in Belgium: A
Qualitative Study and its Implications. J Gen Pract 1: 133. doi: 10.4172/2329-9126.1000133
Page 2 of 8
child’s continuous medical monitoring between several GPs, because
of relocation, conflicts or family blending.
 The difficulties, which separated parents face, diminish the quality
of their children’s continuous medical monitoring.
 Somatic, behavioural, psychological or school-related troubles
occur amongst these children, which are potentially hard to identify
and manage in primary care.
Methods
Subjects and setting
In order to test these hypotheses, eight focus groups with general
practitioners were organized through local groups of medical
evaluation (GLEM)c from ULB’s University Centre for Practical
Medicine. These peer review groups of about 15 practitioners from a
single region, held once per trimester, offer a familiar context suitable
for debates [7,8]. These GLEMs gather various practitioners differing
for their demographics (men, women, young and older physicians),
their type of practice (liberal alone, in association, in group within
medical clinics) and their subsidiary activity (family planning, nursing
homes, paediatric consultations, pedagogical responsibilities, Boardrelated activities, etc.). These GLEMs therefore favoured the intragroup diversification, which is looked for when researching a specific
social entity [9]. Seven focus groups were organized in Brussels, the
Nation’s capital with a population of one million, and one meeting was
held in Mons, population 92,000, therefore ensuring the participation
of GPs with a rural practice. All participants spoke French. Since the
GLEMs’ discussion topics are previously arranged within the context of
an accreditation program of continuous study, the eight focus groups
were scheduled and held between early September and late December
2004.
Focus groups
The focus groups were moderated by a practitioner from ULB’s
DMG (N.K.), accompanied by a sociologist from ULB’s School of Public
Health (SPH) (AF.D.). A committee of expertsd, consisting of general
practitioners, child psychiatrists, a sociologist and a psychologist,
specified the research topics for the focus groups:
 Possible specific issues encountered by children of separated
couples
 Whenever problems arise, what are the attitudes and referentse?
 Which deontology underlies these professional attitudesf?
Discussions were guided by three criteria:
 Testimonies about specific cases rather than generalities
 Couples who had been separated for less than three years
This committee was originally a reflection group, which delimited the research
questions and the framework of the study. This multidisciplinary group consisted of
six general practitioners (ULB professors), two child psychiatrists (one from ULB
and the other, director of the non-profit association “SOS Enfant”), one psychologist
(ULB) and one sociologist (SPH ULB professor).
e
In the case of detected psychological problems, does the GP refer the child to a
specialist, and if so, to which “specialists”?
f
Do general practitioners know the ethical rules of their profession regarding the
necessary consent of both parents in setting up some treatments? Were they ever
confronted with these types of problems when dealing with separated parents?
g
This consensus did not imply that everyone sided with the ideas that were shared.
It simply meant that all participants agreed upon the fact that all the opinions
expressed within the group were included in the summary (“No omission? What
did that really mean?”)
d
J Gen Pract
ISSN: 2329-9126 JGPR, an open access journal
 Children between the age of 0 to 15
Each debate started with an open question:
In Belgium, over 600,000 children are living in the context of a
separated family, what is your professional experience regarding this
situation?
The saturation of information was usually reached after an
average of ninety minutes of exchanges and at the end of each debate,
a summary of all the ideas expressed by the participantsg was looked
for and collectively agreed upon. With the participants’ approval, each
focus group was entirely recorded and transcribed.
Analysis
The data analysis was performed according to a phenomenological
approach in order to deduce codes, categories, and themes based on the
transcripts.8 The latter were studied independently by the four authors.
The coding phase was carried out separately by two researchers who
systematically confronted their opinions. The transcripts were also
analyzed with the help of the QSR N5 software (QSR International
Pty Ltd. N5 software for qualitative data analysis, Australia). The
entire process, which was continuously evaluated by the committee
of experts, ended after recurring discussions between the four authors
until a consensus was obtained regarding all the interpretations and
conclusions. All eight focus groups were analyzed, even though a
saturation of the data was reached after the fourth group’s transcript.
Results
Throughout the eight focus groups, 120 GPs described 242 cases of
children from separated parentsh and discussed them collectively.
Alteration of the professional conditions for the general
practitioner
General practitioners mentioned changes in their working
conditions, which complicated these children’s continuous medical
monitoring, as shown in Table 1, quotes 1-13.
The exploitation of the general practitioner: It is the most
common professional situation associated with separations emerging
in the transcripts. One way to “exploit” the GP is for a parent to use
certificates of incapacity or medical reports provided by the GP as a
“weapon” against the other parent, for financial, juridical or other
reasons. Another way is for a parent to try to have their doctor side
with them in the context of a conflict pertaining to the divorce (Table
1, quote 1).
The analysis reveals that this attitude is often symptomatic of a
parental conflicti lasting after the separation. A “successful” exploitation
frequently exposes the general practitioner to deontologicalj or legal
issues. In addition, this factor may engender further conflicts between
ex-spouses, which could ultimately have detrimental repercussions on
the child (Table 1, quote 2).
Whenever a participant made “general comments” about his experience with
parental separation, the moderator invited him to illustrate his saying with an actual
professional case.
i
Different reasons for the conflict, as observed in the study: the children’s custody,
education and/or health, money; various forms of the conflict: verbal, psychological
and/or physical abuse, vilification, legal actions (filing a claim against the exspouse).
j
Deontological issue: the GP could be summoned to appear before the Board of
Physicians if, for instance, a parent who felt cheated files a complaint against him/
her.
h
Volume 1 • Issue 4 • 1000133
Citation: Kacenelenbogen N, Roland M, Schetgen M, Dusart AF (2013) The General Practitioner and Children of Separated Parents in Belgium: A
Qualitative Study and its Implications. J Gen Pract 1: 133. doi: 10.4172/2329-9126.1000133
Page 3 of 8
• Exploitation of the practitioner by the parents
Quote 1 “A request for a certificate, a document, an attestation. We are asked to be judges, to side with them…”
Quote 2 “Like an idiot, I wrote the certificate… I received an angry phone call from the father, stating he was going to bring a claim against me to the Board of Physicians,
because I prevented him from seeing his child…”
• Fragmentation of the child’s medical monitoring
Quote 3 “When one is upset one is upset! So he has his doctor, and for the mother, it’s me. And my treatment for the child, the father won’t dispense it. And I haven’t
managed to know who is the other doctor…”
Quote 4 “A Portuguese family with a daughter who had to be operated. It took a lot to get the parents to agree!”
Quote 5 “The mother wants homeopathy and the father refuses and this clearly is problematic. Contacting the other physician? The mother doesn’t want to because I am
an allopath.”
• The practitioner only follows one parent
Quote 6 “And sometimes, there is one of the parents I no longer see. But there is no connection with a particular event. It’s an observation, which I have no control on. “
• Difficulty for practitioners following the same child to communicate with one another
Quote 7 “ … aren’t you tempted to maybe contact the other GP? … I’m not tempted but it may be the right thing to do. It’s an admittance of negligence …”
• Difficulty and lack of continuous medical monitoring for the child
Quote 8 “the mother sends the child to the father, who will not give him his medicine. This means I need to make sure the treatment will be over the day he goes to his
father’s…”
• Deontological issues
Quote 9 “I was asked for a document stating that the children would not go to school until the legal decision was taken… and I ended up in front of the Board with a warning
because of it.” )
• Legal issues
Quote 10 “We write certificates, more or less of leniency, which are obviously immediately noticed by the lawyer of the opposite party and end up in front of the court…”
• Ethical and moral issues
Quote 11 “in front of the child, we shouldn’t side with one parent or the other but between parents, I don’t see why we should necessarily remain neutral, for instance if
the ex-husband is violent…”
• Loss of the general practitioner’s central medical role
Quote 12 “… the father asked for my opinion and then, since I didn’t have all the data in my possession because all of the children’s tests had been made by somebody
else…”
Table 1: Continuous medical monitoring of children of separated parents by the GPs: Alterations of the GP’s working conditions.
The GP’s attitude when faced with his “exploitation”: Most general
practitioners are aware that they can potentially be utilised by parents
in the context of a conflict. This is evidenced through the attitudes
chosen to control the consequences:
– The GP refuses to produce the requested document or writes
down objective reports and avoids taking sides.
GL-5 page 3 & 4
“I simply stated there was a contusion, but nothing more. I
mentioned it was at the dad’s request, the magic formula…”
– Very often, the general practitioner attempts to understand and
manage the underlying conflict by communicating with both parents
and by advising them.
GL-4 page 4
“‘Write me a certificate so he can’t go to his father’s.’ I never wrote
the certificate… I also always try to have both parents, so that we can
talk about it.”
– Some participants believe they can be manipulated without their
knowledge and protect themselves by self limiting the range of their
professional action.
GL-6 pages 20 & 21
“We will be manipulated, let’s be careful. Let’s take care exclusively
of the physical, much less of the psychological. Some may criticize this
but that’s where we’re getting to.”
The fragmentation of the continuous medical monitoring:
Analyses of the results confirm that, whenever parents separate, the
J Gen Pract
ISSN: 2329-9126 JGPR, an open access journal
children’s medical monitoring is split amongst several practitioners,
for instance if one of the parents relocates. This alters the quality
of continuity of medical care to the child or young person. The
inconveniences connected to this situation are often related to a
deficient communication between the attending physicians, which is
in turn a consequence of the parental conflict (Table 1, quote 3). The
fragmentation of the medical monitoring connected to the absence
of coordination between general practitioners complicates obtaining
the parental consent for certain treatments. In Belgium, this consent
is mandatory for non-emergency surgical procedures, psychotherapies
and long-term cares, even after the divorce (Table 1, quote 4). The
difficulties to monitor these children are also connected to the fact that
two generalists can practice in a different way, for instance if one of the
two GPs practices homeopathy (Table 1, quote 5).
Attitudes of the general practitioner facing the fragmentation of
the continuous medical monitoring: Some practitioners communicate
with the other colleague. Analysis of the discussions demonstrates that
this approach, which is recommended by the Board of Physicians, is
efficient but rarely possible, due to practical reasons.
GL-2 pages 4 & 5
“In front of the mother, I contacted the doctor out in the province
and between him and I, we created a linked notebook where we wrote
everything down…”
Consequences of the divorce on the child, as observed by the
GP (Table 2, quotes 1-8)
Children without any particular problems: The GP reports
that some children do not suffer any negative psychological or
Volume 1 • Issue 4 • 1000133
Citation: Kacenelenbogen N, Roland M, Schetgen M, Dusart AF (2013) The General Practitioner and Children of Separated Parents in Belgium: A
Qualitative Study and its Implications. J Gen Pract 1: 133. doi: 10.4172/2329-9126.1000133
Page 4 of 8
• Psychological/behavioural disorders
Acute of chronic anxiety; phobia; panic attacks; depressions; self-destructing behaviours; substance abuse; eating disorders; secondary …
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