"Part of the abuse is not letting me get him medical care": A qualitative examination of children's unmet health needs in the context of post-separation abuse.

“Part of the abuse is not letting me get him medical care”: A qualitative examination of children’s unmet health needs in the context of post-separation abuse - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Child Abuse Negl . Author manuscript; available in PMC: 2026 Jun 1. Published in final edited form as: Child Abuse Negl. 2025 Apr 14;164:107451. doi: 10.1016/j.chiabu.2025.107451 “Part of the abuse is not letting me get him medical care”: A qualitative examination of children’s unmet health needs in the context of post-separation abuse Kathryn J SPEARMAN 1 , Lea MARINEAU 2 , Adebola OWOLABI 1 , Kamila A ALEXANDER 1 , Jennifer Hardesty 3 , Viola Vaughan-Eden 4 , Christina Bethell 5 , Jacquelyn CAMPBELL 1 Author information Article notes Copyright and License information 1 Johns Hopkins University, School of Nursing 2 National Institute of Health 3 University of Illinois Urbana-Champaign, 4 Norfolk State University, The Ethelyn R. Strong School of Social Work 5 Johns Hopkins University, Bloomberg School of Public Health Author Contributions: All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE*): (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content. ✉ Address correspondence to Kathryn Spearman, MSN, RN, Johns Hopkins School of Nursing, 525 N Wolfe Street, Baltimore, MD kspearm2@jhu.edu Issue date 2025 Jun. PMC Copyright notice PMCID: PMC12077252  NIHMSID: NIHMS2074663  PMID: 40233554 The publisher's version of this article is available at Child Abuse Negl Abstract Background: Children exposed to intimate partner violence (IPV) experience disparities in health outcomes and healthcare access. Mechanisms explaining how IPV affects children’s health needs, particularly after parental separation, are poorly understood. Objective: The aim of this qualitative study is to examine maternal survivors’ experiences of IPV following separation from an abusive co-parent (“post-separation abuse”) and their children’s health needs. Participants and Setting: The research team conducted individual semi-structured interviews with N = 33 maternal post-separation abuse survivors from 18 states in the United States. Methods: Qualitative interviews were coded and analyzed using ATLAS.ti through an iterative thematic inquiry approach, with each interview coded by at least 2 study team members. Results: Most participants (85%) reported difficulty accessing healthcare for their children. The analysis team identified five broad domains of post-separation abuse tactics contributing to children’s unmet health needs: (1) obstruction and manipulation of children’s healthcare, (2) stalking and intimidation, (3) legal abuse, (4) disregarding children’s well-being, and (5) economic abuse. Conclusions: This study provides foundational insights into specific behaviors by abusive co-parents and court-imposed barriers that impact children’s health needs. Improved understanding of post-separation abuse is essential to design interventions and policies to ensure children’s access to needed healthcare and to reduce health disparities. Keywords: intimate partner violence, children’s unmet health needs, post-separation abuse, family court, medical neglect Introduction Childhood exposure to parental or caregiver intimate partner violence (IPV) is a pervasive public health problem. Based on youth self-reports, up to one in four children in the United States (U.S.) report exposure to IPV during their childhood ( Hamby et al., 2011 ). Based on parental reports, the rate of IPV exposure is 5.4% of all U.S. children according to data from the National Survey of Children’s Health (NSCH) (Child and Adolescent Health Measurement Initiative (CAHMI), 2025). IPV exposures are even greater for children who meet criteria for special health care needs (10.9%) relative to children who do not have special health care needs (3.7%) (CAHMI, 2025). IPV-exposed children suffer harms across physical, mental, behavioral, and academic domains ( Bair-Merritt et al., 2008 ; Bair-Merritt et al., 2015 ; Bender et al., 2022 ; Berg et al., 2022 ; Holmes, Berg, Bender, Evans, Kobulsky, et al., 2022 ; Holmes, Berg, Bender, Evans, O’Donnell, et al., 2022 ; MacMillan & Wathen, 2014 ). IPV exposure is also associated with disparities in pediatric medical engagement and healthcare access, although this is less well-documented ( Holmes, Berg, Bender, Evans, Kobulsky, et al., 2022 ). One study found that children exposed to maternal IPV victimization have approximately three times the rate of unmet health needs as compared to children not exposed ( King & Khanijahani, 2020 ). Other scholars have identified that children exposed to IPV are less likely to have updated immunizations ( Bair-Merritt et al., 2008 ; Wadsworth et al., 2018 ) and have fewer well child visits ( Bair-Merritt et al., 2008 ). Persistent cases of medical neglect often occur in the context of domestic violence. ( Stirling, 2020 ; Victor et al., 2021 ). The robust longitudinal research demonstrating associations between adverse childhood outcomes following IPV exposure ( Gartland et al., 2021 ; Holmes, 2013 ; Vu et al., 2016 ) provides compelling evidence on the strong predictive link between IPV exposure and children’s special health needs, as do studies of adverse childhood experiences (ACEs) ( Felitti et al., 1998 ). Children exposed to IPV are at a higher risk for developing multiple adverse health outcomes through the lifespan. Whether families with children who have special healthcare needs are more vulnerable to experiencing IPV, perhaps due to increased stressors, is not known. The exact nature of the bi-directional association between children’s special healthcare needs and IPV has not been fully established. Furthermore, the pathways linking IPV with children’s unmet health needs or medical neglect are not fully understood ( King & Khanijahani, 2020 ), and scant research has examined these connections. How IPV behaviors manifest in relation to children’s healthcare is unclear. IPV frequently co-occurs with child maltreatment and other ACEs, such as parental separation ( Felitti et al., 1998 ; Tullberg & Vaughon, 2023 ). Separation, or leaving a relationship with an abusive partner, is commonly encouraged as a solution to ending IPV ( Morse et al., 2012 ). Mothers often report that children are a determining factor in their decision-making on whether to leave abusive partners, primarily out of the desire to protect their children and promote their children’s well-being ( Bermea et al., 2020 ; Meyer, 2010 ; Rhodes et al., 2010 ; Scrafford et al., 2022 ). However, leaving does not necessarily end abuse, nor guarantee child safety and well-being. Continued abuse following separation has been referred to as “post-separation abuse” ( Spearman et al., 2023 ; Zeoli et al., 2013 ). Post-separation abuse encompasses a broad array of abusive or coercive tactics targeting fundamental human needs, such as shelter, food, safety, economic resources, and social connections, including survivors’ relationships with children. In population-based data sources, children’s health needs or victimization in the context of exposure to both IPV and parental separation have not been clearly documented. IPV is not a one-size-fits-all exposure ( Tolmie et al., 2024 ); perpetrators utilize their intimate knowledge of survivors’ values, needs, identities, and priorities to target what is most valuable to them. Maternal survivors most often report this is their children and their mothering ( Bermea et al., 2020 ; Broughton et al., 2024 ). It can be challenging to determine perpetrators’ intents or whether the adult or child survivor is the intended target; regardless, children may experience distress and be harmed. Further, perpetrator tactics often intersect with structural barriers and broader systemic patterns of harm and oppression ( Tolmie et al., 2024 ). Together, perpetrator tactics and structural barriers constrain survivors’ autonomy to promote safety, health, and well-being for themselves and their children. In this context, structural barriers include legal system responses to violence in families, which can contribute to or enable ongoing abuse ( Douglas, 2018 ; Gutowski & Goodman, 2022 ; Miller & Smolter, 2011 ). In the U.S., family courts tend to prioritize shared parenting and decision-making for children post-separation as a priority for the child’s best interest ( Raday, 2019 ). A large body of scholarship has highlighted concerns that IPV is often minimized or ignored in family court custody decisions ( Hardesty et al., 2024 ). Coparenting is also encouraged in pediatric healthcare settings ( Ragavan & Murray, 2023 ; Ragavan et al., 2021 ). This means that both survivors and IPV perpetrators are typically involved in their children’s healthcare following parental separation. Yet, little is known about how perpetrator behaviors and legal system-imposed barriers intersect with regards to pediatric healthcare. Although limited, existing literature on children’s unmet health needs in the context of IPV has focused on potential contributing factors such as financial hardship, poor maternal parenting practices, poor maternal mental health, and/or maternal fear of child welfare system involvement ( Holmes, Berg, Bender, Evans, Kobulsky, et al., 2022 ; King & Khanijahani, 2020 ; Rhodes et al., 2010 ), without examining perpetrators’ IPV behaviors as a contributing underlying cause. Few scholars have explored how IPV manifests in healthcare settings, and most of this research has been focused on adult survivors ( McCloskey et al., 2007 ; Wadsworth et al., 2018 ). In pediatric healthcare settings, abusive co-parents may use controlling or abusive tactics that interfere with children’s access to healthcare, as noted in research exploring perspectives of pediatric providers and IPV experts ( Ragavan et al., 2021 ). To our knowledge, the perspectives of maternal survivors on how abusive co-parents constrain access to healthcare for their children is missing from the literature. Understanding survivor perspectives on specific perpetrator tactics and structural barriers contributing to children’s unmet health needs is essential to develop interventions in health and legal systems. Children’s unmet health needs in the context of post-separation abuse is a critical issue warranting further examination, as inequities in healthcare access and unmet medical needs are among leading concerns of health disparities for children. Objectives The purpose of this qualitative study was to (1) examine post-separation experiences of maternal survivors, (2) identify specific behaviors and tactics used by abusive co-parents that impact children’s health needs, and (3) identify structural limitations that exacerbate challenges in accessing healthcare for their children from the perspectives of survivors. Methods Study Design The present study focuses on a subset of qualitative data from a larger exploratory sequential mixed methods study on experiences of post-separation abuse and family court involvement ( Spearman et al., 2024 ). Institutional Review Board (IRB) approval was obtained through the Johns Hopkins Institutional Review Board (IRB00336841) on December 22, 2022. Interview Guide Development The development of the semi-structured interview guide and codebook was informed by the IPV and coparenting after separation (ICAS) theoretical framework ( Hardesty et al., 2012 ), which provides a roadmap to examine the risks and protective factors for survivors navigating co-parenting with abusive ex-partners and resulting maternal child health outcomes. Prior to conducting the qualitative interviews, the interview guide was refined through review with three maternal survivors of IPV and with input from co-authors of this article who are experts in IPV, ACEs, and/or child maltreatment. The interview guide consisted of 42 questions addressing different domains of the ICAS framework. We did ask questions about protective factors in the interview, which is outside the scope of this manuscript. The present study focuses on a subset of questions specific to their children’s health and healthcare: (1) What has your experience been like obtaining healthcare for your children? (2) How does your co-parent/former partner meet your child’s health needs? and (3) Do you feel like there is a connection between your child’s health and their experiences of exposure to the negative experiences after separation and court processes? If so, can you describe? Participants and Recruitment The sample for this study was a convenience, community-based, volunteer sample consisting of ( N = 33) maternal survivors from 18 states in the U.S. Snowball sampling was used to recruit participants through electronic flyers shared with domestic violence advocates, legal aid organizations, and word of mouth from other survivors. The flyer noted that the research team sought women who were interested in sharing their experiences with child custody after separation from an ex-partner and how their children were doing. Participants represented a wide range of geographic, racial, ethnic, educational, and socioeconomic dispersion ( Table 1 ). Table 1: Participant characteristics ( N = 33) Average maternal age (mean, SD) 42.2, 6.3 Number of children 1 12 (36%) 2 13 (39%) 3 5 (15%) 4 3 (9%) Age of children Under 6 6 (10%) 6 to 12 years old 42 (69%) 13 to 17 years old 12 (20%) Highest level of education Associates / Some college 7 (21%) Bachelors 12 (36%) Masters 11 (33%) PhD 3 (9%) Race / Ethnicity Asian 2 (6%) Bi-racial 1 (3%) Black/African American 4 (12%) White, Hispanic 4 (12%) White, non-Hispanic 22 (67%) Current Employment Status Student 4 (12%) Part time employed 4 (12%) Full time employed 16 (48%) Stay-at-home caregiving 9 (27%) Region Southeast 5 (15%) Northeast 3 (9%) Midwest 6 (18%) Southwest 3 (9%) West 13 (39%) Open in a new tab Participants completed semi-structured qualitative interviews from January through June 2023 to describe their post-separation abuse experiences and their children’s health outcomes. There were 178 total individuals who inquired about participation in the study, and were screened via phone interview or by email to see if they met criteria. Most interested potential participants did not meet the inclusion criteria. Inclusion criteria comprised of women who had at least one child between the ages of 6–17, had separated from the partner with whom they shared this child, and lived in the U.S. Because of the literature around the risk of losing custody for maternal survivors of IPV ( Dalgarno, Ayeb-Karlsson, et al., 2024 ; Dalgarno, Katz, et al., 2024 ; Khaw et al., 2021 ; Meier, 2020 ; Saunders & Oglesby, 2016 ), it was important to include a broad range of custody arrangements to incorporate diverse perspectives around barriers to children’s healthcare. Individuals were able to participate as long as they had contact with their child, regardless of the current parenting time arrangements, provided they had information on their child’s health and schooling. Participants were asked during a screening call if (1) they felt they had a say in the outcomes of their child custody case, (2) their custody case was considered to be ‘high conflict,’ and (3) they felt fearful for themselves or their children since separating from their ex-partner. Participants were eligible for inclusion if they answered “yes” to Q(2) or Q(3). Participants with more than one child between the ages of 6 to 17 were asked to discuss child health outcomes related to the child most affected or how their children were differentially impacted. Most participants chose to discuss how it had impacted each of their children. No incentives or compensation were provided, but most participants expressed gratitude for the space to share their story and were hopeful their experiences could be used to help others, lead to policy change, and reform family courts. Data Collection Semi-structured interviews were conducted. Interview participants provided oral informed consent, which covered mandatory reporting guidelines on child abuse per the IRB-approved protocol. Interviews were conducted over Zoom, audio-recorded, and transcribed. Duration of interviews ranged from 47 to 246 minutes, with some interviews conducted over two sessions. In total, 2,988 minutes of audio interviews were collected and analyzed (mean length equal to 91 minutes). Interview duration varied largely based on time since separation and complexity of legal systems involvement. Participants with greater systems involvement and longer duration of separation needed more time to describe their circumstances. Transcribed interviews were de-identified and checked against audio recordings for accuracy, and audio recordings and transcripts were stored on a secure university server. Data analysis Interview transcripts were coded iteratively and independently in ATLAS.ti using an iterative thematic inquiry approach ( Morgan & Nica, 2020 ) by three study team members who met regularly to discuss and reconcile codes. Each transcript was coded by at least two team members using an a priori codebook that contained a code name, definition, and statement of when to use or not use the code. Interview coding was done individually by each team member, crosschecked with other team members, and any disagreements on coding were resolved through collaborative discussion. The research team coded “unmet health needs” when participants described difficulty in accessing healthcare for their children, or that their co-parents had interfered or delayed necessary healthcare. The terms healthcare and unmet health needs broadly included any medical or mental healthcare or other special developmental therapies. After completing coding, the analysis team compiled codes into larger domains for the focus of the present study, concentrating on the quotes where participants described difficulty in obtaining pediatric healthcare. These themes were reviewed and agreed upon by the study team. Identifying information containing participant names, names of their child(ren), names of co-parents, location, insurance, and provider specific information was removed prior to quotations being included in this manuscript. Pseudonyms are used in place of actual names to protect their identities, as well as to further protect them from further threats and violence. Additionally, pseudonyms in this article are different than in other publications ( Spearman et al., 2024 )) to prevent possible identification. We have chosen to minimize reporting demographic information ( Table 1 ) linked to each individual participant to protect participant confidentiality. For quotes, we provide demographic information only where it may provide deeper relevant context for the participant’s experience (for example, immigration status, race/ethnicity, and custody status). Although “ex-partner” or “former partner” is frequently used in the literature to describe former intimate partners, based on preferences voiced by participants in this study, the research team refers to “co-parents” throughout this article, due to the lived experience that many expressed was lacking in “partnership” with their abusive ex. Results Thirty-three community-based maternal survivors of post-separation abuse from 18 states in the contiguous U.S. (Arizona, Arkansas, California, Colorado, Florida, Georgia, Illinois, Indiana, Maryland, Michigan, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Texas, West Virginia, and Wisconsin) participated in semi-structured interviews about their post-separation and children’s health experiences. Participants and their children lived in urban (e.g., New York City, Los Angeles), suburban, and rural (e.g., Appalachia) locations. The mothers were well educated (3 Ph.D.’s, all participants had at least some college education) and majority white (67%) with 12% of mothers identifying as Black and 7% identifying as Hispanic ( Table 1 ). Most participants were within two years of separating from their co-parent at the time of the interview; however, we did extend the criteria to include three participants who reported longer term experiences of post-separation abuse and family court involvement ranging from 4–10 years to both increase diversity of the sample and to better understand the complexities of long-term post-separation abuse. Most ( n = 28; 84.8%) participants identified that abusive co-parents engaged in behaviors that blocked their children’s access to needed medical and mental healthcare, while four participants identified that their children had no unmet healthcare needs at the time of the interview. The focus of the present study is on the participants’ reports of their children’s unmet health needs. Data analysis identified five domains of post-separation abuse tactics perpetrated by abusive co-parents that led to children’s unmet healthcare needs: (1) child healthcare obstruction and abuse, (2) stalking and intimidation, (3) legal abuse, (4) disregarding children’s safety and well-being, and (5) economic abuse ( Figure 1 ). Figure 1 also shows the number of participants who identified each of the domains that as contributing to difficulty in obtaining healthcare. All but one participant identified experiences in at least 2 of the domains, with three participants identifying experiences in all 5 domains and 10 participants identifying experiences in 4 of the domains. Figure 1: Post-separation abuse tactics impacting children’s access to care. Open in a new tab The custody arrangements of participants varied, with most participants having some iteration of joint legal and joint physical custody (e.g., 50/50 shared custody), one participant had supervised visitation with her child twice per month with no legal custody, two participants had weekly visitation with their children and no legal custody, and one participant had final decision making and sole physical custody with the father having supervised visitation. None of the children were in foster care, and all lived with the maternal participant and/or their co-parent. In at least three cases, participants had different legal and physical custody arrangements for siblings (e.g., older children with no contact orders with perpetrator father, younger child(ren) with continued shared custody and unsupervised visitation and shared custody). None of the participants were shelter-based at the time of their interview, although some were living with family or friends. Participants shared a wide range of experiences perpetrated by their co-parents towards themselves and their children. In this community-based sample, all participants had family court involvement, 70% reported they also been involved with the criminal legal system as a result of their co-parent’s abuse (e.g., criminal case for acts of IPV such as strangulation; police had been called to at least one IPV incident), and nearly half (48%) of participants reported their children had involvement with Child Protective Services (CPS) through formal reports. The outcomes of CPS reports of child sexual abuse, physical abuse, emotional abuse and neglect varied. Some reports were substantiated, unsubstantiated, or ruled out. Some reports were not investigated by CPS but were adjudicated during family court proceedings. Additionally, beyond the tactics discussed below, participants reported a wide variety of post-separation IPV experiences including incidents that indicate a high risk of lethality such as strangulation, firearm threats, rape, and stalking. Systems tend to respond to incidents of physical and sexual violence; yet these tactics that impeded children’s healthcare access were part of broader patterns of abuse, both before and after separation. As seen in many of the quotes below, participants described gender bias, racism, and misogynist stereotyping from formal systems in combination with perpetrators’ tactics as further impeding their ability to be believed and obtain healthcare for their children. Domain 1: Child healthcare obstruction and abuse Participants described how abusive co-parents obstructed access to children’s healthcare through withholding, obstruction, and manipulation tactics. Lola, a mother sharing joint custody described that “ part of the abuse is not letting me get him [son] medical care…the abuse is in blocking proper care and treatment. ” This included withholding (1) consent for providers, (2) children’s insurance information, and (3) medication or treatments during the co-parent’s time. Elyzabeth, wanted to find her daughter (age 6) a therapist to help her with behavioral issues that stemmed from emotional and physical child abuse and witnessed domestic violence perpetrated by her co-parent. Elyzabeth discussed her fear that it would be held against her in court if she tried to get her child mental health services while her co-parent was withholding consent, “ When I reached out to my ex…and he was like, ‘no, no, just not giving you any consent.’ ” Elyzabeth continued, I don’t want to do anything wrong. I don’t want to make the wrong choices. I don’t want anybody to come back and say, ‘Why did you do that? He said no, and you went ahead and did it like you are the bad mom, that we think you are.’ Candace described how her daughter (age 6) currently did not have a primary care pediatrician. She was trying to obtain one; however, her co-parent would not agree. Her co-parent then used this against her, insinuating that mom (participant) was engaging in medical child abuse: I would love to get her in with the pediatrician…a few times my lawyer asked him, ‘can we just agree on a new pediatrician…let’s have a discussion’, and he just wouldn’t…So right now, he… claims … she doesn’t have a pediatrician, that I just take her to random doctors whenever I want to…Which is just not true. Other participants identified their co-parents’ withholding of insurance information as contributing to their children’s unmet healthcare needs. Even when courts had ordered their co-parent to provide health insurance coverage for the children, perpetrators would withhold this information and lie to the court about it, making it difficult for these mothers to bring their children in for healthcare visits: He is required to carry insurance for them…he did switch jobs last year and refused to give me the insurance cards or any insurance information…so that was difficult because I did need to take…them. (Keely, mother of 2 children ages 7 and 4) Deirdre, a mother of two children, discussed at length how she is unable to obtain healthcare for her younger child (age 8), because she cannot obtain health insurance information from her co-parent: “ I have final say in medical decision-making, but he holds the insurance. So…it kind of blocks me. I can’t make a final say because I can’t move forward without him giving me the information. ” Another withholding tactic commonly mentioned by participants was through their co-parents withholding or failing to administer medication, like Noelene, a mother of three children ranging in age from 2 to 17: “ A lot of times my kids are prescribed medication. They’re only getting it half the time, because I’m the only one giving it to them. ” Participants described how their co-parents used tactics of “obstructionism” that included appointment manipulation, refusing to provide information about appointments, refusing to take a child to needed healthcare during their parenting time, and threatening providers and their staff. Deirdre shares joint physical and legal custody with her ex-husband who had perpetrated severe physical violence against her before and after separation. She discussed at length at how manipulation of appointment scheduling delayed needed healthcare or made it extraordinarily difficult to obtain for her children. She described how she wished healthcare and legal professionals would: Put themselves in a, you know, a day in the life…[of] Mom, making all these appointments for your child. And then she’s with her dad. Dad says he’s going to take her, and Dad doesn’t take her to any of the appointments. Now, you know, another 6 months goes by. Mom’s gotta reschedule all those appointments. Participants described how their abusive co-parents would not adhere to a provider’s recommended treatment plans, or try to get their family “fired” from their children’s providers. As Noelene described: I feel that he tries to get us kicked out of offices where I have our children established as patients, so that the kids can only go where he wants them to go, which means that they wouldn’t go, because he never schedules anything. Participants identified that tactics of obstructionism, particularly in context of traditional sexism about parental roles where mothers were expected to be responsible for their child’s healthcare compounded difficulties. Participants reported that abusive co-parents were adept at the manipulation of healthcare professionals, which sometimes took the form of spreading rumors and making providers question mothers’ mental health. As Ophelia, a mother of one child described, “He [co-parent] went in there, and had a side conversation with her [pediatrician] , and was like more or less ‘look, I have this testing…this like psychological evaluation…before you take any of [Mom] ’s complaints here seriously.’” Five of the 28 participants who reported that their children had unmet healthcare needs discussed how their co-parent or their co-parent’s attorney had accused them of “Munchhausen by Proxy” during custody proceedings or to a healthcare provider. Candace, a mom of one child who shares joint custody, but had lost the legal right on medical decision-making for her daughter because of her co-parent’s accusation said, “ He just…came with the Munchausen’s accusation. He said that I’m ‘using the medical system to torment and torture our daughter’, that he believes I ‘have Munchausen by proxy’, and he’s going to be filing for full custody. ” Lola, a mother of 3 children described: I hear about the number of times my friends took their kids to the doctor versus me…because he wouldn’t let me. But people don’t see that as like child abuse for some reason. It’s like bizarre, and if I tried to get like medical decision-making, educational decision making, I wouldn’t get it. He’s this Ivy League educated, highly successful man…I’m just a ‘hypochondriac’. This is ‘Munchausen syndrome’ [according to her ex-husband]. Perpetrators’ use of allegations of “parental alienation” to prevent kids from obtaining care were commonly reported. Deirdre described how her co-parent used the children’s appointments to make claims of “parental alienation”: “He turns the tables, and he tells me I’m ‘alienating’ her because she has a physical therapy appointment [that falls during Dad’s parenting time] , and I can’t switch the schedule.” Other participants described how both their co-parent and legal professionals (co-parents’ attorneys, custody evaluators, best interest or guardian-ad-litem attorneys) would accuse them of ‘gatekeeping.’ For example, Candace described: He also has made some claims where I am keeping medical records from him, and I’m not…And they…said that was gatekeeping as well, which I thought was weird… it was a whole thing!…I mean the information’s there [in the patient portal] …I even told him where to find it. So, yeah, they called that gatekeeping as well. ” Participants felt these forms of manipulation made it difficult for them to advocate for their children’s health, and for them and their children to be believed. Withholding consent, insurance information, medication, and treatments, obstruction of access to healthcare, and manipulation of the healthcare environment were the most commonly reported post-separation abuse tactics that resulted in delays or an inability to obtain needed medical care for their children. These tactics caused distress for both mothers and children. Domain 2: Stalking and Intimidation When physical proximity was limited post-separation, children’s healthcare appointments became a venue where abusive co-parents could stalk, threaten, control, and induce fear in survivors. Francette, a mother of three children, described how “ the one time he showed up to an appointment I wasn’t expecting him at, I ended up with a nail on the sidewall of my tire. ” Noelene described how she had to ask for additional support at her child’s pediatric well-visit, I asked her [staff at pediatrician’s office] to please get someone to have us escorted out, because I realized that the only reason he was still there was, so that he could confront us in the parking lot. These repeated acts of stalking and intimidation in pediatric healthcare settings created a sense of fear. They served as a barrier to obtaining healthcare, as mothers were afraid of attending healthcare appointments for their children because of what their co-parents might do. Intimidation and stalking in pediatric healthcare settings also worked to silence mothers’ ability to effectively advocate for their children’s needs during appointments. Maria, a mother of four children, described when her co-parent showed up to attend appointments with them, “ Even when the doctor is asking us all these questions, like, I’m not going to call him [co-parent] out in the middle of it. And I just didn’t wanna put any negativity or any like tension for the girls to have to experience. ” Gaby, a mom of one child, described similarly how it was challenging to advocate for her daughter when her co-parent showed up to appointments: I tell him the therapist name, and he asks for their phone number so that he says he wants to talk to them. But then he doesn’t call…I feel like some of it…is…to kind of intimidate me…and it works because… for example, she has a psych appointment coming up. And I am nervous about him showing up…I worry about being able to properly advocate for her with him there, because he makes me nervous, and then I have to say, you know what’s going on with her, and…he just makes me nervous. Maisy, a mother to one child (age 8), described how it was difficult to disclose to providers what they were experiencing: The nurse asked something very interesting. She said something…like, is everybody safe at home, or something? But she said it in front of [ex]… But that was not the way to do it. Like not in front of the dad. And I think that kid’s pediatrician, should be screening some other way. But it can’t be in front of both parents. It cannot be and that’s the thing…what makes it difficult…But I can’t even freely talk to [pediatrician] that much with him in the room, so I wish there was another kind of way for me to…tell her more. Participants emphasized that stalking and intimidation behaviors perpetrated by co-parents in pediatric healthcare settings disallowed engagement with providers. Domain 3: Legal Abuse Participants reported how abusive co-parents used systems-focused strategies of abuse, including tactics of abuse that exposed survivors to state surveillance such as making false reports to CPS or calling police (described as “coercive violence” by Monterrosa and Hattery (2023) ) and legal abuse (using the family court system to coerce and control) to prevent them from obtaining needed healthcare for their children. Participants described how abusive co-parents would exploit vulnerabilities related to their identities, immigration status, medical or mental health history, or gendered expectations of caregiving. Actions or inactions of courts often compounded these problems and increased their vulnerability, making it hard for the mothers to access healthcare for their children. For example, Lidia is a Hispanic undocumented immigrant mother of two children. She immigrated to the U.S. on a work visa and at the birth of her children became a stay-at-home mom. Her then husband left her off his green card application, so when it was granted, she became out of status because she stayed in the U.S. with her children. Lidia described how after separation, her co-parent: was gonna call immigration on me and tell them that I was illegal in the United States…when you are [in] an abusive relationship, you don’t have the freedom to go, the freedom to pay for consultations…especially when you are an immigrant. Joy, a mom of two children, described how her co-parent used both manipulation of her children’s healthcare appointments and making false reports to trap her, He made an appointment with dentist and didn’t tell me, and now…he tells me I’m neglecting their dental care…he calls CPS on me for that and said I’m neglecting their dental. Legal abuse included perpetrators using courts to revoke mother’s legal authority on medical decision-making. Brielle, a mother to one child, was a stay-at-home mom prior to separation, and she described how her co-parent “ was able to relatively easily…weaponize these tools that are designed to protect people, and instead utilize them to essentially affect continued coercive control ”. Her ex-partner was able to obtain a temporary protective order that, “ gave him temporary physical and legal custody, and…that got extended and extended and extended, so that those temporary orders which were initially meant to last, you know 3 weeks have now lasted…almost 15 months .” Despite a long history of experiencing coercive control and physical violence by her co-parent as well as his suspected abuse toward their child that had been reported, Brielle (mom with weekly visitation only with her 7-year-old) described the impact of the court on her ability to advocate for her son’s health and well-being: I’ve literally been stripped of my… parental rights in terms of having any sort of custody at the moment, and so I’m not allowed…to speak to his doctors…Well, I can call the doctors, but I don’t think they can…have any meaningful conversations…It’s had a significant impact on us…I feel like the orders from the family court basically stripped me from any right, for the most part as a parent, to impact my son’s well-being. Similarly, Adella, a mother with a few hours of visitation a week with her children, described how after her co-parent was granted sole custody, he moved the children to another county, isolated them, and removed them from their existing care providers: The pediatrician we had in our town was great. I think that’s one of the reasons that he did move. Because everyone did know what had happened to them. Now that they’re with all new people, I have no idea what kind of interaction the pediatrician has with the children…What can you ask 7-year-olds about their health when he is standing right there with him and when they depend on him for everything they eat, everywhere they go, and every breath they take? Legal abuse also took the form of forcing maternal survivors to use the family court process to obtain needed healthcare for children. Some participants explained this as legal abuse or economic abuse because of the resulting economic consequences of the costs to engage courts. Hana, a mom of one child (age 6), described how her co-parent would not grant her consent to obtain needed healthcare for her child and the incredible expense of having to use the court system to get permission for care: “ I had to get a court order to get him a flu shot. ” Hana continued, We’ve now been in a phase of a year of me trying to get him [son] back into therapy. The ex has been fighting it because obviously…he doesn’t want our son to like spill the beans, so to speak. So, he’s doing everything to not let that happen. I finally got a court order and got him into therapy. Two of the participants described how the role of the attorney guardian-ad-litem (GAL) representing their children, impacted their children’s access to healthcare. Francette described how her children’s psychologist with whom the children had established rapport was fired by the GAL when the psychologist had tried to set boundaries in response to stalking that was happening during the children’s therapy: She [ GAL ] fired their psychologist because [ ex ] was harassing [psychologist], trying to find out the days and times of our appointments for the girls while they were with me, and the psychologist said… ‘it’s been expressed to me that they’re not comfortable with that. I’ll confirm that they’ve come to their appointments’ … [Ex-husband] filed a motion to have the psychologist removed and the [GAL] supported it. Participants identified how their abusive co-parents would exploit vulnerabilities in their identities, including using racist and misogynist stereotypes during the course of court proceedings. Ayodele, a Black stay-at-home mom of two children (one with special needs who received disability benefits), described how in court the judge, based on her ex-husband’s arguments, “ painted a picture of me as some sort of like greedy welfare queen sort of stereotype. ” The participants in this study identified both gender bias and unequal societal expectations around what mothers versus fathers should do or provide, and how their abusive co-parents would often exploit these societal assumptions. Faith, a mom of four children, described how despite substantiated child abuse against her co-parent and no-contact orders issued for her older children, the court gave liberal visitation and parenting time to her co-parent for their youngest (age 8). Her youngest was exhibiting behavioral challenges including violence towards others and their pets, in addition to having other special health care needs. Faith described how: They [family court professionals] didn’t question their father at all, and they didn’t like say, Well, what are you doing to…better yourself? Or what are you doing to make sure you don’t do this anymore? They [court professionals] didn’t ask him any of those questions. It was all like, well…’what are you [Faith] doing to fix this?…Oh, and…’you have to get him into speech therapy’ …like everything was on me to…get my kids like the services. No responsibility to their dad. And it’s like their dad is the one causing the problems. Why is it on me to like to fix the problems? Why don’t you [judge] just stop the problems from happening? Domain 4: Disregarding children’s well-being Another tactic commonly identified by participants in this study was how their co-parents disregarded their children’s well-being and fundamental needs during the co-parents’ parenting time. Lola described how her co-parent disregards her child’s complaints and attributed this to being “another big part of the abuse and the effect on my son is that his father doesn’t believe him. Gaslights and constantly says, you just need to push yourself. But he [father] blocks treatment”. Participants also discussed perpetrators’ attempts to silence children’s ability to communicate about what they were feeling in their own bodies. As Georgia, a mom of three children, stated about her teenage daughter, He has interfered now with the pediatrician’s office…She’s having somatic symptoms. She tried to communicate with him directly and just tell, that’s what normal people do with parents…He accused her of making things up, he accused me of making things up. He accused me of influencing her, alienating, poisoning her, and so her own sense of her body has been attacked…So, he’s trying to go straight to the source, and he’s trying to manipulate her own experience. So that she does not report the way she feels around him, and what he’s doing to her. In addition to manipulation or gaslighting, other participants described the ways in which this included minimizing the children’s experiences of illness, such as for Francette’s child: In the case of my oldest, she was with him for 2 weeks, begging to go to the doctor, and he told her she was being disrespectful, and bratty…Oh, she came home to me, and she actually needs 2 different antibiotics. This domain also included tactics such as harming a child’s nutrition or feeding children allergens. Meg’s co-parent had supervised visitation only with their children, ordered by the court after he had held Meg and their children hostage with a firearm. During a supervised visit, “ He fed [child]… an allergen. He caused her to have an allergic reaction, and then I had to get an emergency order to say, Dad can’t feed you food, don’t consume anything from Daddy .” (Meg, 4 children). Disregarding children’s needs and well-being was another post-separation abuse tactic that contributed to delays or an inability to access care, and participants voiced were harmful to their child. Domain 5: Economic abuse Participants reported economic abuse as well as financial strain resulting from the economic and legal abuse they were experiencing in courts. They described how their co-parents refused to pay for medical expenses, despite the means to do so, which inhibited children’s access to care. Most of the mothers who participated in this study described how they were at an economic disadvantage to their co-parents and children’s fathers. They attributed this disadvantage to gendered wage gaps and histories of career sacrifices related to childbearing and primary caregiving responsibilities for children, coupled with long term financial abuse. All participants in this study were primary caregivers of their children prior to separation. Ayodele described how her co-parent: He was very sure that I would continue to homeschool them, and I would just sacrifice like working, or, you know, going back to school, or anything like that. And so, he kind of held that over my head… He constantly uses…my wanting the best for them, like my love for them, everything, to just kinda like dangle it over my head. Madison’s story of caregiving for her children, trying to obtain education and employment, and her co-parent’s controlling and financially abusive behaviors during the relationship and its consequences post-separation, exemplifies the challenges that many of the participants faced. But Madison emphasized her economic challenges continued even after separation, because “ my credit is horrible, like not being able to have credit cards to build that during our marriage…our house within strictly his name…I didn’t really have the credit. ” Moreover, coercive violence, legal abuse, and economic abuse combined to increase financial strain. Joy, a mom of two children, described the financial and emotional stress caused by her co-parent when she was receiving unemployment benefits: He called unemployment…and I lost mine [benefits]. I didn’t have a job. I didn’t have any money coming in but child support, and so…the financial aspect of it has been absolutely awful…And here I am wondering how I’m gonna feed my kids. Edith, a mom of two children, described how her child’s father “ refuses to pay out of pocket for anything, and then it falls on me who, you know, I barely make any money, that kind of thing. ” Claudina, who had been a stay-at-home mom and whose co-parent is an attorney making well over six figures a year, described how her children’s healthcare has been affected since separation: [My ex] now refuses payment on uninsured medical costs… now the kids do not get healthcare in the same manner that they used to. My son’s psychiatrist hasn’t been paid since [months ago] . Now the psychiatrist does not want to see [son] anymore. [Daughter’s] therapy was disrupted because… Dad said he couldn’t pay for it. So [daughter] had to say goodbye to her therapist, and then only under the condition of my paying for the whole thing, would she be able to return to therapy. So I, going into debt, paying for her therapy because I still do not receive child support or spousal support. So that’s how they’ve been affected. Deirdre, a mother of two children, bemoaned that: I used to have good credit, my credit is destroyed, and everything. Now, we have to call the police at least every single month about something, and every time I go I hear you have to go get an attorney, and you have to take this back to family court, and I think everyone is forgetting that I’m actually trying to raise a child…on top of her having medical health issues that are very expensive and just life right now, for everyone is astronomically expensive…It’s not a manageable expectation, and the only ones that are ever going to suffer from it are [my daughter] and I. Financial strain was a result of economic abuse tactics both during the relationship and that continued following separation, and economic abuse coupled with financial strain contributed to difficulty in accessing healthcare for children. Discussion To our knowledge, this is the first study to explore maternal survivors’ descriptions of post-separation abuse tactics that impede their children’s access to healthcare. These tactics are positioned in a broader context of other abusive behaviors. Although systems are typically focused on responding to physical incidents of abuse, rather than patterns ( Katz et al., 2020 ), the data from this study suggests that a focus is needed on investigating the contexts in which abuse is occurring rather than responding to incidents alone. Survivors identified post-separation abuse tactics that impeded children’s access to needed healthcare were deeply distressing, for both them and for their children. Figure 1 depicts the broad array of tactics that perpetrators use to hinder children’s access to healthcare, and identifies the number of participants who endorsed each of these domains. This information can be used to help pediatric providers and legal professionals identify barriers to healthcare for children. Through centering survivor perspectives, this study builds on work by Ragavan and colleagues (2021) by identifying ways that abusers use pediatric health settings to control, manipulate, and harass adult and child survivors. This is especially important in addressing disparities in healthcare access. Children with special health care needs make up a greater proportion of those children exposed to IPV (CAHMI, 2025). Future research could examine the role that IPV and these post-separation abuse tactics play as a contributing factor to medical neglect and medical child abuse. Including items on post-separation abuse in population-based surveys on these topics would help make results more generalizable. Coparenting is encouraged in pediatric healthcare and family court settings, and is promoted in state law through presumptions of 50–50 custody or friendly parenting statutes in many jurisdictions. Post-separation abuse behaviors may be insidious and difficult for health and legal professionals to detect. Moreover, participants in this study frequently identified societal expectations and gendered norms of mothering that contributed to the victim-blaming they experienced, particularly around getting children needed services. Participants identified both perpetrator and court action as causal to adverse health outcomes and healthcare access. This finding is consistent with the framework of court and perpetrator induced trauma recently developed by Dalgarno and colleagues in the UK ( Dalgarno, Ayeb-Karlsson, et al., 2024 ). The literature around perpetrators’ use of legal abuse towards survivors is growing ( Gutowski & Goodman, 2022 ; Gutowski & Goodman, 2023 ; Miller & Smolter, 2011 ), and how legal systems can contribute to adverse mental health outcomes for adult survivors. This suggests the key role that judges can play in protecting the physical and mental health of children and their protective parents in family court, and the need for judicial training in this arena. The qualitative narratives in this study highlight how perpetrator tactics intersect with broader patterns of systemic and legal barriers, emphasizing the need to view abusive tactics not just at the individual level but how these overlap with social and systemic entrapment ( Tolmie et al., 2024 ). For example, Lidia described how her ex-husband caused her to lose her legal status as an immigrant in the U.S. when he left her off his green card application, increasing her vulnerability both in relation to him and to State legal systems. More research is needed to explore these intersections. A startling finding of this qualitative study were the five mothers who mentioned that their co-parents and co-parents’ attorneys accused them of Munchhausen’s by Proxy (now known as Factitious Disorder Imposed on Another or FDIA or referred to as medical child abuse) ( Glaser, 2020 ) when they sought needed healthcare for their children. This is a mental health diagnosis that should be made by a licensed medical doctor, and not by attorneys. Additionally, mothers ( n = 18; 54.5%) often were accused of “parental alienation” and gatekeeping when they sought help for their children’s mental and physical health, particularly care that was needed to assist children coping with trauma from the abuse perpetrated by their fathers. Together, these false claims of “Munchhausen’s” or “parental alienation” caused significant fear for mothers. These allegations acted as a barrier, making mothers afraid of taking their children to necessary health appointments or advocating for their children’s needed therapy, for fear of losing custody of their children. These results echo other recent scholarship about the way “parental alienation” allegations cause fear and silence victims of IPV engaged in family courts ( Dalgarno, Ayeb-Karlsson, et al., 2024 ; Dalgarno, Katz, et al., 2024 ; Lapierre et al., 2024 ), policy or position statements from the American Professional Society on the Abuse of Children (APSAC) ( APSAC, 2022 ), and reports from institutions such as the recent report on child custody and violence against women from the United Nations Special Rapporteur on Violence against Women and Children ( Alsalem, 2023 ). Findings from this study can inform screening instruments in healthcare settings, and may be particularly useful integrated with ACE screening protocols in pediatric settings ( Austin et al., 2024 ). Specifically, these findings can help providers identify abusive behaviors experienced among IPV survivors with children that may not rise to mandatory reporting thresholds, but where providers could intervene. They could also help children whose parents are in “high-conflict” custody situations, because these disputes frequently involve allegations of child maltreatment and domestic violence ( Jaffe et al., 2001 ). Providers should ask open-ended questions of parents, such as if they have wanted to obtain medical or mental healthcare for their child, but were unable to, and be attuned to barriers described by parents. Medical, nursing, and mental health providers play an important role in advocating for children’s needs. Their documentation and recommendations are an important component of advocating for children, particularly when it can be entered into evidence in court proceedings for protective parents trying to obtain healthcare for their children. Additionally, health care providers and attorneys working with IPV survivors can engage and educate survivors on these tactics, and help mitigate some of the negative consequences through safety planning. For example, attorneys working with survivors can help craft parenting time orders and motions to family courts requesting specific provisions that can improve children’s access to healthcare in the context of post-separation abuse. It is important for communities to have pro-bono and legal aid accessible for IPV survivors navigating divorce and custody issues to promote their children’s health, safety, and well-being, and there is a critical need for funding in this area. Healing Centered Engagement practices advocate for universal education for abuse identification rather than screening or disclosure of abuse alone ( Auster et al., 2023 ). These practices focus on harm reduction as well as identifying patient strengths and promoting autonomy. Work by Auster and colleagues (2023) provides excellent case examples and motivational interviewing frameworks, techniques, and scripts that can be used by providers as universal prevention education in the context of IPV. All parents and caregivers of children and children themselves should be asked more than the “are you safe at home” question. And providers need to be absolutely clear that parents and co-parents cannot be present when these questions are asked. If there is a co-parenting or a divorce situation, all parents and children could benefit from an exploration of their needs relating to possible exposure to these kinds of abusive tactics. This study has limitations. First, participants were a convenience sample recruited from domestic violence advocates, legal aid, and snowball sampling, and not representative. Second, the participants experienced various forms of IPV and coercive control before and after separation, and the experiences of these participants and their children are not representative of all divorcing or separated parents. Additionally, most participants were within two years of separation, and tactics impeding children’s access to healthcare may change over time. Little is known about the chronicity of post-separation abuse over time, or how these behaviors may change based on both children’s developmental ages and stages. An additional limitation is that this study was conducted in the U.S. where access to health insurance and healthcare varies widely based on socioeconomic status and employment. This sample was relatively well-educated, and may not reflect the experiences of more marginalized populations who experience a disproportionate burden of IPV. Furthermore, all participants had heteronormative co-parenting relationships with their children’s fathers. This study focused on the experiences of mothers who experienced abuse following separation, because of the higher rates of IPV experienced by women in this context as compared to men ( Johnson et al., 2014 ; Rezey, 2020 ), and the disparity in greater homicide risk for women and children following separation ( Adhia et al., 2019 ; Campbell et al., 2003 ; Wilson et al., 2023 ). The experiences of protective, non-offending fathers in seeking and obtaining medical care for their children in the context of separation were outside the scope of this study, but is an important area for future research. While the qualitative interviews did ask questions about social support and protective factors in health and legal systems (e.g., what was helpful), this was not a focus of the present study. However, future research should seek to understand how promotive factors explain variation in how children fare when exposed to post-separation abuse tactics. Additional recommendations for future research include examining how these tactics impact children’s access to care in more diverse populations, across socioeconomic status, family configurations, and other settings using an intersectional lens. The phenomenon of post-separation abuse has not been measured in population-based studies but is an important direction for future research. Since this study was conducted with a U.S. sample, future research should examine differences in how perpetrators may use pediatric healthcare obstruction and abuse in other jurisdictions with access to universal healthcare, and if universal healthcare is a protective factor. Importantly, research is needed to examine the protective strengths and agency survivors use to care and nurture their children, so that providers can recognize and build on those strengths and promote resiliency in families impacted by violence. Conclusion This qualitative study describes the perceptions of 28 maternal survivors of IPV of post-separation abusive, coercive, and controlling tactics that impede their children’s access to healthcare. Although conducted with a limited, convenience sample, this study provides an important foundation for subsequent investigation. Future research should focus on adding to existing screening for ACEs in pediatric settings, measuring experiences of post-separation abuse in population-based studies, and developing evidence-based standards of care for health and legal systems to ensure that children can access needed care post parental separation in the context of domestic violence. These services need to be trauma-informed and specialized for children who have been exposed to IPV, child maltreatment, and/or parental post-separation abuse. Acknowledgement This study would not have been possible without the contributions of the women who trusted us with their stories, and for the advocates who helped recruit participants. Funding details Research reported in this presentation is supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number F31HD111297. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Funding is also provided through a Johns Hopkins School of Nursing Discovery and Innovation Grant. Qualitative data in this presentation was obtained under JHU IRB approval (IRB00336841) “Understanding the impact of post-separation abuse on children’s health and flourishing” Footnotes Disclosure statement The authors report there are no competing interests to declare . Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. 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