William Bernet, 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.

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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.

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

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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.

Treatment and Prevention of Parental Alienation

Parental separation and divorce are common features of contemporary society. About 25% of children in the US live with only one parent.

 The parents may have been married and then separated or divorced; perhaps the parents were never married and never lived together; or perhaps the parents were never married, lived together, and later separated.

Many children are able to deal with their parents’ divorce in a reasonably constructive manner because of their inherent resiliency; the parents’ ability and willingness to communicate and collaborate in a healthy manner; and the support of extended family members and others in the community. On the other hand, children may be battered and injured by factors that are directly or indirectly associated with the divorce: reduced parenting time with one or both parents; financial instability; relocation, which involves changing schools and losing friends; and the inconvenience of traveling between the parents’ homes. Both clinicians and forensic evaluators know that the single most important factor that harms children of divorce is continual conflict between the parents.

 Children are damaged when their parents fight in front of them, over them, and through them.

Mental health practitioners (MHPs) see and hear about children of divorce in a variety of contexts. The MHP may be the therapist for the child or one of the parents. The child may present to an emergency department in a crisis situation. The child may be an observer or victim of domestic violence. In the forensic context, the MHP may conduct a child custody evaluation or participate in an investigation of allegations of child maltreatment. Clinical and forensic practitioners may identify a number of mental conditions in children who experience high-conflict divorce, which are described in this article and assigned appropriate terminology in DSM-5.

[[{"type":"media","view_mode":"media_crop","fid":"42451","attributes":{"alt":"© tigra62/shutterstock.com","class":"media-image media-image-right","id":"media_crop_8094406610409","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4598","media_crop_rotate":"0","media_crop_scale_h":"142","media_crop_scale_w":"125","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"© tigra62/shutterstock.com","typeof":"foaf:Image"}}]]Parental estrangement is not a mental disorder; it refers to a child’s rejection of a parent for a good reason. For example, a child might refuse to have a relationship with a parent who previously was abusive or neglectful or who abandoned the family. If one of the parents perpetrated domestic violence within the family, it is understandable that the child might avoid parenting time with that person. It is not a mental disorder to reject a relationship and avoid spending time with an abusive individual; it is normal for a child to behave in that manner.

Although parental estrangement is not a mental disorder, there are terms in DSM-5 that can be used to identify children who experience this condition. In DSM-5 abuse and neglect are found in the section “Other Conditions That May Be a Focus of Clinical Attention,” which are referred to as “conditions and problems,” rather than “mental disorders.” The section includes 

personal history of physical abuse in childhood and personal history of neglect in childhood

. When a clinical or forensic practitioner determines that a child exhibits parental estrangement, one of those terms may be used to establish the appropriate diagnosis.

Many children of divorce have transitory symptoms, which may take the form of excessive worrying, sadness, anger, oppositional behavior, impaired social relationships, and compromised school performance. These symptoms may occur when the child initially learns his or her parents plan to divorce, when the parents argue excessively, when the parents separate, and when important changes occur in the child’s life, such as moving to a new neighborhood. The typical diagnosis is one of the adjustment disorders (eg, 

A loyalty conflict occurs when the child tries to maintain a positive relationship with both parents, even though the parents are battling with each other.

 For example, when the child is with parent A, he misses parent B; when the child is with parent B, he misses parent A. The greater the degree of parental conflict, the more intense the loyalty conflict becomes for the child. When the loyalty conflict is more intense, the child experiences cognitive dissonance, an uncomfortable mental state that occurs when a person holds at the same time 2 thoughts that are incompatible or contradictory. The greater the cognitive dissonance, the greater the mental discomfort.

Some children try to resolve their loyalty conflict in a manner that seems adaptive, given their difficult circumstances. For example, some children are able to stand up to their parents and say, “Leave me out of it!” When the parents start arguing, the child goes to another room or tries to play outside. When interviewed during the course of a custody evaluation, he or she declares neutrality: he may say that he loves both parents equally and wants both parents to share custody. Some children try to resolve their loyalty conflict in a manner that is clearly maladaptive, ie, by aligning with parent A and rejecting parent B. This mental process is called parental alienation, which is discussed later in this article. The phenomenon of shifting from a loyalty conflict to parental alienation was described by Klosinski,

 a German child psychiatrist, 20 years ago.

When DSM-5 was published in 2013, several new terms were introduced in the section “Relational Problems,” which is part of “Other Conditions.” One of the new mental conditions in DSM-5 is 

child affected by parental relationship distress

, explained as: “This category should be used when the focus of clinical attention is the negative effects of parental relationship discord (eg, high levels of conflict, distress, or disparagement) on a child in the family, including effects on the child’s mental or other medical disorders.”

 If a clinical or forensic practitioner finds that a child is experiencing a loyalty conflict that causes distress or dysfunction, the diagnosis may be 

If the external stressors––especially, high conflict between the parents––continue for an extended period, the child’s symptoms may become internalized and develop into a more serious mental condition. Typically, the symptoms cluster to take the form of an anxiety disorder, a depressive disorder, or a somatic symptom disorder. An important recent study from Sweden showed that children of divorced parents had more sleeping problems, headaches, stomachaches, tenseness, and sadness than children in intact families.

 and suicidality may develop in a child who grieves the loss of his previous family life or the loss of time with the noncustodial parent.

 If the child fears the loss of the custodial parent, he may develop 

. Also, the child who repeatedly witnesses parental conflict during the “switching hour”––when the child transitions from one household to the other––may experience physical symptoms before, during, and after the transition. In that case, the diagnosis may be somatic symptom disorder.

Meredith’s parents argued incessantly both before and after their divorce, which occurred when she was 12 years old. Following a child custody battle and a 4-day trial, the judge assigned primary custody to the mother and ordered “standard visitation” for Meredith’s father-every other weekend (Friday evening to Sunday evening) and 6 weeks over summer vacations. When Meredith transitioned from her mother’s to her father’s custody, both parents bickered and complained about the girl’s activities in the other parent’s household.

During the school year, Meredith had stomachaches and headaches, sometimes accompanied by nausea and vomiting. Her symptoms were most pronounced on the Fridays before the weekends with her father. During most of the weekends at her father’s house, her physical symptoms were mild and usually did not interfere with her having a good time. During the summer, she spent three 2-week intervals with her father and was free of all somatic symptoms during those times.

Once the every-other-weekend visitation schedule resumed in the fall, so did Meredith’s stomachaches and headaches. Her pediatrician reassured Meredith that she was physically healthy, but referred her to a counselor. First, the counselor encouraged Meredith to detach herself from her parents’ arguments by ignoring them as much as possible and by avoiding taking sides. Then, the counselor explained to the parents that their quarreling was making Meredith sick. The counselor encouraged the parents to find ways to collaborate in raising Meredith and to communicate in a constructive manner. Within a few weeks, Meredith was feeling better and her physical symptoms did not return.

A serious consequence of high-conflict divorce is parental alienation, a mental condition in which a child closely allies with parent A and refuses to have a relationship with parent B without a good reason.

 Parental alienation may be considered a maladaptive outcome of an intense loyalty conflict. An adaptive and reasonably healthy way to deal with a loyalty conflict is for the child to seek a neutral position and avoid picking one parent over the other; a problematic way to deal with a loyalty conflict is for the child to align strongly with one parent and totally shun the other.

Parental alienation may also be contrasted with parental estrangement: the latter involves rejecting a parent for a good cause, such as a history of maltreatment; alienation involves rejecting a parent without a legitimate reason. Gardner

 identified 8 symptoms of parental alienation more than 20 years ago (

). Parental alienation comes about as a result of 3 interacting and mutually reinforcing factors:

• Parental alienation usually occurs in the context of a high-conflict separation or divorce, although the seeds of parental alienation may have been sown when the family was still intact

• Almost always, the preferred parent, also called the alienating parent, has indoctrinated or brainwashed the child to fear or dislike the rejected parent8

• Although clearly influenced by the alienating parent, the child adopts and internalizes the campaign to criticize, insult, and denigrate the alienated parent

Robert was 8 years old when his parents divorced. His mother quickly remarried and moved to another state. The parents agreed that Robert would live primarily with his father so that he could continue to enjoy the same home, neighborhood, and school and the father’s extended family. Because his mother lived far away, Robert didn’t spend much time with her. To minimize travel time, the parents initially agreed that Robert would visit his mother during all 3-day weekends and for the majority of winter, spring, and summer vacations.

Before the divorce, Robert had had an excellent relationship with his mother, who was a loving, generous person. His attitude toward his mother changed dramatically soon after she and her new husband moved away. Robert’s mother telephoned or Skyped him several times a week, but his father always said that Robert was “tired” or “busy” or “having dinner.” She sent emails to Robert, which he didn’t answer. When Thanksgiving came, his father said Robert was sick and refused to let him travel to spend the long weekend with his mother. Over Christmas vacation, the father said it was more important for Robert to go on a ski trip with his paternal grandparents than visit his mother. In January, Robert wrote a short letter to his mother that read: “DO NOT SEND ME MORE EMAILS. I NEVER WANT TO SEE YOU. YOUR NOT SON, ROBBIE.” The envelope was addressed and mailed by Robert’s father. The mother immediately traveled to the father’s home to see Robert face to face. When they met, Robert screamed at his mother, spit at her, and ran to his room and barricaded the door.

During the ensuing legal developments, Robert’s mother and father each hired mental health experts to evaluate Robert. Both experts agreed that Robert had a severe level of parental alienation, although they disagreed on what to do about it.

When a clinician or a forensic evaluator establishes that a child exhibits parental alienation, several DSM-5 terms can be used, depending on the circumstances of the particular case. In most cases of parental alienation, it is appropriate to use 

. It is clear that parental alienation always constitutes “the negative effects of parental relationship discord.” If the focus of clinical attention is on the disturbed relationship between the child and the alienated parent, it is appropriate to use 

In addition, almost every writer and researcher in this field considers the indoctrination of a child to fear or dislike a parent to be a form of child psychological abuse. (For example, see the Modified Maltreatment Classification System that is used by the Consortium for Longitudinal Studies of Child Abuse and Neglect.

) Thus, if the focus of clinical attention is on the behavior of the alienating parent, 

 is appropriate. The same term can be applied to both the perpetrator and the victim of child psychological abuse.

Finally, severe cases of parental alienation sometimes constitute a

 or shared psychotic disorder involving the alienating parent and the child. In DSM-5, shared psychotic disorder was incorporated into delusional disorder. The rather cumbersome term is now 

delusional symptoms in partner of individual with delusional disorder

. It is allowed, of course, to use 2 or more terms to identify a mental condition in a given patient or family.

Some legal practitioners and MHPs consider parental alienation to be a controversial concept. Two aspects of parental alienation that have been debated are whether parental alienation should be considered a syndrome and whether it should be included in DSM-5 as a separate diagnosis. However, the vast majority of mental health and legal professionals accept the basic premise of parental alienation. For example, a survey of members of the Association of Family and Conciliation Courts found that 98% of respondents to a questionnaire endorsed the question, “Do you think that some children are manipulated by one parent to irrationally and unjustifiably reject the other parent?”

 In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) published Practice Parameters for Child Custody Evaluation, an “AACAP Official Action.” The practice parameters refer explicitly to and explain “Parental Alienation.”

 In recent years, hundreds of courts in the US and Canada have taken parental alienation into consideration when they address and adjudicate child custody disputes.

Children may follow several paths through battlefield terrain when their parents engage in a high-conflict separation or divorce. The children may avoid much of the conflict by declaring neutrality. Nevertheless, there will be issues that will need to be resolved: the children will likely have some degree of loyalty conflict; they may internalize the stressors associated with the conflict and develop a serious mental disorder; they may experience parentectomy, by becoming enmeshed with one parent and soundly rejecting the other parent because of the false belief that the alienated parent is evil or dangerous.

 Fortunately, DSM-5 includes terminology-

child affected by parental relationship distress, parent-child relational problem, and child psychological abuse

-that help MHPs identify and classify children who experience high-conflict parental separation or divorce.

Clinical personnel and forensic evaluators should consider the differential diagnosis presented here when they assess children of high-conflict divorce. This topic should be addressed in the training of MHPs. Trainees of all mental health disciplines (psychologists, psychiatrists, family therapists, nurse practitioners, social workers, school counselors) should learn how parental divorce affects children and what to do about it. The training of child forensic practitioners––who will conduct child custody evaluations and child maltreatment investigations––should address the theoretical bases and the identification of loyalty conflicts, parental estrangement, and parental alienation.

Dr Bernet is Professor Emeritus in the department of psychiatry at Vanderbilt University School of Medicine in Nashville, TN. He receives occasional royalties from Charles C Thomas Publisher.

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http://www.census.gov/population/www/socdemo/hh-fam/cps2011.html

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Parental Alienation: The Handbook for Mental Health and Legal Professionals

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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

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http://www.afccnet.org/Portals/0/PublicDocuments/2011_may.pdf

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About 25% of children in the US live with only one parent; the fallout from contentious divorces often leaves them susceptible to any number of damaging scenarios.

Children of High-Conflict Divorce Face Many Challenges

Psychiatric Times  December 2004  Vol. XXI  Issue 14

"Arnold" and "Betty" were married for 10 years and had two children. When they divorced, they could not agree on the custody and visitation arrangements for the children. Although they previously loved each other and still had sincere respect for each other, they were gearing up to make extremely angry allegations about each other in court.

When "Calvin" and "Dotty" divorced, Dotty had custody of their 6-year-old daughter and Calvin had regular visitation with her. Rather abruptly after an extended summer visitation with Calvin, the girl said her father was extremely mean to her and refused to go with him for her next scheduled visitation. Dotty accused Calvin of abusing the girl. Calvin accused Dotty of inducing parental alienation syndrome in the child.

These and dozens of similar scenarios come to the attention of both general psychiatrists and child and adolescent psychiatrists every day. There are approximately 1 million divorces in this nation each year. Since many of these divorces involve litigation over custody or visitation, it is common for both clinical psychiatrists and forensic psychiatrists to confront these issues in their work.

Even before parents anticipate their divorce, their child may already be seeing a psychiatrist or other clinician. Once the divorce is imminent, each parent's first impulse is to ask the therapist to take that parent's side in the ensuing custody dispute. The therapist may feel it is obvious that one of the parents should have custody of the child and may readily agree to send a report to the court or to testify. However, that path has many dangers and should be avoided.

Rather than try to influence the outcome of the custody dispute, it is better to simply continue as the child's therapist and help the child cope with the changes in the family. After the parents separate and divorce, it will be particularly important for the therapist to communicate with and have a good relationship with both parents. That is unlikely to occur if the therapist has sided with one of the parents in an angry custody dispute.

The same principle applies if the psychiatrist treats one of the parents. That parent may ask the psychiatrist to testify on their behalf--for example, vouch for that person's superb parenting skills, testify that the patient/parent was abused by the other parent, or testify that the parent's mental illness is not so bad after all. It may happen that the psychiatrist is subpoenaed and must appear in court. If that occurs, it is probably best for psychiatrists to present themselves as "fact witnesses" (meaning that they would simply state what they know about the patient without offering opinions or conclusions) rather than "expert witnesses" (who give opinions, conclusions and recommendations). The goal, of course, is to keep distinct the psychiatrist's role as a clinician and role as a forensic expert. It is almost always preferable to put these hats on separate heads.

If somebody--one or both parents or attorneys, or the judge--wants a psychiatric evaluation that will assist the court in deciding a custody or visitation dispute, the best practice is to arrange for an independent forensic psychiatric evaluation. In this context, independent means that the evaluation is done by a person who is not already the psychiatrist for one of the parties.

A psychiatric custody evaluation is not for everybody--the vast majority of parents who separate and divorce do not need an elaborate and costly evaluation. In most instances, thankfully, parents work these issues out between themselves or with the help of a mediator. 

 indicates the circumstances in which a forensic psychiatric custody evaluation may be indicated.

A forensic custody and visitation evaluation usually consists of psychiatric and/or psychological assessments of the child and both parents. There is no standard method for conducting custody and visitation evaluations. Many psychiatrists, psychologists and legal professionals have published on this topic (e.g., Bernet, 2002; Galatzer-Levy and Kraus, 1999). The American Academy of Child and Adolescent Psychiatry published a practice parameter on child custody evaluations (Herman, 1997). 

 provides the usual components of a psychiatric custody evaluation.

It is almost always assumed that decisions regarding custody and visitation are guided by seeking the best interests of the child. However, parents and attorneys may disagree and argue about exactly what constitutes the best interests of the child in their particular set of circumstances. There is no standard list of factors that should be taken into consideration and what weight should be given to each factor. Not only does each state have its own laws and precedents, but it is likely that evaluators and judges are influenced by their personal values when they make recommendations and hand down decisions in these cases. The factors that many legislatures, courts and mental health care professionals consider important are listed in 

There are many issues that arise in forensic child custody and visitation evaluations that do not occur in a nonforensic clinical practice.

. In conducting a custody evaluation, it usually is best to have access to both parents, any stepparents and all the children. In other circumstances the evaluator might do a one-sided evaluation by interviewing only one parent and the child. For instance, the father might consult a psychiatrist and bring the child for evaluation, but the mother refuses to come to any appointment. In such a case, the evaluator may make limited observations and recommendations, such as commenting on the psychological condition of the father and the child and the nature of the attachment between them. An evaluator who had only seen the father and child would usually not be able to make any recommendations regarding custody because they would have no way of comparing the mother with the father. If a psychiatrist has been asked to conduct a one-sided evaluation, it is important to determine whether the parent who is bringing the child actually has the authority to authorize the evaluation.

. Custody evaluations are not confidential because the written report is distributed to the attorneys and the judge and may eventually become evidence in a public trial. Both children and parents need to be aware how this kind of evaluation differs from an ordinary meeting with a psychiatrist. For instance, one of the parents might bring in a lengthy diary and ask the evaluator to read it. Before accepting this document, practitioners should clearly explain that any material read in conducting the evaluation--including the diary--might eventually be shared with the other side, the judge and even the general public.

. The psychiatrist should be able to assess the child's relative attachment to the two parents. This is important because the child's attachment is an issue that the average judge is not able to determine through ordinary testimony in court. The psychiatrist has access to many sources of data that relate to the child's attachment, including information collected from parents and stepparents and observing the child together with each parent. In interviewing the child, the psychiatrist may determine the child's perception of the parents through direct questions ("Who helps you best with your homework, your Mom or your Dad?"), indirect questions ("Tell me the things you like and the things you don't like about your Mom.") and projective questions ("Let's make up a story about a baby bird that lives in a nest with a mommy bird and a daddy bird."). The child's attachment to the parents can also be assessed through psychological tests such as the Family Relations Test (FRT), the Bricklin Perceptual Scales (BPS) and the Perception-of-Relationships Test (PORT) (Bricklin, 1995).

 Mental health care professionals have noticed that children of divorce may greatly favor one parent over the other and may greatly resist visiting the nonresidential parent. There are several possible explanations for the child's active rejection of visitation, including: abuse or neglect by one parent, so it is natural that the child would not want to visit that household; purposeful or accidental indoctrination of the child to favor one parent and reject the other parent; and/or the child is caught between battling parents and the tension in the child is resolved by believing that they love one parent and hate the other. Gardner (1998) used the term "parental alienation syndrome" for some of these cases, specifically, those in which one parent has consciously or unconsciously induced the child to reject the other parent.

. In joint legal custody, both parents have equal rights and responsibilities regarding issues such as the child's education, medical care and religious upbringing. Joint legal custody works if the parents are able to communicate with each other and are willing to take each other's opinions into consideration. The laws of some states strongly favor joint legal custody; the laws of a few states limit it by requiring consent of both parents before joint custody can be ordered. On the other hand, some states have laws that favor or require parenting plans. Both concepts--

--envision that children of divorce should be nurtured and raised by both parents. Although the operational outcomes may look the same, these are different concepts. Joint legal custody emphasizes the legal end result (i.e., the judge orders the parents to share certain rights and responsibilities). The concept of parenting plans emphasizes the process by which divorcing parents sit down and work out an agreement regarding important aspects of their child's life. In some states that require parenting plans, the terms custody and visitation are no longer used, but the laws simply refer to each person's "parenting time."

Divorce is common, so it is important to find ways to minimize the psychological trauma that is experienced by children of divorced parents. Ideally, divorcing parents would not fight so much over the children, in front of the children and through the children. When disputes do arise regarding custody and visitation, mental health care professionals can inform and assist judges by performing competent custody evaluations. These evaluations should be conducted in a systematic and unbiased manner, should consider the critical factors that are relevant to the court, and should result in recommendations that promote the best interests of the children. Almost always, the goal is for the children to have strong, healthy relationships with both parents. It is usually possible to make recommendations regarding custody, parenting arrangements, and forms of counseling and therapy that will be helpful to the family members.

Dr. Bernet is professor of psychiatry and director of the division of forensic psychiatry at Vanderbilt University School of Medicine.

Bernet W (2002), Child custody evaluations. Child Adolesc Psychiatr Clin N Am 11(4):781-804.

Bricklin B (1995), The Custody Evaluation Handbook: Research-Based Solutions and Applications. New York: Brunner/Mazel.

Galatzer-Levy RM, Kraus L, eds. (1999), The Scientific Basis of Child Custody Decisions. New York: Wiley.

Gardner RA (1998), The Parental Alienation Syndrome: A Guide for Mental Health and Legal Professionals, 2nd ed. Cresskill, N.J.: Creative Therapeutics.

Herman SP (1997), Practice parameters for child custody evaluation. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 36(10 suppl):57S-68S.

When disputes arise concerning custody and visitation, mental health care professionals can inform and assist judges by performing competent custody evaluations.

William Bernet, MD

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