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Custody Evaluation Process and Report Writing
J Korean Acad Child Adolesc Psychiatry 2020; 31(2): 58-65
Published online April 1, 2020
© 2020 Korean Academy of Child and Adolescent Psychiatry.

Dong Sun Chung1, Duk Soo Moon2, Myung Hoon Lee3, and Young Sook Kwack2

1W Psychiatric Clinic, Seongnam, Korea
2Department of Psychiatry, Jeju National University School of Medicine, Jeju, Korea
3Raon Psychiatric Clinic, Incheon, Korea
Correspondence to: Duk Soo Moon, Department of Psychiatry, Jeju National University School of Medicine, 15 Aran 13-gil, Jeju 63241, Korea
Tel: +82-64-717-1850, Fax: +82-64-717-1849, E-mail: dr.moon@daum.net
Received February 17, 2020; Revised February 24, 2020; Accepted March 3, 2020.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
As in western countries, divorce rates in South Korea have recently been rising, and family disruption has become one of serious social problems. Parents are able to express their opinions and wishes confidently, but the thoughts and wishes of children, especially infants and young children, tend to be ignored. Children can also experience several emotional and behavioral problems during the process of and after their parents’ divorce. When South Korean family courts determine custody arrangements, they typically do not have a systematic strategy and process based on custody evaluation to help children and their parents overcome conflicts and build healthy parent-child relationships after divorce. Furthermore, under the current court system, it is difficult for mental health specialists and child psychiatrists to intervene in familial conflicts as mediators or therapists during the course of divorce proceedings. Acknowledging these limitations, the South Korean family court system implemented a formal program for custody evaluations by child psychiatrists and psychologists in 2017. However, they have faced challenges such as a shortage of experienced specialist and lack of a training system or instruments for evaluation. In this paper, the authors aim to share professional knowledge of and experiences with aspects of the custody evaluation process, such as indications, procedures, methods, psychological tests, resources, and final report writing, to better serve children and their parents undergoing a painful divorce process.
Keywords : Child custody; Forensic psychiatry; Psychological test
INTRODUCTION

Custody evaluation is the most complex and difficult process in the field of forensic psychiatry [1]. Given the expansive nature of the underlying psychological issues (i.e., the best interest of the child and the ability of the parents to meet those interest, standard custody evaluations should assess the child’s and parents’ behaviors, abilities, and needs [2]. A custody evaluation may be indicated in the following cases [3]: 1) one or both parents have a significant mental disorder that affects their parenting skills; 2) the child has a mental disorder that must be considered; 3) domestic violence (including abuse by a parent, sibling, or the child) has been alleged or documented; 4) concern about a child’s relationship with the noncustodial parent being damaged by actions of the custodial parent intended to alienate the noncustodial parent.

BASIC PRINCIPLES

A forensic evaluator’s duty is to objectively report psychiatric findings as an expert. Two characteristics are critical: first, the evaluator must have no therapeutic relationship with the subject; and second, there are clear limits to confidentiality in a forensic evaluation [3]. The methodology or order of the evaluation may vary depending on the evaluator’s personal propensity, must include the following parent-related, child-related, and family-related factors [3]:

  • 1) Parent-related: Parenting skills, physical and mental health, substance abuse, current and previous involvement in the the child welfare facilities, and willingness to cooperate with the other parent in raising the child.

  • 2) Child-related: Mental health, attachment to each parent, and preferences regarding custody or living arrangements.

  • 3) Family-related: History of domestic violence, allegations of abuse, and allegations of parental alienation.

EVALUATION PROCESS AND CONTENT

The overall evaluation process includes three areas: interviews with and evaluation of the parents, interview with and evaluation of the child (including observation of parent-child interactions in preschoolers), and collateral information gathering [1]. The courts (including judges) favor a more child-focused report that addresses the best interest of the child and provides recommendations regarding custody and visitation. Timely completion of a report (e.g., within an average of 5–6 weeks) is also highly preferred [4].

Interviews with parents

The initial interview session with the parents should address the following [5]:

  • 1) The parents’ marriage chronology, including the birth of the child, separation, and divorce.

  • 2) The current status of legal proceedings (i.e., trial date).

  • 3) Court orders regarding the custody evaluation.

  • 4) The current visitation schedule and custody status.

  • 5) Each parent’s perception of his or her own relationship with the child.

  • 6) Each parent’s understanding of general information about the child and response to the child’s specific needs.

  • 7) Each parent’s parenting plan if granted custody.

  • 8) Each parent’s personal history, criminal record, family history, social support system, and history of psychiatric treatment.

The initial meeting is also used to schedule all further tests and interviews involved in the evaluation. The forensic evaluator must obtain informed consent from both parents to gather collateral information from the child’s pediatrician, teachers, therapists, and other individuals involved. It is also recommended that the forensic evaluator clearly describe the confidentiality and ethical issues surrounding the role definition early on in the custody evaluation process, informing the child and parents that forensic evaluations do not provide total confidentiality [6].

During the interview sessions with each parent, the evaluator should assess whether the parent is more focused on the child or on the other parent. Many parents waste considerable time during interviews making allegations against the other parent or complaining of the injustice suffered. In such cases, the evaluator must remind the parent of the overall time schedule and make it clear that an inaccurate evaluation due to lack of time would be detrimental to the child’s best interest. The evaluator should also identify the child’s developmental history and usual routine [5]. Typically, this may require either one long meeting of 2 to 3 hours, or several shorter meetings [6]. Finally, to assess the parents’ attitudes and mind toward parenting, the evaluator should ask parents to present a plan for how they would spend time with the child, and evaluate their responses to hypothetical situations such as “If you are granted custody, how will you help your child maintain a good relationship with your ex-spouse?” and “If you are not granted custody, how will you maintain a good relationship with your child?” [5].

Assessments of parenting style may consider each parent’s opinion of how the other parent spends time with the child and how the parent-child relationship would change after custody is resolved. The evaluation may also include questions about each parent’s practice and philosophy of parental discipline [5]. Assessment of each parent’s caretaking history (specifically, which parent is more involved in feeding, bathing, supervising homework, organizing birthday parties, and taking the child to the pediatrician) is crucial. The more involved parent is more likely to be granted custody [6].

The following important details should be considered as part of the custody evaluation [7]:

  • 1) The child’s and each parent’s wishes or preferences regarding custody.

  • 2) The child’s interactions with each parent, siblings, and individuals who may significantly influence the child.

  • 3) The child’s adjustment to home, school, and community environments.

  • 4) The physical and mental health of all individuals involved.

  • 5) Parental attempts at alienation.

  • 6) The quality and nature of the emotional relationship between each parent and the child.

  • 7) Each parent’s emotional and psychological stability.

  • 8) Each parent’s parenting skills.

  • 9) Each parent’s openness to visitation by the other parent.

  • 10) Each parent’s proposals for the child’s custody and visitation arrangements.

  • 11) Each parent’s pre-divorce parental role and parenting capacity.

  • 12) Each parent’s degree of anger and distress related to the divorce.

  • 13) Each parent’s sexual orientation.

The evaluator should also assess possible drug abuse or alcoholism in each parent, and if substance use is revealed, its impact on the child [5]. Finally, it is important for a custody evaluation to assess the presence of mental disease in each parent, with a focus not on the psychiatric diagnosis per se, but impact of potential parental psychiatric impairment on the parent-child relationship [8].

Interview with the child

Interviews with the child are an integral part of a custody evaluation. It may include a clinical evaluation of the child and assessment of the child’s attachment to each parent, the impact of the parents’ divorce or separation on the child, and parental attempts to indoctrinate the child [6].

The evaluator should meet with each child alone unless there are reasons against it (e.g., the child is an infant), and be attentive to any special developmental needs the child may have. If the child is sufficiently mature to express an independent and informed perspective, the evaluator should consider the child’s stated wishes and concerns regarding allocation of parental rights and responsibilities [9]. When preparing the evaluation report, the evaluator should describe the manner in which information concerning the child’s perceptions and/or sentiments was obtained, and specify the weight assigned to these perceptions and/or sentiments [9]. As mentioned previously, when evaluating the child, the evaluator must consider clinical diagnoses, level of attachment to parent, any expressed preferences for either parent, and any evidence of indoctrination by either parent. Siblings should be observed together to assess how supportive they are to each other and how they help lessen each other’s anxiety. Each child should then be separately interviewed at least once or twice, with each parent bringing the child at least once.

In a child interview, the evaluator should first explain the purpose of counseling and the evaluator’s role in the process. Children as young as 3 years can understand an explanation that the evaluator’s role is to help the judge determine who the child will live with [5]. The evaluator may then ask questions to explore the child’s perception of the family’s current situation and what will happen to the family in the future. The evaluator should use appropriate communication materials to develop a warm and comfortable relationship with the child. With younger children, use of a dollhouse can be emotionally evocative and help the evaluator to access the child’s inner world [5]. Children as young as 3 can usually be interviewed alone, if they are comfortable separating from the parent. Generally, the evaluator should be cautious about asking the children, especially young children, where they would prefer to live. If the child volunteers a preference regarding custody, the evaluator should explore the context and reason [5]. Questions should be posed in a way that minimizes their importance. It can be useful to mention that the judge will make the final decision regarding custody, not the child or the evaluator [6]. The opinions and preferences of children aged 5 years or older (adolescents in particular) are regarded significantly. Children’s preferences should be taken seriously only when they are developmentally mature enough to independently express their opinions [9].

Interviews with preschool-age and younger children

Parent-child play session

The evaluator can usually begin the interview in the presence of a parent. In infants, the evaluator should assess the parent’s attachment to the child and the appropriateness of each parent’s plan for the child considering his or her developmental needs [5,10]. The child’s relationships with other adults who live with the child or play a role in caretaking (i.e., grandparents or partners) should also be assessed [10]. Given the lack of standardized observational evaluation instruments, evaluation of parent-child interactions is considered very important [11,12]. The evaluator should observe each parent-child relationship, even for preverbal children, unless such evaluation is impossible or verifiable threats to the child’s physical or psychological safety pose a foreseeable risk of significant harm. If the evaluator is unable or opts not to conduct parent-child observations, he or she is obligated to articulate the reasons why [13]. The evaluator should allow the parent and child to interact however they prefer, and may encourage the parent to participate in play initiated by the child [6] or direct a parent and child of appropriate age to cooperatively complete a task. For example, the evaluator could invite the parent and child to engage in an activity such as drawing pictures or building with blocks together, or ask what they plan to do together on weekends [5]. Parent-child play sessions must be unstructured and take place after the child’s initial visit to the office. The evaluator should observe how comfortable the parent-child interactions appear in terms of interaction methods and communication skills, how the parent reacts to the child’s needs or anxiety symptoms, disciplinary patterns, and methods to enhance the child’s self-esteem [5].

Separation-reunion session

Approximately halfway through the session, the evaluator should ask the parent to leave and explain to the child that the parent will be waiting outside the interview room (this procedure should be explained to the parent in advance). The evaluator can then observe how the parent and child respond to and handle the separation when the parent leaves the room [3].

Individual session

During the remainder of the session, the evaluator may use other techniques to assess the child, including play or games, structured doll techniques, and drawing [14]. At the end of the session, the evaluator should observe how the child and parent handle their reunification.

Interviews with school-aged children

For evaluation purposes, the evaluator can use a semi-structured interview or projective questions, such as the baby bird story, isolated islands story, or magician story. The baby bird story is presented below as a typical example [6].

Evaluator: “Once upon a time, there was a baby bird that lived in a ...”

Child: ‘‘Nest.’’

Evaluator: “The baby bird lived in the nest with ...”

Child: “The mother bird and father bird.”

Evaluator: “One day there was a big storm with a lot of...” Child: “Thunder,” “lightning,” ‘‘wind,” etc.

Evaluator: “There was so much wind that the mother bird was blown over in that direction and the father bird was blown over in the other direction. The baby bird was blown out of the nest. The baby bird, by the way, could fly, but only a little bit. Tell me what happens next in the story.” (The evaluator should then encourage the child to finish the story with as much detail as possible.)

Interviews with adolescents

With adolescents, the evaluator may begin the interview by asking them to share their opinions about the current situation at home. This question aims to determine how they perceive the relationship between their parents, what they know of the reasons for their parents’ divorce, and what effects the divorce is having on their own lives [6].

Most adolescents can discuss the advantages and disadvantages of life with each parent, the merits of particular visitation arrangements, and how they can best protect their own lives from being affected by their parents’ divorce. Adolescents may express definite opinions about where they want to live and what they want to say to the judge. The evaluator should respectfully explore in detail the reasons for adolescents’ custodial preferences and their plans for maintaining a good relationship with both parents [6].

Collateral information

Custody evaluations often rely on collateral information to validate the findings of counseling and the information obtained from the litigating parties. The custody evaluator must recognize that oral reports made by the litigants may have limited accuracy, and thus seek to confirm or reject these reports, claims, or allegations based on information from other sources [3]. The following individuals may be contacted by phone for collateral information (although the evaluator must be aware that they may already be allied with one of the parents): family members or caregivers currently living with either parent, such as stepparents, grandparents, nannies, or siblings not directly involved in the custody dispute; pediatricians; and school or daycare center teachers. Collateral information can also be gathered from police reports, the child’s or parents’ previous or current therapists, and earlier trial hearings [3,6]. The evaluator should be mindful of the importance of gathering information from multiple sources to thoroughly explore alternative hypotheses for issues pertinent to the evaluation [9].

EVALUATION INSTRUMENTS

In child custody evaluations, psychological testing provides objective support for the evaluator’s opinions, helps balance bias and potential errors in clinical interviews, and provides working hypotheses that can be verified by other data sources [15,16]. Although the majority of mental health professionals who conduct child custody evaluations use standard psychological tests, tests specific to custody issues have been developed over the past decade and are being used with increasing frequency [2].

A psychological test to be used for custody evaluation must satisfy five criteria [17]: 1) widespread use and universality; 2) evidence of adequate reliability; 3) relevance to the legal issue at hand, established by validation research; 4) standardized administration for generalizability; and 5) consideration of the effects of response style on the test results (e.g., “faking good,” malingering, and social desirability). When utilizing a psychological test, the custody evaluator should refrain from making substantial changes to the test’s format, administration mode, instructions, language, or content unless extraordinary circumstances make such changes necessary. In such cases, the custody evaluator must articulate the reasons for all changes made.

The following review demonstrates the instruments specifically used for custody evaluation, including psychological testing instruments commonly used in clinical settings (Table 1).

Psychological tests in custody evaluation

Parent Child
Clinical instruments MMPI WISC
Rorschach CAT
TAT
Instruments specified in custody evaluation ASPECT BPS
PSI PORT
PCRI

ASPECT: Ackerman-Schoendorf Scales for Parent Evaluation of Custody, BPS: Bricklin Perceptual Scales, CAT: Children’s Apperception Test, MMPI: Minnesota Multiphasic Personality Inventory, PCRI: Parent-Child Relationship Inventory, PORT: Perception of Relationship Test, PSI: Parenting Stress Index, TAT: Thematic Apperception Test, WISC: Wechsler Intelligence Scale for Children



Minnesota Multiphasic Personality Inventory-2 or Personality Assessment Inventory

The Minnesota Multiphasic Personality Inventory-2 [18] or Personality Assessment Inventory [19] can be used to screen for unidentified parental psychopathology and determine each parent’s overall psychological adjustment. Both tests also contain scales to indicate the subject’s openness to providing sensitive information; identifying a defensive parent is often particularly useful when allegations of abuse or misconduct have been made.

General intelligence tests or projective psychological tests

Projective psychological tests allow an evaluator to observe parents’ efforts to cope with an unstructured and stressful situation and provide information about their psychological resources and characteristics [20].

Ackerman-Schoendorf Scales for Parent Evaluation of Custody

The Ackerman-Schoendorf Scales for Parent Evaluation of Custody (ASPECT) was designed to aid mental health professionals in making child custody recommendations by quantifying characteristics of parents and parent-child interactions conceptually related to effective parenting. It was developed for use with parents of children between 2 and 18 years [21]. Rather than a test, the ASPECT is a system that combines the results of psychological testing, interviews, and observations of each parent and child to provide data regarding each parent’s suitability for custody. The underlying assumption of the assessment is that the “psychological parent,” who provides continuous companionship and a stable environment, is the more effective parent.

Gathering the data needed for the ASPECT requires considerable time and several assessment steps [22]. For example, each parent is asked to complete a Parent Questionnaire that assesses preferred custody arrangements, the child’s development and relationship with the parent, the relationship between the parents, and the parent’s background (e.g., substance use patterns, psychiatric treatment history, and legal history). In addition, parents complete the Minnesota Multiphasic Personality Inventory, the Rorschach test, the Wechsler Adult Intelligence Scale-Revised, and either the Wide Range Achievement Test-Revised or the Norris Educational Achievement Test. Each child is administered an age-appropriate IQ test, the Draw-A-Family Test, and either the Thematic Apperception Test or the Children’s Apperception Test, depending on the child’s age [23]. The clinician uses data from the above assessment procedures to complete 56 forced-choice questions in a yes-no format for each parent. These items contribute to three subscales: the Observational Scale, the Social Scale, and the Cognitive-Emotional Scale [21].

Ackerman and Ackerman [24] asked custody evaluators to rate the importance of various factors to the issue of child custody. The 10 most important factors were as follows, in descending order of significance:

  • 1) The substance abuse status of each parent.

  • 2) The parents’ parenting skills.

  • 3) Parental attempts at alienation.

  • 4) The nature and quality of the child’s emotional relationship with each parent.

  • 5) The emotional or psychological stability of each parent.

  • 6) Each parent’s openness to the child’s contact with the other parent.

  • 7) The parents’ history of compliance with the court during the separation.

  • 8) The parents’ pre-separation roles in caretaking and parenting.

  • 9) The stated preferences of a child aged 15 years or above.

  • 10) The parents’ expressed anger and bitterness regarding the divorce.

Bricklin Perceptual Scales

The Bricklin Perceptual Scales (BPS) measures children’s perceptions about each parent [22]. The BPS consists of 64 questions, half of which pertain to each parent [25]. The questions alternate in their focus on father or mother, each question being asked about each parent at different points during the examination. The questions require the child to indicate how well the item describes the parent. Along with each question, the child is presented with an 8-inch long card showing a thick black line with “not so well” printed at one end and “very well” at the other. The child responds to 64 questions by punching a hole at an appropriate place along the line. Administration of the test takes approximately 20 to 30 minutes. The test is designed for all children older than 6, although Bricklin [26] claims that some children as young as 4 may be able to understand the instructions.

Perception of Relationship Test

The Perception of Relationship Test (PORT) is a projective test that measures the degree to which a child seeks psychological “closeness” with each parent. The current revised version consists of seven tasks [2]. The first task asks the child to draw each parent. The second task presents the child with line-drawings of a mother and a father respectively and asks the child to draw a self-representation on the same page. The third task presents a line drawing of both parents and asks the child to draw a self-representation on the same page. The fourth task requests the child to draw the family and the fifth to draw the family “doing something.” The sixth picture shows two stables, one labeled with “mom” and the other “dad”; the child is asked to draw a line indicating where the horse in the middle of the picture will go. The seventh task presents the child with picture of a little dog asleep in a bed dreaming about mom and another dreaming about dad. The child is asked to describe what the dogs are dreaming about. The test is designed to be used with children 3 years and 2 months of age or older, although Bricklin provides some examples from children as young as 2 years of age [23].

Parent-Child Relationship Inventory

The Parent-Child Relationship Inventory (PCRI) assesses parents’ attitudes toward parenting and their children in several dimensions. It was developed based on the Mother-Child Relationship Evaluation. The PCRI is a 78-item, self-report questionnaire with items rated on a 4-point Likert-type scale ranging from “strongly agree” to “strongly disagree.” Administration takes approximately 15 minutes and requires a fourth-grade reading level [2].

The PCRI is divided into seven content scales, which reflect the major features of parenting and the parent-child relationship, and two validity indicators. The content scales are Parental Support, Satisfaction with Parenting, Involvement, Communication, Limit Setting, Autonomy, and Role Orientation. The validity scales consist of Social Desirability scale and Inconsistency scale intended to measure the tendency to give inconsistent responses. High scores on the PCRI scale indicate positive parenting characteristics and good parenting skills, and low scores indicate poor parenting skills [23].

Parenting Stress Index

The Parenting Stress Index (PSI) was developed as a screening instrument for use with parents of children aged 12 and under [27]. It evaluates the extent to which the parent experiences stress in the childrearing role. The current third version of the instrument includes 101 items rated on a 5-point Likert-type scale ranging from “strongly agree” to “strongly disagree.” Administration takes approximately 20 to 25 minutes and requires a fifth-grade reading level. A 36-item short form of the tool also exists. The PSI has been translated into eight languages.

The underlying assumptions of the instrument are that stress is cumulative and multidimensional in both source and kind. Over 95% of the items included in the PSI were designed in relation to specific research findings. The PSI measures stress in the Child Domain, the Parent Domain, and an optional 19-item Life Stress Domain that measures the number of major life events experienced over the past year.

Research suggests that, overall, higher PSI scores can suggest increased stress in parent-child interactions and an increased likelihood that the child will exhibit or develop behavioral problems in the parent’s care. The tool can also provide information about the types of stress that affect the parent’s functioning, which may be useful in helping the professional further explore that topic. It would be inappropriate, however, to conclude that high PSI scores indicate that a parent is unable to parent or is abusing the child.

CUSTODY EVALUATION REPORT WRITING

The evaluator’s opinions should be based on information and data obtained by applying reliable principles and methods [9]. When writing a custody evaluation report, complex medical terms or jargon should be avoided, considering the judges and court investigators who will be reading the report; if medical, psychological, or psychiatric terms must be used, they should be defined [3]. Judges and attorneys also prefer shorter reports (e.g., 10–12 pages). Generally, legal professionals expect a child-focused report that succinctly addresses the major legal issues before the court (e.g., the child’s needs, the parents’ strengths and weaknesses in meeting those needs, child custody criteria, and recommendations regarding custody and visitation) [1]. Recommendations should be based on clearly articulated assumptions, interpretations, and inferences consistent with established professional and scientific standards [11].

The custody evaluation report should contain the following components and details [6]:

  • 1) Identifying information: Names and birthdates of the children and the contesting parties (usually the parents).

  • 2) Referral information: A brief chronology of the marriage, the current status of the children’s custody and visitation, an excerpt from the court order authorizing the evaluation, and a statement of the circumstances of the referral and the specific purpose of the evaluation.

  • 3) Evaluation procedure: A list of the various meetings/interviews held, the psychological tests used, and the outside information collected.

  • 4) Observations: Observations should be presented in a separate section for each family member. Each parent should be discussed individually, with a summary of the parent’s strengths, weaknesses, personality traits, significant medical and psychiatric problems, and whether these factors affect the individual’s ability to be a good parent. Each child should also be discussed individually, with a summary of strengths, weaknesses, any psychiatric disorder, and how the child is coping with the parents’ divorce. The report also should address the child’s attachment to each parent, whether the child has a preference regarding custody and the reasons for the preference, and whether the child seems unduly influenced by a certain parent.

  • 5) Conclusion: A list of specific statements supported by data (i.e., the aforementioned observations). For instance, the evaluator might conclude that one parent has had a major mental illness in the past that is likely to be a problem again in the future; that a parent has personality traits or a personality disorder that affect his or her parenting abilities; or that the children are more uniformly attached and bonded to one parent than the other.

  • 6) Recommendations: This section should follow logically from the conclusions. The evaluator may make recommendations regarding the custody of the children, the visitation schedule, whether visitation should be supervised, whether any member of the family should be in psychotherapy, whether the parents should attend parenting classes, and other issues important to the particular evaluation case.

CONCLUSIONS

Custody evaluation is part of a process aimed at minimizing emotional problems likely to occur in a child during or after the divorce process (Figure 1). Evaluation conclusions should be preceded by objective assessments, obtained through interviews performed in a neutral setting with each parent, the child, and other individuals significant in the child’s life; a variety of psychometric instruments may be used to ensure standardized professionalism. To conclude the evaluation process, the evaluator writes a custody evaluation report including recommendations based on the findings.

Fig. 1. Process of custody evaluation. ASPECT: Ackerman-Schoendorf Scales for Parent Evaluation of Custody, BPS: Bricklin Perceptual Scales, CAT: Children’s Apperception Test, MMPI: Minnesota Multiphasic Personality Inventory, PCRI: Parent-Child Relationship Inventory, PORT: Perception of Relationship Test, PSI: Parenting Stress Index, TAT: Thematic Apperception Test, WISC: Wechsler Intelligence Scale for Children.
Acknowledgments

None.

Conflicts of Interest

The authors have no potential conflicts of interest to disclose.

Author Contributions

Project administration: Dong Sun Chung. Supervision: Young Sook Kwack. Writing—original draft: Dong Sun Chung. Writing—review & editing: Duk Soo Moon, Myung Hoon Lee.

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