Philip M. Koszyk, MD

Parental alienation (PA) profoundly affects both children and alienated parents. Children of PA are at increased risk for future trust and relationship issues, depression, and substance abuse. For a rejected parent, the pain is excruciating. This article discusses PA from two points of view. The first part relates an account of PA from the perspective of a parent who is also a physician. The second part, by an expert in forensic child psychiatry, explains how the tragedy of PA can be prevented and treated.

“Loss”: Experiencing parental alienation (PMK)

PA impacts people from all walks of life. Dr Jones (name and identity changed) shared his journey with me, and I think this case serves as a good illustration of this devastating condition that damages thousands of families every year.

Like many young professionals, Dr Jones found work-life balance challenging. When his children were little, he loved his time with them. He played Barbies on the floor with his daughter. He played catch for hours with his sons. They often went to the park together, just the three of them. He deferred much of the household responsibilities to their mom. She made the doctor appointments and arranged for dance lessons and play dates. He assumed this unspoken arrangement was natural.

By the time the children reached middle school, things began to change. The marriage was struggling, but he tried to “hang in there for the kids.” They went everywhere with their mother. Dr Jones didn’t notice it at first, but he began having less and less alone time with them. There was always some reason, some excuse. Insidiously, the process of PA was taking hold.

Several years passed before Dr Jones and his wife eventually separated. Dr Jones was ready to be the parent he knew he was without the overbearing presence of his ex, and so he naively set out to re-establish his relationship with his children. But things did not go well. His visitation time was challenged. The children became distant. After a while, they simply refused to go with him. He tried the available channels: mediation, family counseling, and court motions and hearings, with no success. He underestimated the power of PA, an adversary that accepts no compromise.

The concept of PA had been described in the legal and mental health literature for many years, but the phenomenon was given a name in 1985 by Dr Richard Gardner, a child psychiatrist.

 Gardner’s methods were criticized, and controversy has surrounded this topic ever since. Dr Jones tried to learn all he could about PA. He read the literature and took an online class. Everything he read seemed to be spot on. The attitudes and behaviors his children manifested matched the descriptions by Gardner and others. Suddenly, nothing he could do or say was “OK.” When he carefully asked them why things had changed, they strongly responded it was their idea and had nothing to do with their mother. But they could give no specifics.

Dr Jones turned to counselors, highly trained and compassionate professionals in family dynamics. He was told, “You did nothing wrong, but you can’t change what happened. You need to accept it.” Words that are hard for a physician to hear, hard for a father to hear. He sought answers from his pastor. And he prayed. “Like water, my life drains away, all my bones grow soft. My heart has become like wax, it melts away within me.”

Thanks to the efforts of a growing number of dedicated mental health and behavioral clinician-scientists, PA is gaining acceptance as a recognized disorder. It has been proposed as a search term in ICD-11 (

QE52.0 Caregiver-child relationship problem

). The concept of PA is described in DSM-5, if not listed as a formal diagnosis. The 

American Academy of Child and Adolescent Psychiatry

 have both included discussion of PA in society guidelines.

In the years since Dr Jones and his wife split, not a single Father’s Day card. Not a single birthday call. No Christmas anything. Graduations were watched from afar as an uninvited guest. Many milestones-award ceremonies, proms, college visits-were missed. Small moments were missed, as well-having lunch, sharing stories, just spending time together.

Dr Jones finds it difficult to relate to peers, men so proud of their children’s achievements. Conversation, small talk becomes uncomfortable. How does one fit into a community and a society in which we are often defined by our families? How does one deal with the shame?

Another haunting aspect of PA involves a parent’s concern for the 

of his children. The literature on adult children of PA is not exactly encouraging.

 They don’t always “eventually come around,” as good-intentioned people often say. Dr Jones wonders, will he ever see his children again? Will they be able to form trusting, loving relationships? Will they be OK?

Dr Jones learned of the Parental Alienation Study Group (PASG), an organization dedicated to developing and promoting research on the causes, evaluation, prevention, and treatment of PA. Among other academic activities, an international conference is held annually, bringing together mental health professionals, lawyers, social workers, and 

 to further the understanding of this destructive condition. These efforts give hope to parents like Dr Jones around the world. And with hope and understanding comes some degree of acceptance.

PA crosses gender and socioeconomic lines. It is not known if physicians are at increased risk for PA. However, immersion in the practice of clinical medicine can make doctors emotionally unavailable and unaware. The balance between professional and personal life is a precarious one. Increasing awareness of PA for parents and all persons involved in high-conflict divorce is the first step toward 

The tragedy is that PA occurs at all. Some writers have compared PA to an unexpected, premature death. For the rejected parent, it is like the death of their child. For the child, it is comparable to the early death of their parent, except it is complicated by the child’s painful, guilty knowledge that they contributed to the loss of their parent. That is, the child colluded with the indoctrination from the preferred parent and actively rejected the alienated parent-without any good reason.

PA is a mental condition in which a child-usually one whose parents are engaged in a high-conflict separation or divorce-allies strongly with one parent (the preferred parent) and rejects a relationship with the other parent (the alienated parent) without legitimate justification. Note that in PA, the child’s rejection of the alienated parent is without a good reason. We follow the convention of most writers, who use estrangement to refer to warranted rejection of a parent and alienation to refer to unwarranted rejection.

The identification or diagnosis of PA is based on the Five-Factor Model.

 If the following factors are present, it is highly likely that the family is experiencing PA:

 the child actively avoids, resists, or refuses a relationship with a parent.

presence of a prior positive relationship between the child and the now rejected parent.

 absence of abuse or neglect or seriously deficient parenting on the part of the now rejected parent.

 use of multiple alienating behaviors by the favored parent.

 exhibition of many or all of the eight behavioral manifestations of alienation by the child. (See 

Like many psychiatric disorders, the severity of PA may be classified as mild, moderate, and severe.This is an important feature because the appropriate intervention for this mental condition depends on the severity of a particular case. While the choice of treatment depends primarily on the symptoms in the child, it may also depend on the intensity of the indoctrination and the attitude of the alienating parent.

Mild PA means that the child resists contact with the alienated parent but enjoys a relationship with that parent once parenting time is underway. A typical intervention for mild PA is strongly worded instruction or psychoeducation. For example, a judge might clearly order the parents to stop exposing their child to conflict and stop undermining the child’s relationship with the other parent. Or, a parenting coordinator might meet with the parents to help them communicate in a constructive manner and support each other’s relationship with the child.

Moderate PA means that the child strongly resists contact and is persistently oppositional during parenting time with the alienated parent. The treatment for moderate PA-assuming both parents are committed and cooperative with the intervention-usually focuses on changing the behavior of the parents (ie, reducing the amount of conflict, improving communication). A parenting coordinator works with the parents together and individual counseling or coaching is usually arranged for the alienating parent, the alienated parent, and the child. However, this approach will not work if the preferred parent does not endorse and support the treatment program and continues to engage in alienating behaviors.

Severe PA means that the child persistently and adamantly refuses contact and may hide or run away to avoid being with the alienated parent. When the child manifests a severe level of PA, the alienating parent is usually obsessed with the goal of destroying the child’s relationship with the targeted parent. The alienating parent has little or no insight and is convinced of the righteousness of their behavior.

It is usually necessary to protect the child from the influence of the alienating parent by removing the child from their custody, greatly reducing the parenting time with that parent, and requiring the parenting time to be supervised. That is, when a parent purposefully causes a child to reject their relationship with the other parent, that constitutes child psychological abuse. The intervention is similar to what happens in cases of physical or sexual abuse, i.e., removal of the child from the care of that parent, at least temporarily.

It is important to identify PA in its early stages when the condition is mild and relatively treatable; severe cases of PA are much more difficult to address and reverse. For example, it is likely that very early cases of PA come to the attention of therapists in private practice and at mental health centers, who work with children of parents who are headed toward divorce. As PA becomes better understood by front-line clinicians, they will be able to intervene with parent counseling and psychoeducation at an early stage when the condition is highly treatable.

Of course, prevention is even more important than early intervention. Various authors have proposed strategies for the prevention of PA, ranging from interventions with individual children to educational approaches for judges to systemic changes to the entire family court system in the US. For example, there is a prevention approach called 

I Don’t Want to Choose: How Middle School Kids Can Avoid Choosing One Parent Over the Other

 It is a structured program for group discussions with children of divorced parents, which can be implemented by school counselors.

It has been suggested many times that it is important to educate psychiatrists, psychologists, social workers, lawyers, and judges regarding PA, so they can help parents avoid this catastrophe when parents take steps to end their marriages. It has also been suggested that the default arrangement for children after parental divorce should be shared parenting. Typically, shared parenting means that the child lives with both parents at least 40% of the time; a common arrangement is for the child to alternate living a week at a time in each parent’s home.

The most dramatic recommendation for reducing parental conflict after divorce is to revamp the entire family court system in this country. That would involve ceasing the use of adversarial methods of dispute resolution in family court. Then, replacing adversarial methods with obligatory structured family mediation for dispute resolution in cases between parents of minor children. Structured family mediation is a time-tested, nonadversarial, optimal method of family dispute resolution.

PA is enormously frustrating for parents who find themselves despised and rejected by their children-although the parents and the children previously enjoyed a happy and healthy relationship. PA is challenging for the mental health and legal professionals who encounter it in their clinics and courtrooms. As a society, we need to immunize ourselves against this pathogen-a task that will involve teaching our students and trainees about PA, continuing education for mental health and legal practitioners, orienting child protection personnel to recognize child psychological abuse, and influencing government officials to change laws, policies, and practices with regard to children of divorced parents.

 is a gastroenterologist in Bloomington, IL. He reports no conflicts of interest concerning the subject matter of this article. 

 is Professor Emeritus, Department of Psychiatry, Vanderbilt University School of Medicine in Nashville, TN. He receives royalties for books published by Charles C Thomas Publisher. He was the founder and first president of the Parental Alienation Study Group.

1. Gardner RA. Recent trends in divorce and custody litigation. 

 1987. Iowa Falls, IA: Catholic World Press.

3. American Academy of Child and Adolescent Psychiatry. Practice parameters for child custody evaluations. 

4. Cohen GJ, Weitzman CC, AAP Committee on Psychosocial Aspects of Child and Family Health, AAP Section on Developmental and Behavioral Pediatrics. 

Helping children and families deal with divorce and separation

Adult Children of Parental Alienation Syndrome: Breaking the Ties That Bind.

6. Bernet W. Introduction to parental alienation. In: Lorandos D, Bernet W, eds. 

 Springfield, Illinois: Charles C Thomas; 2020.

The Parental Alienation Syndrome: A Guide for Mental Health and Legal Professionals.

 Cresskill, NJ: Creative Therapeutics; 1992.

I Don’t Want to Choose: How Middle School Kids Can Avoid Choosing One Parent over the Other.

 New York: The Vincent J. Fontana Center for Child Protection; 2009.

9. Richard D. Non-adversarial resolution: All cases between parents of minor children. In: Lorandos D, Bernet W, eds. 

 Springfield, IL: Charles C Thomas; 2020.

Articles

When parents take steps to end their marriages, the default arrangement for children should be shared parenting. Psychiatrists, psychologists, social workers, lawyers, and judges can help parents avoid irreparable harm.

Author | Philip M. Koszyk, MD

Articles

Treatment and Prevention of Parental Alienation