By: William Bernet, M.D., Professor Emeritus in the department of psychiatry at Vanderbilt University School of Medicine in Nashville, TN
Parental separation and divorce are common features of contemporary society. About 25% of children in the US live with only one parent.1 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.2 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.
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.
Transitory adjustment problem
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, adjustment disorder with anxiety).
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.3 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,4 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.”5 If a clinical or forensic practitioner finds that a child is experiencing a loyalty conflict that causes distress or dysfunction, the diagnosis may be child affected by parental relationship distress.
Internalized chronic stress
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.6
Regarding possible DSM-5 diagnoses, major depressive disorder 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.5 If the child fears the loss of the custodial parent, he may develop separation anxiety disorder. 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.
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.3 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. Gardner7identified 8 symptoms of parental alienation more than 20 years ago (Table). 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.
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 child affected by parental relationship distress. 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 parent-child relational problem.
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.9) Thus, if the focus of clinical attention is on the behavior of the alienating parent, child psychological abuse is appropriate. The same term can be applied to both the perpetrator and the victim of child psychological abuse.5
Finally, severe cases of parental alienation sometimes constitute a folie à deux 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?”10 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.”11 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.12
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.13 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.