William Bernet, MD

Based on current research, over 22 million adults have been targets of parental alienation in the United States. An estimated 10 million adults have experienced what they perceive to be severe alienation from their children.

 Even so, the clinical problem of parental alienation has been underreported and underappreciated in the public at large. It is a silent epidemic that must be acknowledged.

Parental alienation is a pathological phenomenon

 in which a child is convinced by one parent that his or her other parent is unworthy and dangerous and should be rejected.

 The child is convinced through a variety of tactics and maneuvers by the alienating/offending parent. If these maneuvers are successful, the child develops the mental condition of parental alienation. This 

alienation can be mild, moderate, or severe in intensity.

 In severe cases, the relationship with the rejected/targeted parent is completely severed due to the child’s mental condition. Even in mild and moderate alienation, there is damaging disruption in the parent-child relationship.

The rejection of a parent due to parental alienation is a devastating and tragic event for the child. Research clearly shows that children need both of their parents to be actively involved in their lives. The rejection of a parent is associated with many long-term, negative consequences for the child. Depression, anxiety, poor self-esteem, lack of trust in relationships, and self-defeating behavior are just some of the deleterious consequences.

Causing parental alienation in a child is on par with physical and sexual abuse. It is 

considered child psychological abuse and is subsumed in DSM-5 (V995.51).

 Parental alienation is real, definable, and toxic. In severe cases, it is so malignant that it can undermine a child’s psychological development. It is not hyperbole to say it can be catastrophic.

A case of parental alienation needs to be investigated rigorously by the state’s protection agency, similar to what is done in cases of suspected physical or sexual abuse. To do otherwise is to miss the central point—that causing parental alienation is as toxic and damaging as these other forms of abuse.

Cases of parental alienation must be taken seriously by all professionals involved with the family. For example, 

attorneys are in a unique position to make a major difference in diagnosis and treatment

Attorneys for alienating parents must forcefully communicate to their clients that their alienating behavior is toxic and must stop immediately. Zealous representation of a client is not applicable in these alienation cases. In fact, confrontation of the alienating parent must be a top priority for the attorney, no matter how difficult or uncomfortable it may be. Short of that, attorneys will be condoning and enabling the alienation of the child.

Attorneys for alienated children—guardians ad litem—must take active steps to make sure the alienating parents stop their behavior while also assuring that the children get therapy to reverse their alienation.

Attorneys for the rejected or targeted parents must assure that reunification therapy is pursued with diligence and positive expectation so that the child’s alienation is corrected as quickly as possible.

In cases of physical and sexual abuse, the child is removed from the offending parent. That decision is not controversial. Similarly, a child who totally rejects the targeted parent due to parental alienation must be removed from the offending parent, at least temporarily. The removal of a child has been shown to be warranted and effective. In other words, removal of the child is the best option available.

Other professionals involved in a case of parental alienation—such as mediators, counselors, pediatricians, family physicians, teachers, social workers, and others—must play an attentive and corrective role in the process. Allowing alienation to continue unchecked is highly destructive to the child.

One final note: Mild parental alienation is much easier to correct than moderate or severe alienation. This principle must be kept in mind by all professionals who have contact with the child and the parents.

Parental alienation is a psychiatric emergency and interventions should be put in place as quickly as possible because it is as toxic and pernicious as physical and sexual abuse.

is a clinical and forensic psychologist in private practice in Birmingham, Alabama. He can be reached at 

is professor emeritus in the department of psychiatry at Vanderbilt University School of Medicine in Nashville, Tennessee.

1. Harman JJ, Leder-Elder S, Biringen Z. 

Prevalence of adults who are the targets of parental alienating behaviors and their impact.

2. Blotcky AD. Parental alienation unlocked. 

https://www.psychologytoday.com/us/blog/parental-alienation-unlocked/202105/how-recognize-parental-alienation

3. Are there different degrees of parental alienation? 

https://psychlaw.net/are-there-different-degrees-of-parental-alienation/

[Parental alienation, child psychological abuse and DSM-5].

5. Blotcky AD. Winning parental alienation cases: a roadmap for family lawyers. 

https://familylawyermagazine.com/articles/winning-parental-alienation-cases/

Articles

Parental alienation is devastating and toxic for the child.

A Silent Epidemic: Parental Alienation in a Child is on Par With Physical and Sexual Abuse

Parental alienation is a mental state in which a child—usually one whose parents are engaged in a high-conflict separation or divorce—allies strongly with 1 parent (the offending, but favored parent) and rejects a relationship with the other parent (the alienated parent) without legitimate reason.

 This condition occurs in the context of a maladaptive family dynamic involving at least 3 individuals: the alienating parent, who intentionally and purposefully manipulates the child to reject the other parent; the child, who experiences parental alienation; and the rejected, alienated parent. A variety of tactics and maneuvers are used by alienating parents to achieve their goal, ranging from bad-mouthing and disruption of visitation time to false allegations of abuse and criminal charges.

Research indicates that parental alienation is present in 11% to 15% of divorce cases. It has also been found that 20% to 25% of parents engage in alienating behavior as long as 6 years after divorce. Alienating parents can be either mothers or fathers.

Parental alienation is poorly understood by many mental health professionals, not to mention attorneys, guardians ad litem, and judges. It is a confusing and vexing problem because many of its features and dynamics are hidden behind the scenes, ferociously denied, and counterintuitive from what one would expect.

Because of its counterintuitive nature, many false assumptions are made by professionals who are involved in cases of parental alienation. Much can be learned from recognizing and understanding these false assumptions, both in terms of diagnosis and treatment. This is especially important since early diagnosis and intervention are predictive of better outcomes for the child.

What follows is a description of many false assumptions that are made routinely in alienation cases. Richard Warshak, PhD,

 have written about fallacies and fundamental attribution error in these cases, and 1 of us has written about misinformation in alienation theory.

 The following concepts serve as the foundation for our fuller understanding of the role of false assumptions in parental alienation cases.

. When we think intuitively, our decisions tend to feel “right,” regardless of whether they are or not. To accurately understand parental alienation, a clinician must have an advanced understanding of the typical dynamics in these cases. Relying on intuition can lead to major mistakes right from the get-go. For example, just because a parent seems healthy or believable, does not make it so.

 It is a common fallacy that both parents are equally responsible for high conflict during a separation or divorce. It is always important to consider the possibility that 1 parent may be the aggressor, while the other parent is the victim. In most cases, both parents are not equally responsible for the ongoing conflict. It can be a major blunder to assume so.

Outward demeanors are indicative of truth. 

Alienating parents typically present as calm, verbal, and convincing. In contrast, alienated or rejected parents usually present as agitated, angry, and afraid; they are victims.

 In many cases, the alienating parent appears to be healthier and more believable—but that is a manipulation and a distraction from their intentionally alienating behavior. The rejected parent appears more psychologically disturbed, and so it is assumed that he or she is the one engaging in problematic behavior. Outward demeanors can be quite deceiving and must be considered cautiously in diagnostic decision-making.

 The intrapsychic defense of projection is often seen in cases of alienation. In essence, the alienating parent accuses the rejected parent of being the aggressor. If you fall for the offending parent’s distortion and misperception, poor diagnostic decisions will be made, and the case can quickly go haywire. Projection can lead to the wrong person being identified as the alienating parent.

Children’s denials and “truths” are gospel. 

Simply believing a child’s denial of alienation by a parent can be a recipe for disaster. Children are not usually aware of the maneuvers employed by the offending parent to turn them against the rejected parent. Plus, such children are frequently enmeshed with the offending parent and will defend that parent to the bitter end. Independent thinker phenomenon is often seen, whereby alienated children assert that their rejection of a parent is solely their idea and decision—not due to the offending parent’s influence. So just listening to a child’s denials can be a serious error that will undermine good decision-making in a case. There is a body of literature that tells us that children and teenagers do not know what is in their own best interest.

 This is especially true when they are the unwitting participants in alienation by a parent.

Alienation does not involve total rejection. 

Children naturally want to love both of their parents without interruption or impediment. A child does not totally reject a parent unless there is an alienating influence in the mix. This is true even for abusive parents. Indeed, children who have been verbally, physically, or sexually abused by a parent experience profound ambivalence because they still love the parent. They are upset and in turmoil by the fact that they cannot have a continued relationship despite the well-established abuse.

 As such, total rejection by a child is much more indicative of alienation. And to use a child’s rejection of a parent as corroboration or validation of the rejected parent’s badness can be flat-out wrong.

Estrangement and alienation are the same thing

. When children resist contact with a parent for legitimate reasons, this is called estrangement, not alienation. Estrangement is very different than alienation; it is important not to confuse them. For example, it would make sense for a child to be estranged from a parent if that parent engages in substance abuse during the child’s visits. Estrangement can be corrected if the parent is willing to make the necessary changes. Alienation, in contrast, tends to be camouflaged, insidious, and recalcitrant.

Alienating behavior is relatively harmless and will not impact the child’s long-term mental health. 

Engaging persistently in alienating behavior is child psychological abuse. It is a mistake to deny it or rationalize it away. According to DSM-5, child psychological abuse is nonaccidental verbal or symbolic acts by a child’s parent or caregiver that result, or have reasonable potential to result, in significant psychological harm to the child. In light of this, parental alienation is considered a psychiatric emergency, especially in moderate to severe cases. Minimizing the severity of the problem does a terrible disservice to the child. Unfortunately, it enables the abusive behavior to continue unchecked.

Since persistent alienating behavior constitutes child psychological abuse, the top priority should be to protect the child from further abuse. Until this is accomplished, no form of psychotherapy will be effective. In other words, protecting the child from further abuse must be the first step before psychotherapy of any kind is started. This mistake is common. In many court cases, it is erroneously assumed that psychotherapy can fix the problem when, in fact, little or nothing can be accomplished because the alienating behavior is ongoing.

Removing the child from the home is harmful. 

There is no credible evidence that removing an alienated child from the home of the offending parent causes a significant risk of psychological harm. The opposite is true. In almost all severe and some moderate cases of parental alienation, the risks of not protecting the child are far greater than the risks of protecting the child. Removal of the child from the offending parent’s care may be necessary, at least temporarily. Children and teenagers may fuss about it, but they will comply with, and benefit from, such an intervention.

Reunification therapy can start at any time and is easy. 

Reunification therapy cannot be successful unless the alienating behavior by the offending parent is stopped. Otherwise, progress will be impeded by the continued alienation, and everyone will be perplexed as to why significant gains are not being made. The reunification therapy itself may not be the issue at all. Its progress may be stalled by the omnipresence of alienating behavior by the 1 parent.

Reunification therapy is difficult and complex. It requires a knowledgeable and seasoned therapist. The therapist must be directive and assertive, not passive, lethargic, or naïve. An inexperienced or unknowledgeable therapist can make things worse. Such therapists can begin to feel overwhelmed, frustrated, and disappointed. A negative expectation for improvement can take over and become a complicating and limiting factor.

There are no interventions for alienation situations. 

Active interventions for parental alienation are available and they do work. The interventions must be aimed at (1) stopping the alienation by the offending parent, (2) clarifying and resolving the alienation in the child, and (3) repairing the child-rejected parent relationship. More traditional psychotherapies that do not target these specific areas are doomed to fail. The right therapy at the right time is critical.

Children’s school performance is the best guide. 

Just because a child is doing well in school or other activities does not mean they are doing well psychologically or emotionally. This is a common misconception. Focusing on school grades can miss the larger issues at hand.

The truly guilty party will confess eventually. 

No matter how much pressure is applied, the severely alienating parent will never admit to their intentionally harmful behavior. There is never a 

 moment. Do not be misguided or misled by this parent’s persistent denials, as they are disingenuous and untruthful.

Alienating behavior always results in alienation. 

Not all children who have an alienating parent become alienated. However, even if the child is not alienated does not mean the parent’s alienating behavior is harmless. The negative consequences of alienating behavior tend to be cumulative over time. In addition, the child might become alienated if the damaging behavior does not cease.

All cases of parental alienation are fraught with complexities and difficulties. None are easy or straightforward. False assumptions are pitfalls to be understood and avoided in these cases. Missteps anywhere along the way can result in misdiagnosis, miscalculations, and ill-fated interventions.

Early diagnosis and intervention are important in alienation cases. The offending parent’s behavior must be stopped as soon as possible. All professionals—from mental health experts to attorneys to judges—must understand this principle. It is unacceptable to turn a blind eye. By doing so, complicity with the offending parent will be established and the child’s mental health will be rendered unimportant.

Professionals want to help children and their parents when they are embroiled in high conflict and escalating acrimony. But falling for any of these false assumptions can take a case down a dangerous path. And, in every instance, a child’s psychological wellbeing and mental health are at stake.

is a clinical and forensic psychologist in private practice in Birmingham, Alabama. He is also a clinical associate professor in the Department of Psychology, University of Alabama at Birmingham. He is a member of the Parental Alienation Study Group.

is professor emeritus, Department of Psychiatry, Vanderbilt University School of Medicine in Nashville, Tennessee. He was the founder and first president of the Parental Alienation Study Group.

. Springfield, Illinois: Charles C Thomas Publisher Ltd. 2020.

Current controversies regarding parental alienation syndrome

3. Miller SG. Clinical reasoning and decision-making in cases of child alignment: diagnostic and therapeutic issues. In Baker AJL, Sauber, SR, eds., 

Working with Alienated Children and Families: A Clinical Guidebook

. New York, New York: Routledge. 2013:8-46.

Recurrent misinformation regarding parental alienation theory

Payoffs and pitfalls of listening to children

6. Baker AJL, Creegan A, Quinones A, et al. 

Foster children’s views of their birth parents: a review of the literature

Ten parental alienation fallacies that compromise decisions in court and in therapy

Here’s how to avoid false assumptions in cases of parental alienation to ensure better outcomes for children.

Avoiding the Pitfalls of False Assumptions in Parental Alienation Cases

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.

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.

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.

William Bernet, MD

Articles

A Silent Epidemic: Parental Alienation in a Child is on Par With Physical and Sexual Abuse

Avoiding the Pitfalls of False Assumptions in Parental Alienation Cases

Treatment and Prevention of Parental Alienation

Children of High-Conflict Divorce Face Many Challenges

The Psychiatrist's Role in Divorce Custody Battles