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About half of marriages end in divorce, and approximately 6 out of 10 divorces involve children. Even when amicable, a divorce is a difficult situation. However, divorces can be tumultuous, and children often pay the price. One way this is manifested is in false allegations of abuse in child custody cases. Typically, one parent accuses the other parent of physical and/or sexual abuse of their child to gain leverage in their court proceeding. This tactic can be particularly impactful because judges tend to award primary physical custody to the parent who made the allegation, even if the accused parent’s actions are not substantiated. Thus, false allegations can be a powerful weapon to limit or deny custody and/or visitation in a vindictive manner.

Although a strong visceral reaction to an abuse allegation is expected, it can be counterproductive. Similarly, a rushed response can make the situation worse. In contrast, a wait-and-see attitude leaves the door open for a thorough evaluation before a disposition is decided upon.

To be clear: False allegations of abuse are a form of parental alienation. Alienation involves the concerted effort of one parent to undermine the other parent’s relationship with their child. Nothing could be worse than a custody decision that is based on a false allegation. To make matters worse, once a custody decision has been issued, modification of it is burdensome and an uphill challenge.

The clinical evaluation is an important part of proceedings in which allegations have been made. A successful case requires coordinated efforts among the judge, attorneys, and a court-appointed evaluator, who is often a psychiatrist or clinical psychologist.

The approach outlined in this article is based on years of experience with hundreds of cases of abuse allegations, and it consists of sequential steps. The evaluation process is aimed at determining if an allegation of abuse has occurred or not—in other words, whether the allegation has been fabricated by a parent with the intent of sabotaging and harming the other parent.

For obvious reasons, the evaluation must include both parents and the child to understand the entire narrative. All 3 individuals—the accused parent, the accusing parent, and the child—must be a part of the evaluation process. After all, we want our conclusions and recommendations to be based on full and accurate information.

The accused parent is often advised by their attorney not to participate in the evaluation process. This is ill-conceived advice. By doing so, the mental health professional evaluator will be deprived of critical information that can shine a light on the falsity of the claim. Otherwise, all the information will be coming from the accusing parent, whose allegation will hold greater weight if it is not disputed.

It is always a good idea for the child in such a case to be seen for an independent forensic evaluation. This would be in addition to the child’s involvement with the court-appointed evaluator.

If this is the first allegation of abuse, and it occurs during a child custody case, its validity must be questioned. In fact, there is a significant probability that the allegation is false, as it is unlikely that a parent’s first abuse of the child occurs after the child custody case has been initiated. Thus, if a parent does not have a history of abusing the child, it is not likely that the first abuse is occurring during the legal proceeding.

A series of allegations against a parent during a child custody proceeding is also a major red flag. An accusing parent often believes that multiple allegations against the other parent are more convincing to a judge than a single allegation. However, repeated abuse of a child during a circumscribed time period—during a child custody case, for example—is quite improbable.

Detecting a false allegation is easier with the use of a timeline. Marking the major occurrences in a child custody case can show the specific sequence of events. A false allegation of abuse may occur during the custody case, and not before. It may also occur in response to legal action taken by the other parent. For example, if a mother files for full custody of her child, this sets the stage for the father to report a false allegation of abuse against the mother with the hopes that the allegation will derail the mother’s quest. The motive of the false allegation can be detected by examining its place on the timeline of events.

False allegations of abuse often include unwitting help from the children. Children aged between 3 and 7 years can be easily coached by a parent to testify against the other. Because most children want to please their primary parent, they are easily swayed, cajoled, convinced, and brainwashed. It is difficult for children to know the truth once a parent has coached them extensively. False allegations can involve older children and teenagers as well, but their coaching is more easily transparent and adolescents may even admit to it.

There are 5 common beliefs that motivate a parent to lodge a false allegation of abuse against the other parent (

). If any of these beliefs are discovered, the allegation of abuse is likely false. Detecting these beliefs in a parent requires careful interviews over several sessions. A parent will never admit to fabricating a false allegation. The clinician must be skilled to see through the defensiveness, deceitfulness, and/or distractions of an offending parent.

Harmful and false beliefs by the accusing parent can also be detected through interviews with the child and the accused parent. Usually, the child or the accused parent will provide critical clues as to the accusing parent’s belief system. Bits and pieces of information will fit together into a detailed narrative that exposes the falseness of the allegation at hand. Remember, the accusing parent generally does not recant nor apologize for their attempts at relationship interference.

Once an allegation of abuse has been declared by a parent, there is a process that should ensue.

First, the judge should appoint a psychiatrist or clinical psychologist to evaluate the child and both parents. This evaluation must include interviews, psychological testing, and a review of collateral data (eg, emails, texts, recordings, pictures, etc). The evaluator should have access to other independent assessments of the allegation, such as Department of Human Resources investigations or a forensic evaluation of the child.

The psychiatrist or clinical psychologist must be experienced in child custody evaluations. Similarly, there should be a wait-and-see attitude about the allegation until the evaluation process has been fully completed. In other words, no assumptions or decisions should be considered until all the facts and information have been collected and assessed. The evaluation by the mental health professional should be aimed at determining the validity of the stated allegation of abuse.

During this time, attorneys should not respond to an allegation of abuse by filing motions for dramatic or extreme action, such as obtaining full custody of the child. However, granting a parent temporary custody until the matter is settled may make sense, especially if the child’s physical safety is of acute concern. Similarly, the attorneys must not try to sabotage the evaluator in order to win their case. The evaluator’s conclusions and recommendations should be given strong weight in the judge’s final decision.

A false allegation of abuse by a parent should be met with firm consequences, such as a fine, supervised parenting time, court-ordered counseling, and/or loss of primary custody. Swift and decisive consequences will dissuade future false allegations of abuse.

The accusing parent may not be appropriate for primary custody. Even shared custody may not be appropriate. A parent’s willingness to fabricate an allegation of abuse against the other parent is a poor prognostic indicator. It is not simply an accident or a mistake. A false allegation is an intentional and purposeful attempt to undermine the child custody proceeding.

Similarly, the false allegation has implications for the future well-being of the child, and a false allegation should be considered a form of parental alienation. This experience, especially if they are asked to take an active role in the allegation, teaches the child to be dishonest, deceitful, manipulative, conflictual, and blaming. Furthermore, the love the child should have for both parents is compromised and potentially destroyed.

A false allegation of abuse is serious, and it must not be tolerated in the court system. Based on the consequences, a false allegation represents a psychiatric emergency. As such, it must be handled and dealt with in a direct and timely manner. A child’s mental health and well-being depend upon it.

is a licensed clinical psychologist in private practice in Birmingham, Alabama. His forensic practice focuses on child custody and alienation cases. He is also a clinical associate professor in the Department of Psychology at the University of Alabama at Birmingham.

False allegations of abuse during a custody battle can seriously harm children. Here's how psychiatrists can separate fact from fiction. 

Child Abuse Allegations: Sorting Out Lies Versus Truths

As with any cutting-edge innovation, digital therapeutics (DTx) have their detractors. This is particularly evident when concerned doctors focus upon 

, such as trauma, in which DTx “might not be able to replace face-to-face therapy.”

 What practical considerations arise when the results of DTx interventions are interpreted in forensic as opposed to other medical settings? Using DTx can have variable results, as we will illustrate in 2 vignettes, both of which are composites of actual legal matters involving DTx. Regardless of the outcome of any individual case, it is important to consider how DTx can help physicians make clinical decisions and improve patient care.

Barriers to Treating Psychiatric Disorders in Forensic Settings

Forensic settings can be free-standing, secure medical facilities, or they can be correctional settings in which individuals accused of criminal offenses are housed while awaiting trial. These patients are being assessed for competency to stand trial, criminal responsibility, or other legally relevant issues. They may be receiving psychiatric treatment in order to become competent, or perhaps they are being retained in a forensic setting so they remain competent and legal proceedings will not be delayed any further.

Individuals who have already been convicted may be retained in forensic settings as well. These services are typically delivered in jail and prison environments, and sometimes draw upon the same resources as those used for pretrial assessment. Patient care may focus upon such issues as serious mental illness, anger management, sexual offender recidivism, and societal reintegration. Forensic services can also be rendered subsequent to release in the context of mental health courts, drug courts, and outpatient commitment.

Serious mental illness is significantly overrepresented in jail and prison populations. A recent 

 of reviews on this topic identified, for example, notably high prevalence rates for psychotic disorders (males, 4%; females, 4%), major depression (males, 10%; females, 14%), alcohol misuse (males, 18-30%; females, 10-24%), and drug misuse (males, 10-48%; females, 30-60%).

of jail and prison treatment practices conducted by the Treatment Advocacy Center concluded that

Not only are the numbers of mentally ill in prisons and jails continuing to climb, the severity of inmates’ illnesses is on the rise as well.

Many inmates with mental illness need intensive treatment, and officials in the prisons and jails feel compelled to provide the hospital-level care that these inmates need.

The root cause of the problem is the continuing closure of state psychiatric hospitals and the failure of mental health officials to provide appropriate aftercare for the released patients.

Why does this matter? In no particular order, the nationwide status of mental health services for individuals behind bars is costly, ineffective, and ethically challenging. Approximately 14% of prison health care spending is used for 

 Increasingly, blatant shortcomings in treatment adequacy are leading to 

 Given the procedural as well as budgetary hurdles they face in attempting to wring needed care from minimal resources, doctors can hardly be blamed for focusing on the ethical and medical ramifications of subpar and delayed services for those with chronic and severe mental illness.

How Can Digital Therapeutics Address These Problems?

DTx is not a panacea, but it offers exciting new opportunities for cash-strapped, understaffed, and overutilized forensic operations.

In inpatient forensic settings, DTx enables clinicians to gather more data, which leads to more accurate assessment and more focused treatment. This process also helps correctional staff and court personnel to conduct tracking and feedback functions with pretrial detainees.

DTx allows for real-time risk prediction based upon sensor data and contributes to early detection of evolving mental health conditions. This is particularly important in light of the problems that can emerge when forensic detainees are deprived of services during the pendency of 

 DTx has been shown to reduce variations in inpatient care, and to enable the delivery of more 

Furthermore, DTx has a vital, supplemental role to play in outpatient forensic settings. It assists in keeping patients in the community and out of the criminal justice system, in large part by reducing medication noncompliance for those who have mental illness and a history of violent behaviors during acute exacerbation such conditions. This, in turn, can improve the prognosis concerning both mental illness and medical comorbidities for a particularly high-risk population.

DTx affords better remote monitoring and automatic check-in options for appointments with treatment providers, probation/parole officers, and others, which is a particular boon given how little we otherwise have learned about how individuals with mental 

 Additional benefits include monitoring court-ordered medication, identifying relapse triggers, and providing built-in incentives for compliance-oriented behaviors.

offers a checklist for psychiatric professionals who are considering DTx.

“Drew” is awaiting trial on charges of kidnapping and murder. The judge ruled 6 months ago that Drew was incompetent to stand trial, based upon the opinions of 2 forensic psychiatrists—1 for the defense, 1 for the prosecution—both of whom agreed that the most relevant underlying diagnosis was posttraumatic stress disorder (PTSD). The East Dakota Forensic Psychiatric Center has placed Drew in its Competency Restoration Program.

Numerous problems have arisen. Drew complains that “trying to deal with a machine” while addressing prior traumatic events is “cold,” “boring,” and “impersonal.” When Drew is informed that the doctors who conducted the competency evaluations would have a conflict of interest in providing treatment, and that the office of the only board-certified trauma specialist in the state is located 100 miles away, Drew suggests that “maybe at least one of the guards can read me this stuff instead of my just seeing it on a screen.”

Screen access itself is a problem. The Psychiatric Center’s few available computer terminals are dominated by a combination of court hearings and attorney video conferences. Psychiatric staff actually took up a collection to purchase a smartphone so that Drew could utilize DTx resources on a regular schedule; the device was branded as contraband by prison administrators and never used.

Responding to Drew’s concerns about what sorts of unhelpful disclosure might be occasioned by the Psychiatric Center’s use of DTx, defense counsel are demanding to review the manuals and algorithms for the DTx being utilized. They want to attend DTx-based sessions themselves, and to record them if possible.

Faced with a lagging restoration timeline due to a lack of progress concerning Drew’s PTSD symptoms, psychiatric staff obtained a budgetary waiver that allowed one of their clinical psychologists to receive specialized weekly telephonic supervision from the state board-certified trauma specialist. The trauma specialist also agreed to travel to the Psychiatric Center on a monthly basis to meet with Drew and the clinical psychologist in person. Psychiatric staff remain convinced of the value of DTx, but they recognize that the parties with whom they must collaborate are not yet ready.

“Shawn” is subject to outpatient commitment as part of a diversion program, after pleading no contest to half a dozen different charges of robbery in the first degree. The focus of court-ordered treatment is a combination of anger management, medication compliance, and community living skills. According to the court’s Diversion Coordinator, group therapy alone will not suffice; individual treatment—by DTx, if feasible—will be necessary.

The XYZ Community Treatment Center is a brand-new facility located just outside of Capital City in West Carolina. It has been hiring staff at an impressive pace, but it has yet to develop much of an integrated service team or attract many senior specialists. Groups are filling, but seats in those groups are still available. A licensed clinical social worker is willing to provide individual therapy for community living skills, but she has declared outright that some other source of treatment will be necessary for anger management and medication compliance.

Shawn does not own a personal computer, and Shawn’s defense attorney insists that the public library is not a suitably private venue for receiving DTx services. Although the smartphone Shawn owned prior to his arrest is still functional, it has insufficient memory to handle the DTx programs identified by the Treatment Center Director in consultation with the Court’s Diversion Coordinator.

Fortunately, the Treatment Center’s licensed clinical social worker has been able to obtain funding for Shawn to obtain a smartphone with sufficient memory, a large screen for viewing (since Shawn is also visually challenged), and other up-to-date features. What Shawn has not been able to secure is WiFi access at home, where paid WiFi services are prohibitively expensive, and where the publicly available wireless signal is too weak for DTx to function effectively.

The Treatment Center has a solution. Shawn can use one of the empty offices at the Treatment Center and access that facility’s WiFi free of charge with a special password. The Treatment Center’s licensed clinical social worker has also managed to obtain extra travel vouchers for Shawn to travel to the center for DTx sessions when they do not coincide with a group counseling session or an individual community living skills session. Shawn responds well to DTx, meeting the Treatment Center’s milestones for clinical progress and the court’s requirements for compliance.

In forensic settings, it is important to think of DTx and other technologically informed options as physician extenders rather than as a tool for enabling nonclinical entities to make clinical decisions. In the hands of those with alternative agendas, or of those who might misinterpret psychiatric data willfully or otherwise, digital information can gravely harm individuals and can serve to make a stigmatized population even more vulnerable.

Similar concerns can be—and have been—leveled at every successive innovation in modern psychiatric care. There is no percentage in unthinking technophobia for forensic psychiatric personnel and the systems they support. DTx is here to stay, and the advantages far outweigh the disadvantages for those ready to proceed with due foresight and caution.

is the Director of the Psychiatry, Law, and Society Program (PSLP) at Brigham and Women’s Hospital in Boston, Massachusetts. She is a board-certified forensic psychiatrist with a focus on social systems, cultural dynamics, criminal justice reform, and legal issues impacting psychiatric care.

is the Affiliated Lead of Psycholegal Studies for the PSLP. He is an attorney and board-certified forensic psychologist with a focus on expert witness testimony and trial consultation.

Drs Biswas and Drogin both serve on the faculties of Harvard Medical School and the Harvard Mass General Brigham Forensic Psychiatry Fellowship, of which Dr Biswas is the Co-Director.

1. Makin S. The emerging world of digital therapeutics. 

2. Fazel S, Hayes AJ, Bartellas K, et al. Mental health of prisoners: prevalence, adverse outcomes, and interventions. 

3. Torrey EF, Zdanowicz MT, Kennard AD, et al. The treatment of persons with mental illness in prisons and jails: a state survey. Treatment Advocacy Center. April 8, 2014. Accessed July 14, 2021. 

4. State prison health care spending: an examination. The Pew Charitable Trusts. July 2014. Accessed July 14, 2021. 

5. Prison mental healthcare lawsuit to proceed as class action. Associated Press. November 26, 2016. Accessed July 14, 2021. 

6. Biswas J, Drogin EY, Gutheil TG. Treatment delayed is treatment denied. 

7. Marion-Veyron R, Lambert M, Cotton SM, et al. History of offending behavior in first episode psychosis patients: a marker of specific clinical needs and a call for early detection strategies among young offenders. 

8. Dell'Osso B, Glick ID, Baldwin DS, Altamura AC. Can long-term outcomes be improved by shortening the duration of untreated illness in psychiatric disorders? A conceptual framework. 

9. Forrester A, Exworthy T, Olumoroti O, et al. Variations in prison mental health services in England and Wales. 

10. Lovell D, Gagliardi GJ, Peterson PD. Recidivism and use of services among persons with mental illness after release from prison. 

How can digital therapeutics overcome barriers to psychiatric treatment in forensic settings? 

Interpreting Digital Information in Forensic Settings

False allegations of abuse in child custody cases are an all-too-common phenomenon. Typically, one parent accuses the other parent of physical and/or sexual abuse of their child to gain leverage in their court proceeding. Nothing can befuddle or sidetrack a custody case more than an allegation of abuse. This is particularly important because judges tend to award primary physical custody to the parent who made the allegation, even if the accused parent’s actions are not substantiated. Thus, false allegations can be a powerful weapon to limit or deny custody and/or visitation in a vindictive manner.

Handling an allegation of abuse is a sensitive and thorny problem for attorneys and judges. All allegations of abuse must be taken seriously. While a strong visceral reaction to an abuse allegation is expected, it can be counterproductive. A rushed response can make the situation worse. In contrast, a wait-and-see attitude leaves the door open for a thorough evaluation before a disposition is decided upon. In essence, evaluation needs to occur before disposition.

Let us be clear: false allegations of abuse are a form of parental alienation. Alienation involves the concerted effort of one parent to undermine the other parent’s relationship with their child. Nothing could be worse than a custody decision that is based on a false allegation. And once a custody decision has been issued, modification of it is burdensome and an uphill challenge.

Clinical psychologists, psychiatrists, and other mental health professionals are often turned to in cases of abuse allegations. The court appoints them to evaluate the parties involved and to make recommendations. Allegations of abuse call for a coordinated effort between the judge, the attorneys, and the court-appointed evaluator.

A clinical approach to evaluating allegations of abuse presented here is based on years of experience with hundreds of cases of abuse allegations. This approach consists of sequential steps that should be taken. The evaluation process is aimed at determining whether an allegation of abuse has occurred or not—in other words, whether the allegation has been fabricated by a parent with the intent of sabotaging and harming the other parent.

The evaluation of possible abuse must include both parents and the child. Seeing just the child, just the accused parent, or just the accusing parent is not sufficient to understanding the entire narrative. All 3 individuals must be a part of the evaluation process. After all, we want our conclusions and recommendations to be based on full and accurate information. This can only be accomplished with the participation of all 3 individuals

The accused parent is often advised by his/her attorney not to participate in the evaluation process with the psychologist or psychiatrist. This is ill-conceived advice. By doing so, the mental health professional will be deprived of critical information that can shine a light on the falsity of the claim. Otherwise, all the information will be coming from the accusing parent, whose allegation will gain weight if it is not disputed.

If this is the first allegation of abuse, and it is occurring during a child custody case, its validity must be questioned. In fact, there is a significant probability that the allegation is false. It is unlikely that a parent’s first abuse of a child will occur after a child custody case has been opened. Thus, if a parent does not have a history of abusing the child, it is not likely that the first abuse is occurring during the legal proceeding.

A series of allegations against a parent during a child custody proceeding is also a major red flag. An accusing parent often believes that multiple allegations against the other parent are more convincing to a judge than a single allegation. But repeated abuse of a child during a circumscribed time period—during a child custody case, for example—is quite improbable.

Detecting a false allegation is easier with the use of a timeline. Marking the major occurrences in a child custody case can show the specific sequence of events. A false allegation of abuse may occur during the custody case and not before. It may also occur in response to legal action taken by the other parent. For example, if a mother files for full custody of her child, this sets the stage for the father to report a false allegation of abuse against the mother, with the hopes that the allegation will derail the mother’s quest for custody. The motive of the false allegation can be detected by examining its place on the timeline of events.

Children between the ages of 3 and 7 years are easily coached by one parent against the other. False allegations of abuse often include unwitting help from the children. Children want to please their primary parent. They are easily swayed, cajoled, convinced, and brainwashed. It is difficult for them to know the truth once a parent has coached them extensively. False allegations can involve older children and teenagers as well, but their coaching is more easily transparent and even admitted to by the adolescent in question.

There are 5 common reasons why a parent will lodge a false allegation of abuse against the other parent. There are certain powerful beliefs that an accusing parent will have that lead to the promulgation of false allegations (

If any of these beliefs are discovered, the allegation of abuse is likely to be false. Detecting these beliefs in a parent requires careful interviews over several sessions. A parent will never admit to fabricating a false allegation. The clinician must be skilled enough to see through the typical defensiveness, deceitfulness, and/or distractions of an offending parent.

Harmful and false beliefs by the accusing parent can also be detected through interviews with the child and the accused parent. Usually, the child or the accused parent will provide critical clues as to the accusing parent’s belief system. These clues can be pieced together to provide a full understanding of the destructive dynamics at play. Bits and pieces of information will fit together into a detailed narrative that exposes the falseness of the allegation at hand. But, again, the accusing parent will never recant and will never apologize for his/her underhanded attempt at relationship interference.

Critical Points to Keep in Mind During the Evaluation

Once an allegation of abuse has been declared by a parent, the following process should ensue:

1. The Judge should appoint a clinical psychologist or a psychiatrist to evaluate the child and both parents. This evaluation must include interviews, psychological testing, and a review of collateral data (emails, texts, recordings, pictures, and others). The evaluator should have access to other independent assessments of the allegation, such as DHR investigations or a forensic evaluation of the child.

2. The clinical psychologist or psychiatrist must be experienced in child custody evaluations.

3. There should be a wait-and-see attitude about the allegation until the evaluation process has been fully completed.

4. Attorneys should not respond to an allegation of abuse by filing motions for dramatic or extreme action, such as obtaining full custody of the child.

5. Giving a parent temporary custody until the matter is settled may make sense, especially if the child’s physical safety is of acute concern.

6. The evaluation by the mental health professional should be aimed at determining the validity of the stated allegation of abuse.

7. The attorneys must not try to sabotage the evaluator in order to win their case. The evaluator’s conclusions and recommendations should be given strong weight.

A false allegation of abuse by a parent should be met with firm consequences, such as a fine, supervised parenting time, court-ordered counseling, and/or loss of primary custody. Swift and decisive consequences will stop future false allegations of abuse.

A false allegation must be considered a form of parental alienation. By being involved in one way or another, the child learns to be dishonest, deceitful, manipulative, conflictual, and blaming. The love the child should have for both parents is compromised and even destroyed by the process of a false allegation. False allegations of abuse must not be tolerated in the court system.

The accusing parent may not be appropriate for primary custody. Even shared custody may not be a good idea. A parent’s willingness to fabricate an allegation of abuse against the other parent is a poor prognostic indicator. It is not simply an accident or a mistake. A false allegation is an intentional and purposeful attempt to undermine the child custody proceeding.

A false allegation of abuse is serious business. It represents a psychiatric emergency. As such, it must be handled and dealt with in a direct and timely manner. A child’s mental health and well-being depend upon it.

A clinical approach to detecting false allegations of abuse in child custody cases.

Finding the Difficult Truth 

C. A child molester is by definition a pedophile

What does the scientific evidence tell us about treatment for pedophilia? The answer might surprise you.

Mini Quiz: Treatment for Pedophilia?

(COVID-19) pandemic has brought a lot of unknowns into the practice of medicine. Doctors are trying to see patients while keeping their patients, themselves, and their staff safe from infection and balancing the threat of being sued for not taking the proper precautions. Stephanie Sheps, vice president of claims at Coverys Specialty Insurance Company, a medical liability insurance provider, shared her thoughts on liability risk in the age of COVID-19 in an interview with 

There are the obvious risks, including transmission of COVID-19, both to patients and to staff. It is a novel issue because we do not fully understand this virus yet, and things continue to evolve daily. Based on patient and provider awareness and precautionary measures taken to mitigate these risks, I believe that the greater liability stems from pandemic-related or contextual realms. Pandemic risks are those that do not involve the diagnosis, transmission, or treatment of COVID-19, but are instead related to the changes in how health care is being delivered or not delivered. These risks include the denial of services to patients because of lack of capacity and lack of 

Medical visits, especially for checkups and management of 

, that are deferred or held virtually present some risk. There is a reason we see our providers in person: they get to put eyes on the patient, they get to take labs, they get to really assess the patient using all of their senses. When that is limited by doing visits through telehealth, I think that could present some greater risk in the future.

Are there oversights that make practices more vulnerable to COVID-related lawsuits?

Yes and no. These are common issues that would have existed before COVID-19, like the failure to document informed consent or informed refusal of treatment. Obviously, there are specific risks related to exposure in the office. The greatest risk right now, however, is that providers are so focused on these COVID-related safety issues that they may overlook traditional typical patient safety and risk mitigation efforts.

Have there been any cases that offer insight into how the courts will look at these COVID-19 issues?

It is a little bit early in the lifecycle to consider potential suits related to COVID-19. Not many have been filed related to COVID-19 that are not just contextual or pandemic-related, as it takes some time for things to wind their way through the court system. There was 1 decision in the federal district court in New York that remanded a case filed in the federal courts, but it was remanded back to the states so that it would not have the protections of the 

Public Readiness and Emergency Preparedness Act

Are there any states or regions where COVID-related actions are more prevalent than others?

Again, it is a little too soon to tell where things are more prevalent because not a lot has been filed in terms of COVID-specific lawsuits. We will likely see more case activity in states that do not have specific immunity for COVID-related countermeasures. Some of those are legislated, some of those are by executive order, but those states will probably see more activity. We will probably see more activity in states without tort reform, or states that do not have caps on noneconomic damages. Finally, states that have had limited or no specific guidance on public health and safety measures like wearing masks, by logical extension, may see more claims activity related to COVID-19 because those states are more likely to have more patients who contract COVID-19. Everything, just like the virus, continues to spread exponentially in the states that have passed legislation to help protect businesses from COVID-related lawsuits.

Do the state legislation protecting businesses from COVID-related suits help medical practices?

Absolutely, they do. The broadest protection comes from the federal extension of the PREP Act, which happened in March of this year. The PREP Act provides immunity to certain individuals, in this case, health care providers, for countermeasures taken to deal with health crises during. Many states have taken the initiative to invoke their own state-related 

, and some of those are even stronger, broader, and more encompassing to protect health care providers than the PREP Act itself. There are good protections out there for health care providers, but like anything else, there are ways around them.

What should practices do to minimize their risk from COVID-related legal action?

One of the things that we have been advocating is to continue traditional risk management and clinical risk management practices, and also employ tactical risk management. Those are things that we need to do now in anticipation of the claims we might have to defend in the future. For tactical risk management, we bucket our recommendations into timeline, record keeping, and memory. We recommend that health care providers, their practices, as well as facilities, keep a very detailed timeline of everything that has transpired related to the pandemic. If cases come up, most will be heard by a jury 3 to 4 years from now. With any luck, this pandemic will be a distant memory by then, and juries will need real reminders of what things were like.

It is important to be proactive about keeping records. We want to memorialize them on a timeline. Note the date that the first COVID-19 case appeared in your practice, the date testing became available, and the dates of any declaration of a state of emergency in your jurisdiction. Note dates when PPE was limited. Any dates relating to staffing shortages, furloughs, or reallocations should also be listed. These dates are critical.

In terms of record keeping, make sure that you have 

, including the purchase orders, letters from suppliers, etc. It is also important to have records of patient logs, like when they had visitors, when they left, or dates when the visitation may have been limited or flatly refused.

Document staff training, along with any furloughs and leaves of absence for providers who were concerned about the disease. Maintain a floor plan noting how isolation works for patients that are COVID-19 positive or suspected COVID-19 positive. Also, keep evidence of any reviews of quality assurance or compliance. These tasks contribute to preserving memory.

Memorialize the subject matter experts within your facility, including human resources and office manager personnel. If a deposition is later needed during litigation , you do not want to have to think back to who was working in 2020; you want to have that recorded. If possible, have a video of a day in the life at your facility or practice. It is so important, since memories fade, to get a context and to have a living example of how you functioned during this pandemic to 

 what it was like to deliver health care during a pandemic.

Remember, the strategy behind tactical risk management is that it is never too late to start. It will be more difficult to gather documents in the future. It will benefit the defense to have all of this information in 1 place, starting with your timeline; then connecting to all of your records and documentation; and finally preserving the memories of the actual people who are in charge of those decisions, creating the protocols, and following state federal guidelines with respect to the pandemic.

Does the typical malpractice insurance policy cover COVID-related claims?

Typically, yes, a medical professional liability policy covers what we call professional services, which is insurance company lingo for rendering medical care. However, most policies exclude willful or intentional conduct and many also exclude gross negligence.

 is the vice president of claims at Coverys. She is also a member of the International Association of Defense Counsel, the Professional Liability Underwriters Society, and serves as vice chairperson of the Professional Liability Foundation of Massachusetts

Does the typical malpractice insurance policy cover COVID-related claims? That question and more answered.

Physician Liability During COVID-19: What You Need to Know To Protect Your Practice

 in terms of the harm caused to individuals, the damage caused to property, and the financial implications for individuals and society. Between 2010-2014, an estimated 261,330 intentional fires were reported to US municipal fire departments each year, resulting in 440 deaths, and 1310 injuries, and the economic cost of fire setting was estimated to be as high as $328.5 billion per year.

 In the United States, 1 in 100 adults self-reported a lifetime history of deliberate fire setting; 38% of these fire settings persisted beyond the age of 15 years.

 Although estimations of the number of people who set fires within a population are almost certainly imprecise due to methodological limitations such as variations in study design, definition of fire setting used, data analysis techniques, ungeneralizable samples, and response bias, they do provide insight into the scale of the problem.

Various terminology, with somewhat different meanings, has been used within the literature to describe offending behavior that involves fire (

 are terms used to describe intentional fires set within specific contexts (eg, legal or psychiatric), 

 is the current preferred term in the literature to describe acts of deliberately started fires regardless of their legal or diagnostic status.

Comorbidity is common among adults who set fires. Common diagnoses include personality disorder, psychosis, substance dependence, and mood disorders.

 Reported prevalence rates of pyromania are relatively low, ranging between 0 to 10% of adults who set fires.

 Lower cognitive functioning, intellectual disabilities, and other developmental disorders (eg, autism) are also common, although exact prevalence varies widely depending upon the population sampled (ie, inpatient, community, prison samples).

Despite the development of reliable and valid assessment tools in other areas of offending behavior (eg, sexual offending), the systematic development of tools specific to fire setting has been slower to progress. Nevertheless, several tools have been developed to support the process of systematically collecting and collating clinical information from a range of sources (eg, self and informant reports, behavioral observations, file reviews and clinical assessments) in order to formulate risk and identify treatment needs and intervention plans for individuals who set fires (eg, the Tranah Firesetting Inventory,

 St Andrew’s Fire and Arson Risk Instrument,

 Northgate Firesetter Risk Assessment-2.0,

). These tools do not represent validated risk assessments for fire setting, however, a few fire-specific psychometric measures have been developed to assess fire-related factors (although they lack sufficient evaluation) (

Most recently, the properties of the Fire Interest Rating Scale, Fire Attitudes Scale and the Identification with Fire Questionnaire were analyzed using factor analysis and 4 clinically relevant constructs identified across the 3 scales (ie, the Four Factor Fire Scales): 

However, data collected to validate these measures was limited (eg, ungeneralizable/small samples). Nevertheless, despite fire specific measures not having undergone rigorous reliability and validity evaluations, they can still be used by experienced clinicians as part of a comprehensive assessment.

Those who engage in fire setting are often complex individuals with a diverse set of treatment or intervention needs warranting a specialist approach that reduces their risk of further offending. Most specialist treatment programs are underpinned by a 

approach, targeting a range of criminogenic needs and factors associated with fire setting, including cognitive distortions, poor problem solving, communication difficulties, self-regulation deficits, and relapse prevention. Treatment often includes a component on fire safety education and the consequences of fire setting, while also address­ing a range of associated interpersonal problems (eg, low self-esteem, social competence difficulties, and poor goal setting). 

 summarizes empirically evaluated treatment programs.

Existing interventions that target fire setting behavior in adults include an adapted version of the Fire Awareness Child Education UP (FACE-UP).

 More recently, a cognitive-behavioral group-based intervention for individuals with developmental disabilities called the Northgate Firesetters Treatment program was developed.

 Investigators reported follow-up data for 24 participants (16 men, 8 women) who completed the Northgate Firesetters Treatment Programme, between 4 years and 12 years, 9 months posttreatment. The majority of participants (n = 17) were living in community settings and only 1 female participant was reported to have set a further fire, although suspicions were raised concerning another 2 participants.

 Despite these positive findings, both of these treatment programs are grounded in theoretical perspectives that predate more recent advancements in the field (ie, Functional Analysis Theory,

). Furthermore, their effectiveness are limited in their comparability to other generic interventions, small sample sizes, and lack of robust evidence in terms of their effectiveness in reducing reoffending.

The Firesetting Intervention Programme for Prisoners (FIPP)

 and the Firesetting Intervention Programme for Mentally Disordered Offenders (FIP-MO)

 are based on the latest comprehensive theory of fire setting: the Multi-Trajectory Theory of Adult Firesetting (M-TTAF).

 The M-TTAF integrates parts of existing psychological theory that are supported by empirical evidence including psychological vulnerabilities, developmental factors, cultural factors, social learning factors, biological factors, and contextual factors related to fire setting into a detailed multifactorial theory.

Following a pilot evaluation of the FIPP, positive findings were reported posttreatment on measures related to fire interest/problematic associations with fire, offence supportive attitudes (ie, fire specific, violent, antisocial), locus of control, and anger regulation, which were stable at 3 month follow-up.

 However, the evaluation of the FIPP was conducted solely with adult males in a prison environment; thus, its effectiveness for women and adults with 

intellectual and developmental disabilities

 has yet to be established. Consequently, the FIP-MO was developed to address fire setting and fire-related risk behaviors for both men and women across secure forensic psychiatric hospitals in the United Kingdom. Significant improvements on self-reported interests, beliefs and attitudes about fire, as well as improvement in anger expression.

It is important to note that due to the paucity of research on fire setting by adults with intellectual and developmental disabilities, the generalizability of the M-TTAF to such groups, and the interventions underpinned by it, has yet to be established. Further, despite evidence suggesting that between 0.4% to 43.6% of adults who set fires have intellectual and developmental disabilities,

 no treatment program to date has been rigorously evaluated for this population. Yet, there is evidence to suggest this small but important group have different characteristics and offence specific treatment needs requiring a 

 Nevertheless, the FIPP and FIP-MO represent the first standardized specialist interventions for individuals who deliberately set fires and have been subject to a multisite research evaluation, with results showing that they are effective in reducing some of the fire setters’ key deficits.

Evidence suggests general recidivism is as high as 60% among adults who set fires; reoffending with fire is much lwer with estimates between 4% and 16%.

 However, the operational definition of recidivism, study methodology, setting and sample populations vary widely. Nevertheless, recidivism has been largely associated with younger age, single relationship status, a diagnosis of personality disorder, a history of criminal offending, an interest in fire, and a number of attributes suggestive of childhood disturbance.

 Furthermore, reported length of stay in hospital for adults with intellectual and other developmental 

 and history of fire setting vary from 950 days to 1725 days.

 However, very few studies have included details pertaining to length of stay, which is inevitably effected by many confounding variables, such as mental health, engagement in treatment, previous offending history that are not accounted for within the data.

Whilst there have been significant advancements in our understanding of deliberate fire setting in recent years, further research is urgently needed to understand the etiology of fire setting and to further develop specialist assessment and treatment protocols. In particular, little is known about the relationship between cultural factors and fire misuse, gender-specific factors, or the needs of individuals with intellectual and/or other developmental disabilities. In addition, research on fac­tors that influence the maintenance and desistance process for fire setting will aid the construction of valid and reliable risk assessment tools and ensure individualized treat­ment approaches are taken and practice is evidence based. Focusing on these areas will also ensure that treatment efforts evolve to meet the needs of individuals who have set fires regardless of the treatment setting.

is a postgraduate researcher at the Tizard Centre, School of Social Policy, Sociology and Social Research, University of Kent, UK. 

 is a lecturer in forensic psychology at theSchool of Psychology, Victoria University of Wellington, New Zealand, and Honorary Lecturer in Forensic Psychology at the University of Kent, UK. 

is a chartered psychologist and lecturer in forensic psychology and intellectual and developmental disabilityat the Tizard Centre, School of Social Policy, Sociology and Social Research, University of Kent. Ms Collins and Dr Barnoux have nothing to disclose regarding this article. Dr Tyler is involved in providing training and evaluating the FIPP and FIP-MO programs and has received funding from Fire and Emergency New Zealand to conduct research on their Fire Awareness Intervention Programme (FAIP) for youth.

1. Home Office. Fire statistics data tables. May 14, 2020. Accessed July 23, 2020. 

https://www.gov.uk/government/statistical-data-sets/fire-statistics-data-tables

2. Campbell R. Intentional fires. National Fire Protection Association. July 2017. Accessed July 23, 2020. https://www.nfpa.org/News-and-Research/Data-research-and-tools/US-Fire-Problem/Intentional-fires

Accessed July 23, 2020. http://www.stoparsonuk.org/arson/documents/Arson-Prevention-Forum-Booklet.pdf

4. Zhuang J, Payyappalli VM, Behrendt A, Lukasiewicz K. 

. National Fire Protection Association. October 2017. Accessed July 23, 2020. https://www.nfpa.org/News-and-Research/Data-research-and-tools/US-Fire-Problem/Total-cost-of-fire-in-the-United-States

5. Blanco C, Alegria AA, Petry NM et al. Prevalence and correlates of fire setting in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). 

6. Vaughn M, Fu Q, DeLisi M, et al. Prevalence and correlates of fire setting in the United States: results from the National Epidemiological Survey on Alcohol and Related Conditions. 

Diagnostic and Statistical Manual of Mental Disorders, DSM-V. 

8. Bell R, Doley R, Dawson D. Developmental characteristics of adults who set fires: are recidivist offenders distinctive? 

9. Geller JL, Bertsch G. (1985). Fire-setting behavior in the histories of a state hospital population. 

10. Lindberg N, Holi MM, Tani P, Virkkunen M (2005). Looking for pyromania: characteristics of a consecutive sample of Finnish male criminals with histories of recidivist fire-setting between 1973 and 1993. 

11. Lees-Warley G, Rose J. What does the evidence tell us about adults with low intellectual functioning who deliberately set fires? a systematic review

. International Journal of Developmental Disabilities

12. Tranah T, Nicholas J. Interventions for young people with intellectual disabilities who commit arson. 

Fire setting is the current preferred term in the literature to describe acts of deliberately started fires regardless of their legal or diagnostic status.

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