Parental Alienation Disorder: Why Label Children with a Mental Diagnosis?

Abstract

The proposal to include Parental Alienation Disorder (PAD) in the new proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) creates a host of problems. The first major problem is the labeling of children with a mental disorder who may simply be reacting with anger to the changes in their lives from the separation and divorce of their parents by rejecting one parent and aligning with the other. Diagnosis may bring with it shame and have a chilling impact on parents report of domestic violence. Although proponents of PAD are aware that it is inappropriate to diagnose children who have been exposed to child abuse and/or domestic violence with PAD, they do not clarify how to make such differential diagnoses. It is suggested that there are insufficient empirical data to differentiate abused and traumatized children from those who are alienated or estranged from the rejected parent. Nor are there sufficient scientific data to account for other child vulnerabilities such as neurological immaturity, Attention-Deficit/Hyperactivity Disorder (ADHD), other anxiety and mood disorders, or oppositional defiant disorder. There are too few comparisons between the risks and benefits of adding a new diagnosis of childhood disorders to justify its inclusion in the DSM-V. Appropriate intervention strategies recommended for PAD children include contact with the rejected parent, which differ widely from trauma victim/survivors who need assurance of safety and healing before contact is re-established. Ethical standards that may be impacted by this new diagnosis and admissibility issues raised by its predecessor, Parental Alienation Syndrome (PAS), are also discussed by the authors.

KEYWORDS:

• alienation
• child abuse
• child custody evaluations
• diagnosis
• domestic violence
• DSM-V
• estrangement
• PAD
• PAS
• rejection

Parental Alienation Disorder (PAD), a newer form of what was originally called Parental Alienation Syndrome (PAS) (Gardner, 1992), is the latest in a series of new proposals to the committees studying mental disorders to be added to the childhood disorder section of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). The proponents of PAD claim that children who reject parenting time with one parent during separation or divorce have a specific mental health problem that comes as a result of the non-rejected parent' s alienating behaviors toward the rejected parent (Bernet, 2010). Alienation in families has been discussed and debated most recently in terms of divorcing parents when a child refuses to spend parenting time with one parent (see special issue on alienation in Family Court Review: An Interdisciplinary Journal, 48(1), January 2010 for the most recent arguments). However, for as long as it can be remembered, when a child had a conduct disorder or other behavioral problem, the first question child psychologists were trained to ask was whether he or she was the product of a single parent or “broken” home. Even parents of children with the commonly diagnosed Attention Deficit Hyperactive Disorder (ADHD) receive such scrutiny. If this category is accepted into the DSM-V, PAD may be replacing child abuse and domestic violence as the most frequently believed cause of a child's mental health disorder without sufficient data to support such a conclusion.

Biological vulnerabilities have always competed with environmental causes when analyzing children's problems, underlying some of the most compelling debates in psychology such as the nature versus nurture arguments. Recently, however, the debate around the role of separated and divorced parents in raising healthy children has filled the child custody literature with some, but not sufficient, scientific data to resolve the question of the role of parental alienation in children's mental health. It is the authors' contention that adding PAD to the diagnostic categories will cause more harm than benefit to divorcing families.

While acknowledging the paucity of scientific data demonstrating that PAD is a mental disorder in children, Bernet and his colleagues still have petitioned the American Psychiatric Association, the publishers of the most popular nosology listing diagnoses—the Diagnostic and Statistical Manual of Mental Disorders—to add a new category of mental disorder of childhood, PAD, to the DSM-V due to be published in 2012. This paper will review the Bernet (2010) proposal as put forward in a panel discussion at the Annual Meeting of the Association of Family and Conciliation Courts (AFCC) held in Denver Colorado in June 2010 (see Table 1 for the criteria proposed and www.afccnet.org/members.afccaudio47th.asp). The authors will comment on three main reasons why the Bernet proposal should be rejected: 1) insufficient empirical data to support the benefits of adding a new childhood disorder; 2) insufficient data to differentiate the symptoms from trauma, specifically child abuse and domestic violence from PAD; and (3) insufficient data to demonstrate the necessity of the court's using PAD to force reunification of children with an alienated parent in order for them to grow up healthy.

TABLE 1 Diagnostic Criteria for Parental Alienation Disorder

A. The child, usually one whose parents are engaged in a high-conflict divorce, allies himself or herself strongly with one parent and rejects a relationship with the other; thus, alienating one parent without legitimate justification. The child resists or refuses contact or parenting time with the alienated parent.

B. The child maintains the following behaviors:

1. A persistent rejection or denigration of a parent that reaches the level of a campaign.

2. Weak, frivolous, and absurd rationalizations for the child's persistent criticism of the rejected parent.

C. The child manifests two or more of the following six attitudes and behaviors:

1. lack of ambivalence;

2. independent-thinker phenomenon;

3. reflexive support of one parent against the other;

4. absence of guilt over exploitation of the rejected parent;

5. presence of borrowed scenarios; and,

6. spread of animosity to the extended family of the rejected parent.

D. The duration of the disturbance is at least 2 months.

E. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.

F. The child's refusal to have contact with the rejected parent is without legitimate justification. That is, parental alienation disorder is not diagnosed if the rejected parent maltreated the child.

As a caveat, the insufficiency of data in these areas makes it necessary to bring in research from other similar areas to develop the arguments set forth in this paper, including some theoretical, clinical, and anecdotal data that appear to be underlying much of the controversy today. The authors each have over forty years of forensic psychology experience in child development (Walker), determining parental access to children (Walker), feminist psychology (Walker), forensic guidelines (Shapiro), ethics (Shapiro), assessment for forensic evaluations (Shapiro), risk assessment (Shapiro) impact from family violence on children (Walker), and trauma treatment (Walker). Knowledge from these areas shall support the argument that it is detrimental to the child's best interests to add a new and mostly unsupported diagnosis, PAD, to the DSM-V.

Should There Be a New Childhood Disorder?

As mentioned previously, proponents of PAD suggest that the behaviors seen in an alienated child are sufficiently different from those seen in children who have other diagnostic labels, warranting a new diagnostic category in the childhood disorder section of the DSM-V (Bernet, 2010). However, the data are not convincing at this time. Although the proponents acknowledge the methodological problems in published studies of alienation, they also believe that clarifying the criteria for PAD will bring more research into diagnosis and treatment. While that may indeed be a result of the new disorder, the history of the DSM system suggests that placing a diagnostic category into the “book” actually reifies the disorder and perhaps even creates it rather than simply clarifying disorders (Caplan & Cosgrove, 2004; Frances, 2010).

Frances (2010) discusses the impact of social contextual forces on over-diagnosis and suggests that “fads” or areas that draw a lot of professional and public attention want labels as a way to explain human suffering and deviance. It can be argued that when 50% of all marriages in the United States end in divorce (Symons, 2010), and 50% of those involve dependent children, the aftermath of divorce on children needs explanation. Frances cites a National Institute of Mental Health prospective study in which 25% of the population was found to have a diagnosable mental disorder. He states that there are no objective tests in psychiatry like x-rays or laboratory results that help understand what is normal and what is considered a disorder. Most children want to be with both parents during separation and divorce. When a child rejects a parent it is unusual, and both professionals and the lay public look for explanations.

The DSM diagnostic system—with its lists of diagnostic criteria—make it possible for the general public to diagnose themselves. Thus, although professionals are trained to understand thresholds and the clinical subtleties of assessment and diagnosis, those who are not trained in a particular area are no better than the general public in over-diagnosing what may be normal variants of conditions such as anxiety, sadness or depression, and oppositional behavior. Rarely is the public aware of the bias that has been found to exist in many of the diagnoses, and it can be anticipated based on earlier study of PAS that PAD will have some of the same biases (Caplan, 2004). In this case, the possible harm to the rejected parent may be what is propelling the desire to create a new diagnosis. Such a diagnosis will inevitably put the rejected parent in the position of being the “good” injured party while the alienating parent is seen as the “bad” party. In fact, research has shown that the rejected parent is often not so innocent, and the issues are far more complex (Johnston, Olesen, & Walters, 2005a, 2005b; Johnston, Lee, Olesen, & Walters, 2005; Neustein & Lesher, 2009).

Frances (2010) goes on to explain that another possible reason there are new diagnostic categories for children proposed for the DSM-V is due to the drug companies' push to sell old drugs into new areas. Although no new drug has been mentioned yet to “cure” the child, it is not far-fetched to expect off-label use of current medications with new drug trials scheduled to follow.

Yet, another reason that Frances offers is that special education services for children often require a diagnosis. Thus, what might simply be a normal variant for children whose parents are divorcing (i.e., rejection of one parent and alignment with the other) may end up getting labeled as a mental disorder of the child because the category exists in the diagnostic system even if it is not a mental disorder and has no long lasting harm to the child. Further, if there is harm to the child, it may be the stigmatization caused by labeling the diagnosis as a mental disorder rather than the alienation from the parent.

Given the changes in the family law over the last 30 to 40 years to add a presumption of joint parental responsibility, alienated children and alienated parents, who may previously have left the parenting responsibility to the non-rejected parent with sole custody, now may be seen as deviant when forced by law to interact with each other. Although the professional community rarely cites one of the major reasons for the adoption of the presumption of joint custody (i.e., to keep the father financially involved with his children), feminist jurisprudence scholars are suggesting that it may have created more problems than it resolved (Cahn, 1991; Mahoney, 1991).

One of the most frequently cited studies on the mental health of the alienated child was conducted by Johnston (2003). More recently, Johnston and Goldman (2010) interviewed parents and children from Johnston's original research on high conflict families 15 to 20 years later. The children were also administered standardized assessment measures of their emotional functioning, intimate relationships, and parental relationship over the years. Although a small sample, there was substantial agreement among the child's parent, counselor, and the child about the existence of alienating behaviors. Unfortunately, the methodology could only assess the impact of the alienation at the two points in time and could not assess prospectively for any intervening variables that may have caused the child problems in development. This issue has critical importance when reviewing Johnston, Olesen et al. (2005a, 2005b) and Johnston, Lee et al. (2005) research finding that the alienator in many of the cases they studied was not the mother, as was the court finding, but rather the father, who was an abuser and alienator and who attempted to or actually sabotaged the mother's relationship with the children. Drozd and Olesen (2010 [this issue]) using these data created a theoretical model that attempts to distinguish alienating behavior from protective parenting.

As discussed, alienation is almost always alleged when the child does not want to be with a parent when there does not appear to be any ‘rational' reason for these feelings. Of course, the definition of “rational” in these cases remains totally subjective to the person making the evaluation. Although proponents of labeling these children with PAD claim that using this label will assist in formulation of treatment goals and techniques, there are no empirical data to support this position (Bernet, 2010). Using the definition put forward by the American Psychological Association (APA) which requires two scientific studies replicating each other, there are no empirically validated interventions that support evidence that forcing a child to be with an unwanted parent will promote mental health.

Several treatment programs have been developed, most notably by Warshak (2010) and his colleagues (Warshak & Otis, 2010). He has proposed that putting the alienated child together with the rejected parent can have positive outcomes for the child and the rejected parent. He does not take into account the psychological damage that may be done to the child and the non-rejected parent as their relationship is forced to change. Neither did Gardner (1992) pay sufficient attention to the psychological harm that could be caused by removing the child's psychological parent who has provided security and developmental growth for the child. Gardner's writings advocate breaking the parent-child bond on the identified alienator, who is treated as a mean, vicious, and hateful person without taking into account the detrimental effects on the child or parent. In a particularly compelling documentary, Gardner's own words advise parents to “beat” the child who complains about a rejected parent (Waller, 2008).

Jaffe and his colleagues do describe some of these issues in discussing the need to balance the risks and benefits of intervention in these cases (Jaffe, Ashbourne, & Mamo, 2010) and in their earlier publication on child custody with batterers (Jaffe, Lemon, & Poisson, 2003); Bancroft and Silverman do as well (2002). Further discussion of how PAD may impact domestic violence families is in a separate article by these authors (Walker & Shapiro, in preparation, this issue) as well as articles by Neustein and Lesher (2009) and Meier (2010, this issue). The needs of children change as they grow and develop, which means that the child's developmental growth trajectory must be taken into account when designing any intervention program (Johnston, Roseby, & Kuehnle, 2009). Each case needs to be carefully analyzed so that interventions are appropriate for all members of the family to meet the best interests of the child standard (Friedlander & Walters, 2010).

Others suggest that if PAD were to appear in the DSM-V, it should not be considered a diagnosable disorder of childhood, but rather, it should be placed in the category that specifies a conflict in the family relationship (See Appendix A). While on its face, this may appear to be a good compromise solution, it still labels the child as having the problem when the exact cause of the child's behavior is not clearly understood, and it may be the rejected parent's problem, a family system problem with no one person to blame, or a family variant with no one having a significant alienation problem. Sullivan, Ward, and Deutsch (2010) describe a “family camp” program for children resisting contact with a parent but insist that this only occurs when the child is ready without clear definitions of how to define readiness. Courts are not sophisticated enough to make those decisions.

Child Abuse, Domestic Violence, and PAD

Although most proponents of PAD as a diagnostic category seem to agree that exposure of the child to domestic violence in the home may be considered a valid reason to reject a parent, and therefore is not alienation, rarely does the family violence expert's definition of abuse satisfy proponents of PAD; moreover, that definition is conspicuously absent from the PAD proposal submitted to the APA (see Table 1 for the actual proposal). Discussions fill the child custody journals attempting to describe how much abuse is needed before it can be called “real” domestic violence or whether the abuse is simply a part of a “high conflict” family. While it is true that the domestic violence research is heavily based on retrospective reports of abuse, the consistent findings of the impact from trauma on the mental health of victims/survivors provides good reliability and validity (Bancroft & Silverman, 2002; Jaffe et al., 2003; Stark, 2007; Walker, 2009).

Mental health clinicians and legal professionals often misinterpret how much data are needed before paying attention to the details of the abuse to which the child is exposed (Meier, 2010). This is problematic as the underlying PAS diagnosis comes from the parents' behavior and not the impact it has on the child's perception of safety and security. In addition to understanding the child's exposure and it's impact on him or her, it is also necessary to know about any other biological or situational vulnerabilities of a child (or the parent) that may cause the child other problems in addition to rejecting a parent. For example, a child who has witnessed other traumas in addition to parental conflict may respond differently than one who is not so exposed. Or a child diagnosed with a neurological disorder such as ADHD or sensory integration problems may perceive events to be more frightening than one who is more neurologically intact. Poverty, immigration, multiple moves, discrimination, and other forms of oppression all can and do cause similar mental health problems in children (Walker, 2009).

Professionals with expertise in child abuse have adopted specific interview and assessment techniques to obtain information about children's risk of exposure to violence. Guidelines are published by the American Psychological Association (1996, 2002) and the American Professional Society on the Abuse of Children (1998, 2002). Websites that attempt to correct myths and misinformation can be located on the Internet including the influential Leadership Council on Child Abuse (www.theleadershipcouncil.org) and the International Domestic Violence Institute (www.DVIWorld.org).

Drozd and Olesen (2010 [this issue]) expanded their theoretical model that has attempted to differentiate high-conflict from domestic violence families. Their model supports domestic violence as well as child abuse and maltreatment as a legitimate reason to reject a parent, and they call it estrangement, not alienation. However, their model is theoretical and does not yet have the empirically supported details that can separate high-conflict from domestic violence families. There is some question as to whether high-conflict families at the time of separation and divorce are actually a separate group from domestic violence families. Often, what appears to be high-conflict or violence that arises from the separation and court situation is really just an escalation of abusive power and control into more physical abuse that existed previously. Neither are there data to demonstrate that forced parental interaction will have a positive impact on the child from either type of family.

Meier (2010, this issue) critiqued the model from a domestic violence perspective suggesting that despite the well intentioned effort to assist the court in making these difficult decisions, no child or parent where domestic violence occurs should be forced into contact with the abuser. Further, she suggests that PAD is being used in courts against abuse victims without paying attention to Drozd and Olesen's (2010 [this issue]) and Drozd, Kuehnle, and Walker's (2004) “Safety First” requirements. It may be helpful for this model to be used as a tool for the courts if its further development weaves safety measures in its use. However, this means that all reports of domestic violence and child abuse be seriously investigated by specialists in the field rather than the average court-appointed child custody evaluator with little training in such assessment.

It is important to differentiate alienation from estrangement as trauma treatment, which works well in helping estranged children heal from the abuse to which they have been exposed, but has not been the treatment of choice that those who do provide interventions for PAD children recommend. Proponents of PAD suggest on forcing the child to be with the rejected parent, sometimes even changing primary custody if the other parent blocks parenting time while trauma treatment calls for healing from the trauma and assuring the child's safety first. There are several types of trauma treatment that call for desensitization to the trauma triggers. Based on her observations from many forensic cases, Walker (2009, 2010) has proposed that the rejected parent serves as a trauma trigger for the abused child. Interventions, then, must first neutralize the trigger or the child will continue to develop Post Traumatic Stress Disorder (PTSD) or other mental disorders based on continued exposure to the trauma trigger without safety. People who suffer from PTSD cannot perceive neutrality; either someone is perceived as he or she will protect them or that person is seen as leading them into harm. Thus, it is almost impossible to neutralize a trauma trigger without helping the child heal from PTSD from all traumas to which they have been exposed. This usually means a hiatus from parenting time with the rejected parent while treatment is ongoing.

Once a child (or adult) has developed PTSD, responses to trauma triggers will continue to precipitate PTSD symptoms even when the actual abuse or trauma is not reoccurring in vivo but is reoccurring in the child's mind. Greenwald (2009) has developed models for such trauma treatment for young children. He has combined adapted versions of prolonged exposure, desensitization, and EMDR interventions based on F. Shapiro's Eye Movement Desensitization and Reprocessing (EMDR)(F. Shapiro & Forrest, 1997), and Briere's trauma therapy approach (Briere & Scott, 2006). Walker (2009) has adapted the Survivor Therapy Empowerment Program (STEP) originally designed for domestic violence survivors for teenagers who have been exposed to abuse in their families. Gold's (2000) treatment model for survivors of childhood trauma calls for an analysis of the impact of environmental and parental conditions. None of these treatment models would support changing custody of the child from the mother who was a victim of domestic violence to the father, which is what Gardner (1992) and others recommended and is currently used when PAS, the predecessor to PAD is used without understanding the impact of domestic violence and child abuse, Although some risk assessment tools are available to custody evaluators, they rarely use them in these cases (Briere, 1997; D. L. Shapiro, in press; Walker, 2009; Walker & Shapiro, in preparation). These interventions are more fully described in a separate article focusing on the difficulties of distinguishing the psychological effects from child abuse and domestic violence from PAD (Walker & Shapiro, in preparation).

Feminist Theories and Alienation

Feminist scholarship in psychology and feminist jurisprudence in the law over the past 50 years have looked at gender discrimination in the legal arena and attempted to correct misperceptions with scientific data. Feminist jurisprudence has studied the impact of gender discrimination on legal decisions and produced a body of literature that demonstrates the bias against women in all areas (Cahn, 1991; Mahoney, 1991; Shafran, 1990) including child custody decisions. It is understood that although the statistics indicate that only about 10% of custody cases involve contested access to children, the other 90% are not free from significant problems that may impact on the mental health of all family members (Symons, 2010). Meier (2010, this issue), for example, suggests that any access to a child should be screened for safety even if the parent or child does not raise domestic violence or child abuse due to various reasons, not the least of which may be encouragement from attorneys or judges to resolve the case quickly without contest. The presumption of joint custody and shared parental responsibility has not been the panacea that many of its proponents had hoped, often because so many parents cannot share, play fair, put their children's interests above their own, or stay in one place when getting on with life after divorce.

As stated earlier, the common layperson still believes that children from single parent homes are more likely to get in trouble than those from two-parent homes. Usually that meant the single mother, who is often the primary parent, was not doing a proper job in raising the child (see both Caplan, 2004 and Chesler, 1997/1989/1972 for further discussion of this widely and strongly held myth). The mothers' main fault was mostly seen as an inability to properly discipline the child. Rarely was the father's over-discipline seen as excessive or even abusive; nor was it thought that too much discipline could cause the child's problems even though there is a substantial body of literature in the family violence field that demonstrates the dangers from harsh and overly strict discipline (Jaffe et al., 2003 Stark, 2007). Today, these beliefs continue to cause people to blame mothers for their children's problems without looking carefully at the multiple causes of children's behavioral difficulties or the role of the father in alienating the child (Johnston & Goldman, 2010).

Although written in gender-neutral terms, PAS often has been seen within the feminist community as simply one more attempt to blame mothers without considering fathers' abuse of power and control, even if in the name of discipline, that negatively impacts children (Chesler, 1997/1989/1972). Based on prior experience, feminist scholarship anticipates that PAD will continue to be used to further the evaluator's and court misperceptions about women and mothers wanting to get all men out of their lives. Although most women actually want to share custodial time with their children's fathers, and feminism encourages such equal sharing of responsibilities so women can work or fulfill other areas of their lives rather than simply being child-bearers, this misperception persists (Cahn, 1991; Mahoney, 1991; Shafran, 1990). Further, feminist theory rejects excessive labeling as negative stereotyping so, for feminist theory, perhaps most importantly, the use of the term PAD itself carries with it the belief that a child who rejects one parent has a mental disorder. Most mothers would have difficulty in labeling their child with a mental disorder that originated due to their own difficulties in getting along with the child's father. Domestic violence advocates suggest that placement of PAD in the DSM-V would have a chilling impact on women reporting spouse abuse for fear their children would be assigned the label of PAD (Meier, 2010, this issue). Caplan and Cosgrove (2004) warn of the danger of using the PAS diagnosis in their review of biases in psychiatric diagnosis.

WHAT IS PAD?

As was stated earlier, Richard Gardner (1992), a psychiatrist involved in performing child custody evaluations himself, proposed that a child whose parents are engaged in a high conflict divorce, who is strongly allied with one parent (the alienator), and who rejects any contact with the other parent (the alienated or rejected parent), has a disorder that he called Parental Alienation Syndrome (PAS). Although Gardner had no empirical data to support this theory, and in fact, self-published his ideas, PAS was immediately accepted by some professionals in the legal and mental health professions dealing with these complex and often dangerous child custody and parental access cases for some of the reasons discussed earlier. In 1994, the American Psychological Association's Council of Representatives found that there were no empirical data to support PAS as a diagnosis and cautioned psychologists that it was unethical to use any diagnosis without supporting data. This pronouncement occurred after the Presidential Task Force on Violence and the Family, chaired by Walker, reviewed the available literature and took testimony from psychologists around the United States (c.f., APA, 1996). The concept of PAS has been modified during the past 20 years, and the idea of a syndrome has been dropped while the mostly untested clinical details originally proposed by Gardner remain as the core of PAD (Bernet, 2010). In fact, prior to Gardner's death, he, too, proposed dropping the “syndrome” requirement and only recommended introduction of parental alienation in the courts (Gardner, 2002).

Courts typically follow Gardner's recommendations to change custody to the alienated or rejected parent or to order children into “reunification” treatment programs without a careful assessment of why the child rejects the parent or whether it is in the child's best interests (the usual standard of proof needed in most jurisdictions) to have a relationship with the rejected parent (Darnell, 1999) who may also be an abuser, which may seen as the larger problem (Bancroft & Silverman, 2002; Drozd et al., 2004; Jaffe, 2010). Anecdotal and clinical evidence supports the view that since PAS has been introduced in the courts, it is frequently mothers who are accused of being the alienators against fathers in divorce cases where women also claim to be domestic violence victims. Often these women are attempting to continue to protect the children from an abusive father, and their protective behavior may appear to be alienation. The behaviors serving as a gate-keeping function to protect a child may not be distinguishable from those that are labeled “alienation.” This is discussed in greater detail in other articles (Walker & Shapiro, in preparation). Further, the construct of alienation has a long history in the attachment literature in psychology, and the mechanisms by which it occurs in that literature do not resemble the behavior of the so-called alienated children in PAD (Walker, Brantley, & Rigsbee, 2004).

PROPOSED DIAGNOSTIC CRITERIA FOR PAD AND MAKING A DIFFERENTIAL DIAGNOSIS

The proposed diagnostic criteria for PAD can be found in Table 1.

Perhaps the most egregious part of this newly proposed diagnosis is the impossibility of making a differential diagnosis based on the child's signs and symptoms and not the parents' alleged behavior. Johnston (2010) discussed the confusion currently in the courts dealing with PAS/PAD and, in particular, defining who is alienated, the rejected parent or the child? There are so many explanations other than alienation for a child's rejection of a parent during separation or divorce that to give children a new mental illness diagnosis is neither necessary nor appropriate. Surely anxiety disorders including PTSD from abuse are primary as has been discussed herein, as are other mood disorders, particularly depression. The criteria for children's depression often include acting-out behavior and rejection of people and things that they used to like to do. Although not without problems, Drozd and Olesen's (2010 [this issue]) decision tree may be helpful to both the court and the psychologist once it is empirically tested. Judges are requesting such tools as they deal with these difficult and complex cases. However, Meier (2010, this issue) cautions that such a tool should only be used for screening and not to allow the courts to forgo their own duties to fully examine their own role in disrupting family relationships. Surely, in those courts where cases are not decided for years, leaving parents and children in limbo, family relationships are further fractured.

It is not appropriate to diagnose a child with a mental illness based on the parents' behavior. In many cases known to the authors, both in practice and in supervision of other forensic evaluators, the child's behavior could have been diagnosed as an adjustment disorder with anxiety or depression. Separation and divorce often means a new home or even two homes, new schools, new friends, and new schedules. Even when all goes well this can be a daunting challenge for most children. Some may have symptoms associated with neurological immaturity or dysfunction. Some may have a severe case of PTSD from what they experienced as a trauma while others in the same home observing the same behavior regarded the situation as inescapable. The factor called “resilience,” a hardiness that some children have and others do not, was not even listed as a consideration by the proposers of the PAD diagnosis.

Under the differential diagnosis section of the PAD proposal to the DSM-V Task Force, the authors do cite the fact that even in normal development, some children will become polarized with one parent and then, perhaps, with the other one, going back and forth depending on the child's developmental stage and adjustment to new events in his or her life. These may be children who do feel guilty and display feelings of loyalty conflicts. They would not be diagnosed with PAD. Again, there is no reliable or valid way of making these distinctions.

There also is a section that attempts to exempt children who actually are abused or neglected or disliked by the custodial parent or paramour of the parent; and, the suggested diagnosis for them is physical abuse of child or sexual abuse of child or perhaps even relational disorder between parent and child. However, there is no similar section that acknowledges the negative psychological impact that the child may experience from exposure to domestic violence. Exposure to all forms of family violence should be understood to possibly create traumatic reactions, not PAD. Based on the authors' experience in family court hearings, rejected fathers who have engaged in physical, sexual, or psychological abuse have been using PAS as a defense in the courts and would be expected to continue to use PAD, gaining more credibility and attention in court battles to retain their abusive power and control.

In addition, as noted in a previous section, the proponents of PAS state that when there is a history of abuse, the diagnosis of PAD should not be given. However, in the Associated Features section of the document submitted to the DSM-V Task Force as their proposal, they caution that there may be false allegations of abuse made by the preferred parent. There is no such caution about the possibility that the alienated parent is attempting to manipulate the court for his or her own reasons. The obvious question, then, which the PAD proponents do not address, is how to differentiate real from false allegations of abuse. The authors address this issue in another article (Walker & Shapiro, in preparation) as the differential diagnosis in these cases can be complex. But, it is important to state here that the rate of false allegations of domestic violence and child abuse is no different than false allegations in any other case, and they occur in a very small percentage of all known cases. In some studies it has been reported as less than 1% (APA, 1996) and in others it is only as high as 5% to 8% (Tjaden & Thoennes, 2000).

In any given situation, if a mother makes a complaint of abuse, the father would be able to counter saying it is a false allegation designed to alienate him from the children. In fact, this is already occurring in family courts using PAS despite its insufficiency in meeting Daubert and perhaps even Frye admissibility standards (Hoult, 2006). But, rarely are such admissibility hearings held in family court (Walker et al., 2004). The entire definition becomes a circular one and makes the standard of proof to protect women and children from further abuse much more difficult.

In some cases, these fathers demand more time-sharing with the child to reduce their child support obligations. This was not even discussed by the PAD proponents. Some states, such as Pennsylvania, set child support rates according to the amount of parenting time. (Title 21 Domestic Relations, Part 6 Children and Minors, Chapter 53 Custody, Subchapters 5303 & 5304). The parent who has 51% of parenting time gets to pay significantly less in child support payments to the other parent. Although this is clearly an abuse of power and control, it is rarely seen that way by courts. In these cases, it is possible to conceive of a judge being the professional making a finding of fact of parental alienation without input from a mental health professional, and therefore, being the only professional to cause a diagnosis of PAD despite the admonition in the front pages of the DSM–IV, and presumably DSM–V, not to use these diagnostic categories for legal purposes. However, this proposed category of PAD is specifically designed for use during high-conflict divorce cases.

A child who displays the same signs and symptoms of PAD may have a separation anxiety disorder or a specific phobia. The authors of the proposed new diagnosis acknowledge that during parental separations, children may be preoccupied with unrealistic fears that something bad may happen to one or both parents, fueling what is really a separation disorder. The differentiation is said to be that the PAD child's preoccupation is with unrealistic fears that the rejected parent is dangerous. However, it is possible that the child's perception of danger promotes separation anxiety, phobias, and PTSD such as in the case of a young child who hid under the covers in his parent's bedroom and fell asleep as a way to manage his fears before a visitation exchange occurred. These children would also have to be differentiated from those who have been traumatized by abuse and the abuser has become a conditioned “trauma trigger.” Obviously, placing a child with a parent to whom the child has become so conditioned would strengthen the fear, not eliminate it. Some children who reject a parent may have developed an oppositional defiant disorder or perhaps even a mood disorder with depression and/or manic mood swings. In either case, the continued conflict between the parents may have caused these symptoms to worsen, and rather than cause a new diagnosis the original ones might well suffice, especially when guiding treatment. If the child's symptoms are reduced once the parents' behavior was controlled by court orders, it strongly suggests a situational mood disorder, not PAD.

Interestingly, the proposed PAD diagnosis states that the primary differentiation is the PAD child's campaign of denigration and weak, frivolous rationalizations for the child's persistent criticism of the alienated parent. There are many reasons for the criticism of a parent during separation and divorce, especially when there are conflicts around forming new family relationships to one another. Judging the child's perceptions as “weak” or “frivolous” disrespects the child's view of the changes in his or her life and of normal concerns about what will happen to all that he and she knows as safety and security. Their very stability is at issue during non-conflict divorces as well as those with high-conflict and abuse. They have very little power or control over what happens as their parents sort it all out for them. Perhaps, it is the reification of the entire situation that creates the child's anxiety, not just the parent's behavior.

ETHICAL ISSUES

Interfacing with many of the issues raised earlier is a series of troubling ethical issues. First and foremost, psychologists are required to base findings on empirically, scientifically, or clinically validated assessments. Since there is no such body of scientific, empirical, or clinical literature to support the construct of PAD, a psychologist who renders such a conclusion is immediately involved in ethically questionable behavior (APA, 2002).

Another ethical issue that is closely related is the fact that psychologists cannot render conclusions or diagnoses unless they have sufficient data on which to base their opinions. Clearly, if there is limited scientific and clinical basis for the theory, it is impossible for there to be sufficient basis for an opinion, conclusion, or recommendation. The Specialty Guidelines for Forensic Psychologists (1991) have always made it clear that using diagnosis without a firm basis is highly questionable. However, if the diagnostic category is put in the DSM-V to encourage gathering the necessary data, it may be used to justify the use of an otherwise insufficient diagnosis.

Proponents of PAD demonstrate a certain “tunnel vision” when they assert that a child's refusal to visit a parent is based on the fact that the other parent is alienating him or her. They fail to take into account the numerous situational variables such as domestic violence, sexual abuse, anger toward the parent for leaving the home, changes in their stability and security, and consequent fear of the abusive parent's anger. Of course, the PAD proponents maintain that in the presence of “genuine” abuse, PAD cannot be diagnosed. However, as noted earlier, they also maintain that there are frequent false allegations of abuse (which is not true according to national statistics (Tjaden & Thoennes, 2000)), which then essentially makes it impossible to use this exception since they do not specify even their own criteria for distinguishing a genuine from false report of abuse.

For example, Tjaden and Thoennes (2000) found that 52% of women reported being physically assaulted by a husband/partner in a national survey with about one-half of them being injured. This is compared to 8% of men. In fact, the difference between men and women becomes greater as assault seriousness increases. In cases where there is insufficient evidence to make a finding of child abuse, it is typical for state agencies to use the term “unfounded,” which does not mean the abuse did not occur—rather, that it did not have sufficient evidence to meet the legal standard. It is not unusual for children, especially young children, in these cases to have many but not all of the signs and symptoms that meet the criteria for PTSD that strongly suggest that some form of trauma actually occurred. Not respecting these criteria may place the child in harm's way. The failure to deal with these situational variables brings the PAD proponents into direct conflict with another ethical standard, which requires that psychologists take into account significant situational variables before interpreting the results of assessments.

A closely related ethical standard is the requirement that psychologists qualify their conclusions in terms of the limitations of validity and reliability when there are missing data. Clearly a theory that has no scientific or empirical basis has major limitations requiring such validity. In the authors' experience, it is rare for a clinician who opines on PAD to comment on the limitations of its validity and reliability in a forensic report.

Despite all of these concerns, many courts appear to have embraced the concept of PAS quite enthusiastically. These courts have referred a client for a PAS evaluation or have referred a child for treatment to undo the alienation and reunify the child and rejected parent. The labeling of the treatment as “reunification therapy” in and of itself can set up the treatment for failure. The goal of treatment, instead, should be to help the child, including if the child has been traumatized, to treat the trauma first. Another goal of treatment may be to help the child learn that each of the parents may engage in good and bad behaviors when the child is ready to move beyond the belief that one parent is all good and the other all bad. When ready, children need to learn how to deal directly with problems rather than simply avoiding them (Drozd & Olesen, 2010 [this issue]; Friedlander & Walters, 2010).

Ethically, if a psychologist receives such a referral, it must be modified or rejected, especially since there is no recognized empirically-based treatment or assessment dealing directly with such alienation that meets the psychological standard. The referral question, instead, should be to assess the reasons why the child appears to be alienated from the rejected parent or if all the possible hypotheses are already stated, then to design a treatment plan that assures the child's rejection of the parent is appropriate to the situation and is not harmful to the child, and to help the child find helpful ways to deal with adverse situations.

Obviously, such rejection may be harmful to the “out” parent, but the legal standard is what is in the best interests of the child, not the parent. If it is not in the best interests of the child, detrimental to the best interests of the child, or will cause irreparable harm to the child, then it should be legally sufficient to make a ruling that may encourage but does not force the child to be with that parent. The forensic psychologist's job is to render an opinion on whether or not, based on data, in this particular situation, not seeing the rejected parent will be harmful to the child.

Another ethical standard requires psychologists to practice only in areas in which they have competence, and if called upon to do work in an area in which they do not have competence, they must obtain the necessary training, consultation and/or supervision in order to gain it if they proceed with the referral. Competence is defined in terms of knowledge, skill, training, supervised, and professional experience. It is not possible to gain competence in an area that has no scientific, empirical, or professional basis. There the entire enterprise of becoming an expert witness to comment on PAD based on an evaluation is ethically questionable.

Finally, and perhaps most important, is the harm that can come from forcing a child to have contact with an abusive or violent parent, following a finding that the other parent has alienated the child. Ethically, all mental health professionals are required to take reasonable steps to prevent harm where it is reasonably foreseeable. Making a recommendation that a child spend time with a parent whom he or she fears based on a questionable finding of PAD clearly violates this ethical standard.

ADMISSIBILITY ISSUES IN COURTS

Courts have a variety of rules regarding criteria for admissibility of expert testimony. While many of these standards originated mostly in the courts in the United States, the authors' experience has found that many other countries have adapted them to their own legal system or at least have their own rules of admissibility that are similar. Most of the cases where challenges to the admissibility of expert testimony have occurred are in criminal or civil law cases, not family law (Hoult, 2006). It is rarely tested in family law cases primarily because it is expensive to have a separate hearing or to take a case up to the appellate court. Further, most family law cases are to a trial court judge, not a jury in the United States, and therefore, it is widely accepted that judges have more information on which to judge expert testimony than do laypersons who may serve on a jury. A listing of cases in which the admissibility of PAS has been litigated can be found in Walker et al. (2004).

The Frye Standard, Frye v. U.S. 293 F. 1013 (D.C. Cir 1923) in the US is based on case law where evidence was ruled admissible if it met with ‘general acceptance' in the relevant scientific discipline. Given the widespread criticism of PAS/PAD as a scientific construct, at this time, it probably would not meet the general acceptability standard. When asked to raise their hands, fewer than half of the participants at the AFCC conference in Denver Colorado in June 2010 supported the construct being introduced into the DSM-V at this time. However, if it should appear as a diagnostic category in the DSM-V, it most probably would then become admitted in states that use the Frye Standard. Frye is still the appropriate admissibility standard in about one-third of the states in the US.

In 1975, the Federal Rules of Evidence, Pub. L. 93-595, 88 STAT 1926, were adopted, and many state courts also changed from Frye to these standards. Of some interest, is that the Federal Rules of Evidence define an expert as one who has knowledge, education, skill, experience, and training in a particular area. This is very similar to what the psychology and other mental health professionals' ethics codes define as competence. The rules further state that an expert may render an opinion if scientific, technical, or other specialized knowledge would be of assistance to the trier of fact and out of the knowledge base of the average juror. Furthermore, the techniques that are used by the expert need to be reasonably relied upon by other experts in the same field. It is doubtful that PAD, as constructed today, can meet even these standards. Outside of it being a poorly defined construct, there is still only a small body of literature that systematically describes and tests its parameters or differentiates PAD from other causes of a child rejecting a parent.

The Daubert Standard, Daubert v. Merrell Dow Pharmaceuticals, 509 U.S. 579 (1993), is a more recent admissibility standard that comes from case law made in a civil case. This standard further defines what methodology an expert should use in order for the judge to make the decision if what will be testified to is sufficiently reliable and valid to admit into evidence. Daubert suggests the Court must evaluate the scientific integrity of the knowledge that is the basis for an expert opinion including whether or not there is a “known error rate” of false positives and negatives. The Federal Rules of Evidence were updated in 2000 to reflect the more stringent scientific guidelines set forth in Daubert. This standard suggests that the judge be presented with a testable hypothesis with a known error rate from prior testing in addition to several other requirements including other published scientific studies in peer reviewed journals, to demonstrate its acceptance by others in the field. Conceivably, the PAD proponents will suggest that the clinical publications are sufficient to meet this standard, but in none that are currently available is there a testable hypothesis with a known error rate to help the court judge its reliability or validity. As PAD does not have sufficient clarity in its underlying theory or empirical data to support its reliability and validity as a diagnosis, no well-validated psychometric properties, or any established protocols, it would not meet these standards for admissibility either.

CONCLUSIONS

In conclusion, the proponents of PAS have petitioned the American Psychiatric Association to include PAD as a new diagnosis in the forthcoming DSM-V. Although Bernet (2010) and his colleagues would prefer to have it inserted in the section on children's disorders, they are willing to have it considered as a relational disorder or even in the category of the manual where disorders that still require further study are placed. Proponents believe that all who work with children know that alienation does occur, and placement in the so-called “book” would clarify the construct and permit more data to be collected and analyzed. The authors believe that the premature introduction of this new diagnostic category would unnecessarily label children with a mental disorder and perhaps even reify and create the new category. There is a consensus among those who work with high conflict families, those with a family systems perspective, and domestic and family violence advocates, in as much as these groups oppose the inclusion of this diagnostic category in the official DSM nosology. Their reasons include the lack of scientific and empirical data underlying the construct, the inability to separate the causes of parental rejection in addition to alienation and denigration by one parent against the other, and the harm that can come from forcing a child who has been abused to be with the abusive parent. Further, the danger of having a child receive a mental health diagnosis based on the behavior of a parent during a high conflict or abusive custody battle is potentially more harmful than permitting the child to take a hiatus from parenting time with that parent and restoring contact at a later date, when hostilities have been reduced and fear and trauma triggers reduced.

Finally, there are insufficient data to determine that rejection of a parent is harmful to the child or that the child and parent will remain disconnected over time if the child is permitted to reestablish a new safe and secure environment. What is being termed as alienation may well be a normal variant of family structure based on many variables in that particular family system and that forcing reunification may itself be more detrimental to the parent-child relationship over a period of time.