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Mental health experts and clinicians anticipated an increase in self-harm and overdoses among children and adolescents as a result of the stresses associated with the COVID-19 pandemic. Now, a new study shows the opposite may be true.

, professor at the University of Toronto, and colleagues compared the risk of self-harm or overdose among teenagers and young adults living in the Ontario province in Canada during the pandemic with the 2 years preceding the pandemic via a population-based cohort study of teenagers and young adults who were born in Ontario between 1990 and 2006. Ray et al compared data for these youth between April 1, 2020 to June 30, 2021, to March 1, 2018 to February 28, 2020, looking at emergency department encounters and hospitalizations for either self-harm or drug overdose. Secondary measures included self-harm, overdose, or all-cause mortality.

A total of 1,690,733 teenagers and young adults were included in the cohort. A little less than half of the cohort were female (48.7%); the median age was 17.7 years at the start of follow-up. With 4,110,903 person-years of follow-up, investigators found that 6224 participants had experienced a primary outcome of self-harm or overdose during the pandemic (39.7 per 10,000 person-years) vs 12,970 (51.0 per 10,000 person-years) prepandemic, with a hazard ratio (HR) of 0.78 (95% CI, 0.75-0.80). Furthermore, the investigators found that the risk of self-harm, overdose, or death was lower during the pandemic than in the preceding period (HR, 0.78; 95% CI, 0.76-0.81). This was not true of all-cause of mortality (HR, 0.95; 95% CI, 0.86-1.05).

Ray et al noted a limitation of the study was that less life-threatening cases may have been missed as a result of the design. Similarly, suicides that occurred outside of the hospital setting were also not captured.

“The robust nature of the current findings suggests that, at least up to the middle of 2021, the COVID-19 pandemic has not led to an excess of intentional injury among adolescents and young adults,” Ray et al concluded. “It should be determined if this phenomenon continued within subsequent waves of the pandemic, or if unrealized self-harm or overdose events have occurred outside of a hospital setting.”

1. Ray J, Austin P, Aflaki K, Guttmann A, Park A.

 Comparison of self-harm or overdose among adolescents and young adults before vs during the COVID-19 pandemic in Ontario

New research finds evidence that contradicts previous hypotheses.

Did Rates of Self-Harm and Overdose in Youth Actually Decrease During the Pandemic?

Helicopter parenting is understudied, especially in parents of adolescents with attention-deficit/hyperactivity disorder (ADHD). At the American Professional Society of ADHD and Related Disorders (APSARD) 2022 virtual conference, Brooke Molina, PhD, of the University of Pittsburgh and her colleagues presented a poster detailing their findings on the psychometric properties of helicopter parenting in adolescents with ADHD.

“Most people have heard of the over-involved and controlling helicopter parent before, but this is a relatively new field of study,” Molina stated.

Helicopter parenting was established as a distinct form of parental control, separate from behavioral or psychological, in 2012.

 Molina shared that most research on helicopter parenting was conducted with college-aged participants, leaving a gap in knowledge about effects on adolescents—a gap she and her colleagues hoped to fill.

Molina and colleagues evaluated responses from 341 parents and 333 adolescents aged 13 to 18 with ADHD enrolled in a study on efficacy of primary care physician training on stimulant diversion prevention, in the hopes of examining the factor structure of helicopter parenting in adolescents ADHD.

Assessing statements included items like:

-“I make important decisions for my teen (eg, which classes to take, what activities to do, if and where they work).”

-“My parents take over when I have problems with friends.”

-“I manage my teen’s money for them.”

-“My parents solve any crisis or problem I might have.”

-“My parents make plans for me to hang out with friends.”

A 2-component solution best fit their data. The first parenting type, labeled “intervention helicopter parenting,” encapsulated how likely parents were to intervene when their child has a problem or a decision to make. The second parenting type, “monitoring/short-term planning helicopter parenting,” characterizes how likely parents were to provide ongoing oversight or make plans for their child.

Higher averages of both types together were found in single parent homes. Higher averages of intervention helicopter parenting were found in families of a marginalized racial or ethnic identity (t(89.8)=2.73, p <.01), or if the child was assigned male sex at birth (t(157)=2.79, p <.01), and was positively associated with parental warmth (r =.18, p <.01). Monitoring/short-term planning helicopter parenting was higher amongst parents who had younger adolescents.

Both helicopter parenting types were associated with higher parental knowledge of the child’s activities and correlated with positive parenting.

Molina concluded that more research is needed to determine if these behaviors are adaptive.

Black hawk down?: Establishing helicopter parenting as a distinct construct from other forms of parental control during emerging adulthood.

Helicopter parenting in teens with ADHD: What are the types and how do they affect children?  

Helicopter Parenting & Adolescents With ADHD: Associations and Conclusions

“ADHD in preschool children is a valid and reliable condition,” Ann Childress, MD, told attendees of the 

American Professional Society of ADHD and Related Disorders 2022 Conference

Research data support this notion, explained Childress, president of the Center for Psychiatry and Behavioral Medicine, Inc, and adjunct associate professor at the University of Nevada Las Vegas School of Medicine and Touro University Nevada College of Osteopathic Medicine. According to the 

2014 National Survey of Diagnosis and Treatment of ADHD and Tourette's

, 30% of children are diagnosed with ADHD before the age of 6, and 16% are diagnosed at age 4 or younger,

 adding that impairment can be great for these patients. For example, an epidemiological review of preschoolers diagnosed with ADHD found more than 40% and about 16% had been suspended and expelled, respectfully, from school or daycare.

 In comparison, less than 1% of young children without ADHD were suspended. Childress noted this may be due to the higher levels of hyperactive impulsivity found in younger patients than older children. “I had a little girl who wanted to use the monkey bars and another little boy wouldn't get off so she decided she was just going to give him a good kick in his private parts then he would get off the monkey bars,” Childress shared. Their actions also pose safety risks, she added. “These are kids that are running out in traffic. They're jumping off of things and breaking bones. They're doing things that are dangerous, and they really need treatment for their safety.”

In addition, 18% of children aged 2 to 5 have been prescribed medication for ADHD, 

 “That's a lot of kids who are on medicines,” Childress said. “And guess what, there aren't a lot of medicines [nor] a lot of data… There aren't a lot of medicines approved for ADHD in this young age group.”

To better understand this conundrum, Childress reviewed efficacy and safety data for methylphenidate, atomoxetine, amphetamine, lisdexamfetamine, and methylphenidate modified release formulation. Overall, studies showed some improvements for the study medications, but those improvements were often small. In addition, medications were associated with adverse events; the events varied based on the agent and included insomnia, gastrointestinal issues, irritability, sedation, and repetitive behaviors and thoughts. She also noted not all of these medications have been approved for the youngest patients.

The good news is that there is evidence for the efficacy of nonpharmacological interventions for preschoolers with ADHD, Childress reported. “More than 77% of the 2- to 3- year-olds had—or their family had—received some behavioral treatment, and more than half of the 4- to 5-year-olds [had received behavioral treatment],” she said. The 

series were among the programs she noted that have demonstrated efficacy. Furthermore, she spoke highly of parent training models that foster the implementation of positive reinforcement to promote positive behaviors; ignoring low-level provocative behaviors; and responding in a clear, consistent, and safe manner to unacceptable behaviors.

Childress concluded with a few take-home messages for attendees: “ADHD does occur in young children; it can be highly impairing, and it's not all that uncommon…You have to carefully consider both developmental aspects and comorbidity when you're establishing a diagnosis, and the medication efficacy and tolerability profile may not look as good in the little guys as it does in older children.”

1. Visser SN, Zablotsky B, Holbrook JR, et al. 

The epidemiology and diagnostic issues in preschool attention-deficit/hyperactivity disorder

3. Danielson ML, Bitsko RH, Ghandour RM, et al. 

Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents, 2016

Ann Childress, MD, shares insights into ADHD in very young children at the 2022 APSARD Conference. 

What About the Little Guys: ADHD in Preschool

Representative Jason Ortitay (R-Washington/Allegheny) introduced legislation, 



“Data, especially in recent months, has shown that social media has a negative effect on young people and contributes to 

increased body dissatisfaction and eating disorders

,” Ortitay said. “With the growing use of social media, we need to take steps to bring attention to this issue. Many parents may not recognize the warning signs of an eating disorder. I’m hopeful this legislation will give parents the information they need and also help them recognize negative body image messages in society today.” 

Under 

, which was introduced in December, schools would be required to provide parents and guardians of students in grades 6 through 12 with information regarding eating disorders annually. Additionally, an eating disorder taskforce would be created within the Pennsylvania Department of Education that would develop guidelines for the information provided by the schools.

Pennsylvania legislators worked with eating disorder survivors to develop House Bill 2158, individuals like Emily Rosenberg.

“I have been passionately working with Pennsylvania legislators on this bill over the years to raise awareness of the serious nature of eating disorders. My hope is for parents and guardians to become educated on eating disorders to help with early identification and prevent long-term suffering,” said Rosenberg. “As a survivor, I use my voice and lived experience to educate and bring hope to those struggling by sharing the message that recovery is possible. Eating disorders are not a choice and nobody deserves a life with one. I did not give up on my recovery and I will not give up the fight to pass this needed legislation.”

Senator Steve Santarsiero (D-Bucks) is sponsoring a similar bill in the Senate.

 “Eating disorders exist across the broad spectrum of age, race, ethnicity, gender, and socioeconomics affecting more than 30 million Americans. As we see younger children expressing dissatisfaction with their bodies and 

, it’s important to equip parents early with up-to-date information and local resources on this condition,” said Santarsiero.

Martha Watson, a Pennsylvania resident and advocate, lost her daughter to an eating disorder. “She was diagnosed at the age of 11, but sadly the eating disorder was already entrenched and though we fought a valiant 10-year battle, we lost her. I don’t want other families to have the same outcome, so I have become a passionate advocate for raising awareness and understanding about eating disorders,” said Watson. “By providing parents and schools with tools to identify an eating disorder early and resources to help intervene, this bill will definitely save lives.” 

The founder and CEO of the National Alliance for Eating Disorders, Johanna Kandel, also supports both bills. “Eating disorders wreak havoc on Pennsylvania families, the local economy, and the already-overburdened medical system. With this legislation, parents and school leadership will be better equipped to recognize when eating disorders present themselves and to refer youth for appropriate care. Not one more life should be stolen by this insidious disease. The National Alliance for Eating Disorders strongly urges the Pennsylvania Legislature to swiftly pass House Bill 2158 and Senate Bill 988 because students deserve better.” 

House Bill 2158 has been referred to the House Education Committee for review. 

1. Ortitay proposal to require schools to raise awareness about eating disorders. News release. December 14, 2021. Accessed January 6, 2022. 

http://www.reportitay.com/News/22981/Latest-News/Ortitay-Proposal-to-Require-Schools-to-Raise-Awareness-about-Eating-Disorders-

3. Senator Santarsiero introduces legislation to help young Pennsylvanians and their families combat eating disorders. News release. December 15, 2021. Accessed January 6, 2022. 

https://www.senatorstevesantarsiero.com/senator-santarsiero-introduces-legislation-to-help-young-pennsylvanians-and-their-families-combat-eating-disorders/

Representative Jason Ortitay and Senator Steve Santarsiero have introduced legislation to help increase awareness of eating disorders in children. 

Pennsylvania Legislators Push to Increase Awareness of Eating Disorders in Children

can have a lasting impact on behavioral problems for children at age 10-11 years, according to new research.

In the study, Ariel A. Williamson, PhD, and colleagues, identified whether distinct sleep problem trajectories from infancy through middle childhood were linked to multiple aspects of child well-being at ages 10-11 years.

Williamson et al used data from the first 6 waves of the Longitudinal Study of Australian Children—Birth Cohort, which involved 5107 children recruited at birth.

Each caregiver included in the study reported on sleep problems for the children at each time point; the investigator indexed child well-being outcomes at ages 10-11 years using a combination of caregiver-reported, teacher-reported, and child-completed tasks. The outcomes included emotional and behavioral functioning such as internalizing and externalizing symptoms and self-control, health-related quality of life, cognitive skills, and academic achievement.

The authors identified 5 distinct sleep problem trajectories over time using a latent class analysis,. The problems were persistent sleep problems through middle childhood (7.7% of the sample), limited infant or preschool sleep problems (9.0%), increased middle childhood sleep problems (17.0%), mild sleep problems over time (14.4%), and no sleep problems (51.9%).

The results showed children with persistent sleep problems had the greatest impairments across the different outcomes, other than cognitive skills (perceptual reasoning), with moderate to large effect sizes.

On the other hand, children with increased middle childhood sleep problems also experienced greater internalizing and externalizing symptoms with a worse quality of life.However, there were few academic impairments in this subgroup of patients.

In addition, the participants with limited infant or preschool sleep problems and mild increases over time trajectories also showed internalizing concerns and worse caregiver-reported quality of life. These effects were smaller than the other sleep trajectories.

“The linkages between sleep problems and negative child outcomes across domains underscore the importance of early identification and targeted intervention to address sleep problems and promote child well-being,” the authors wrote.

“[F]ew studies have examined the continuity of sleep concerns and their association with developmental outcomes from infancy, when behavioral sleep problems are the most prevalent,” Williamson and colleagues noted. “More research is needed that assesses the impact of sleep problems from infancy through middle childhood, particularly as the first 10–11 years of life is a period of important child development, with the acquisition of foundational psychosocial and cognitive/academic skills and the transition to a formal school setting.”

A version of this article was originally published by our sister publication 

1. Williamson AA, Mindell JA, Hiscock H, Quach J. 

Longitudinal sleep problem trajectories are associated with multiple impairments in child well-being

Researchers highlight the need for early interventions.

Study Explores Link Between Early Sleep Disturbances and Later Behavioral Problems 

A study found that racial and ethnic minority children experienced increased rates of anxiety, depression, and social risks during the first year of the COVID-19 pandemic.

The study, led by researchers from Boston Medical Center (BMC),

 included 168 caregivers of racially and ethnically diverse children between ages 5 and 11 who had completed screenings for behavioral and emotional risks as part of a well visit at an urban, safety-net pediatric primary care practice before the onset of the pandemic. The pre-pandemic visits occurred between September 2019 and February 2020, and participants were reassessed mid-pandemic between August 2020 and January 2021.

 Of the participating caregivers, 54% identified as non-Hispanic Black and 29% as Hispanic, and 22% did not speak English. Study visits were conducted in 3 languages: English (79%), Haitian Creole (16%), and Spanish (5%). The Pediatric Symptom Checklist (PSC) was used to measure behavioral and emotional symptoms of anxiety and depression, including attention and internalization and externalization of symptoms. Results showed that the rate of both depression and anxiety rose from 5% pre-pandemic to 18% mid-pandemic.

According to the researchers, the aim of the study was to compare negative symptoms of mental health among urban, racially and ethnically diverse children before and during the pandemic.

 This study is also among the first to include both pre- and mid-pandemic data in research involving urban children.

 “Our fear is that the pandemic has led to a 

 for both caregivers and children following the incredible stressors that COVID-19 has put on families,” said Andrea Spencer, MD, lead author of the study, in a press release. “We specifically looked at our urban and diverse patient population who are already at higher psychosocial risk and also most susceptible to the impacts of the pandemic, therefore raising particular concern for their mental health.”

To this end, the study also analyzed the children and caregivers’ social risk and unmet social needs—including food and housing insecurity, unemployment, difficulty paying bills, and difficulty with dependent care and transportation—pre- and mid-pandemic using BMC’s THRIVE screening tool.

 Higher social risks were reported, with all THRIVE items except for difficulty with transportation being ranked as significantly more prevalent mid-pandemic compared to pre-pandemic. For example, 50% of participants reported food insecurity mid-pandemic compared to 16% pre-pandemic.

“These findings point to the critical need for public health efforts to mitigate the psychosocial effects of the pandemic on racial and ethnic minority children and communities while searching for solutions to support the increased demand,” said Spencer, who is also an adult, child, and adolescent psychiatrist at BMC and an assistant professor of psychiatry at Boston University School of Medicine, in a press release. “We need new or expanded community-based, school-based, family-based, and trauma-informed treatment and prevention programs to reach the most affected families.”

New study finds COVID-19 pandemic exacerbated anxiety and depression in racial and ethnic minority children

. News Release. Boston Medical Center. December 8, 2021. Accessed December 13, 2021.

2. Spencer AE, Oblath R, Dayal R, et al. 

Changes in psychosocial functioning among urban, school-age children during the COVID-19 pandemic

Research also shows increased prevalence of social risks and unmet social needs.

Higher Rates of Anxiety, Depression Reported Among Minority Children

A survey recently revealed that only 50% of parents who attempted to obtain mental health services for their children during the COVID-19 pandemic were successful in doing so.

The survey, sponsored by pediatric teletherapy provider DotCom Therapy,

 was conducted in late September 2021 to gauge the impact of the pandemic on mental health among children, as well as the impact of the reentry to school in Fall 2021 following a year of lockdown and online learning. The survey gathered responses from 1109 parents and guardians in the United States who have at least 1 child under 18.

 The survey results highlighted the disjointed mental health care system and its impact on child mental health.

Respondents reported that lack of access and resources was the biggest barrier to obtaining mental health care for their children, with only 35% stating that they believe their school systems currently provide adequate mental health support and 78% stating that they believe educational and health care systems need to provide more and better mental health support for children. Additionally, 39% of respondents reported a shortage of therapists as a significant barrier to adequate mental health services; 38% cited a lack of resources to help them find the right therapist for their child; and 62% said they were unaware of the full extent of mental health services offered by their school systems.

 Further, one-third of parents said they did not attempt to access mental health services for their children, even when they were aware of their children’s mental health challenges, such as social and general anxiety and panic attacks.

According to the survey, parents are receptive to pediatric therapy.

 “Parents want to help their children, but many are overwhelmed and don’t know where to turn as mental health resources have diminished across educational and health care institutions,” said Rachel Mack Robinson, MS, founder and president of DotCom Therapy, in a press release. “Fortunately, pediatric teletherapy provides an immediate and effective solution to the ongoing therapist crisis that benefits patients and families while providing much-needed support and resources to schools, hospitals, and clinics.”

These results are significant, as it is estimated that the full extent of the pandemic’s impact on youth is only just beginning to develop.

 According to the Centers for Disease Control and Prevention (CDC), nearly 1 in 5 children have a mental, behavioral, or emotional disorder (ie, attention-deficit/hyperactivity disorder [ADHD], depression, anxiety, disruptive behavior disorder, or Tourette syndrome), but only 20% of these children are currently receiving care from a specialized mental health provider.

“Today’s stressed youth—still reeling from the pandemic—could become the next Lost Generation if we don’t get them the mental health support they need,” Robinson said in a press release. “The pandemic placed our society in a state of collective trauma and deprived children of central development opportunities, which could do irreversible harm to their wellbeing. Many children returning to school this fall are experiencing lingering after-effects of isolation, and parents want to alleviate those issues, but cannot access the help they need.”

New independent survey reveals that only 50% of parents who tried to access mental health resources for a child during the pandemic were able to

. November 16, 2021. Accessed December 2, 2021.

Back-to-school 2021: the mental health and wellbeing on children in America research brief

Teens in America: how the COVID-19 pandemic is shaping the next generation

. November 12, 2021. Accessed December 8, 2021.

4. Centers for Disease Control and Prevention. 

Improving access to children’s mental health care

Centers for Disease Control and Prevention

Survey respondents cited lack of access to services and therapists as a significant barrier to children’s mental health care.

Study Finds Parents Are Frustrated by Lack of Mental Health Services

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

The December holidays this year may be more normal than those of 2020, but the psychological stressors of the 

 are still in play. For many families, the pressure to get back to normal may itself be a stressor. For example, many parents are wrestling with whether to share a meal with unvaccinated family members or to expose vulnerable older adults, friends, and family to unvaccinated young children.

Furthermore, holidays can be difficult for children and teenagers with depression, anxiety, and other disorders, even during the best of times. Thanks to the many issues related to the pandemic, these have not been the best of times. The American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association recently declared 

a national emergency in child and adolescent mental health 

due to the skyrocketing incidence of mental illness, particularly among teenagers, during the pandemic.

Also more pronounced during this holiday season are experiences of loss and grief. According to findings from a recent study, approximately 140,000 children have lost a parent or grandparent caregiver due to the COVID-19 virus, with losses concentrated among children of color.

All these factors may make this year’s holiday season difficult for young patients and their families. That makes this a good time to redouble efforts on behalf of pediatric patients.

A basic step is simply to use the holidays as a reason to check in with patients and caregivers as follows: “So the holiday season is coming up. How are you feeling about that?” More probing questions can follow, depending on the response.

Because family support is a strong predictor of child resilience,

 checking in with caregivers is important. Psychiatrists can listen to caregivers’ concerns about the upcoming holidays and their child’s emotional state. Sometimes being heard may be sufficient. If not, clinicians can continue to educate parents about how to deal with their child’s mental health challenges, using the holidays as a jumping-off point.

It is important to emphasize the importance of structure when talking with older children and teenagers as well as parents and/or guardians of younger children. One reason for December meltdowns or increases in depressive symptoms may simply be due to the lack of sleep as well as changes in routine when schools are not in session. Remind patients and families that keeping to normal bedtimes and mealtimes—standard advice for reducing stress during any holiday season—is more important this year than ever.

One reason for December meltdowns or increases in depressive symptoms may simply be due to the lack of sleep as well as changes in routine when schools are not in session.

Patients and families who are mourning may need special support. In addition to monitoring patients for signs that healthy grief is sliding into depression, consider suggesting self-help steps such as joining a support group. 

The National Alliance for Children’s Grief

 offers a list of local bereavement resources by state and region, as well as its own resources. The Dougy Center also has resources for dealing with bereavement, including a grief support program finder.

 (SAD). Although SAD commonly begins in young adulthood, it can affect adolescents. A diagnosis of SAD requires at least 2 instances of depression that begin in fall or winter and remit in spring. Light therapy is the gold standard treatment for SAD, often combined with cognitive behavioral therapy and medication.

Finally, clinicians should, as always, carefully monitor their own emotional health. The stressors that affect patients’ families during the holidays may also affect psychiatric professionals and their families. Self-care routines, including opportunities to share emotional burdens with close friends or trusted colleagues, take on greater importance in proportion to the distress manifested by one’s patients.

is CEO of The REACH Institute, a nonprofit organization that trains primary care providers, therapists, and health care institutions in evidence-based therapies for child and adult mental health issues. She is also a licensed psychologist with expertise in cognitive behavioral therapy in clinical practice in Princeton, New Jersey.

1. Hillis SD, Blenkinsop A, Villaveces A, et al. 

COVID-19-associated orphanhood and caregiver death in the United States

Although the holidays are considered to be joyful and festive, some pediatric patients and their families are experiencing difficult times. 

Helping Pediatric Patients and Families Through the Holidays

The National Commission on Correctional Health Care (NCCHC) announced that the American Academy of Pediatrics (AAP) has endorsed its position statement on the use of restrictive housing in juvenile correctional settings this fall.

The NCCHC position statement, originally released in February 2021, calls for juvenile correctional settings to stop using or limit the use of restricted housing, which refers to several forms of housing conditions including solitary confinement, protective custody, and disciplinary segregation.

 The position statement also offers several alternatives to restricted housing and asks these facilities to establish clear and specific guidelines for cases in which restricted housing may be unavoidable.

Adverse effects of solitary confinement and other restrictive housing practices include higher risks of suicide among youth.

Child & Adolescent Psychiatry