Parental Alienation, DSM-5, and ICD-11
Children begin by loving their parents;
after a time they judge them;
rarely, if ever, do they forgive them.
As child psychiatrists, we often come across emotionally disturbed children from broken families in our clinical practice. Research indicates that the emotional well-being of children after parental separation and divorce can often be predicted by the relationship between parents after such a separation. Most clinicians in the field have wondered about how children deal with such dilemmas that are forcibly superimposed on their tender years. In such circumstances, it is not uncommon for children to align with one parent’s viewpoint while rejecting outright the other, a phenomenon often referred to as parental alienation. The author of this book, Dr William Bernet, discusses this concept and the accompanying research, while making a fairly convincing argument to introduce this concept in DSM-5 and ICD-11.
The author defines parental alienation as when "a child, usually one whose parents are engaged in a high conflict divorce, allies himself or herself strongly with one parent and rejects strongly the other parent without legitimate justification (such as abuse or neglect)" (p 3). On the basis of a literature review, the author argues that parental alienation may have a prevalence of around 1% of the child and adolescent population in the United States and causes significant impairment in relationships for such children. Furthermore, he suggests that failure to recognize it may lead to unnecessary delays in treatment. The author proposes that this concept needs to be recognized as such and should be included either as a psychiatric disorder or as a relational problem in our future classificatory systems.
The initial chapter defines parental alienation syndrome (PAS) as a cluster of characteristic behaviors such as a "campaign of denigration" led by the child against the alienated parent, lack of ambivalence of the child, and extension of the denigration to family members of the alienated parent. The next chapter thoroughly reviews the 20 reasons why parental alienation should be considered as a diagnostic entity in the upcoming editions of both DSM and ICD. The author suggests that in the newer classification, the syndrome could be clustered with either attachment disorders or relational problems or lumped with the developmental disorders. He acknowledges the overlap in symptoms of parental alienation and parent-child relational problem but argues that PAS merits its own place since there are two separate parent-child relational problems manifested: one between the alienating parent and the child, and another dysfunctional relationship between the alienated parent and the child. The author advocates that by including such a diagnosis, one may be able to shed light on a "serious mental condition" that "has a predictable course that often continues into adulthood" (p 110). Making it a diagnosis will help bridge the information among different specialists and get the patient the help needed. It will also permit more research to be conducted on the topic.
Dr Bernet has made an excellent attempt to shed more light on PAS, define it, help clarify the controversies around it, and facilitate its inclusion in DSM-5. He further suggests practical criteria to include it as a disorder (in Appendix A) or as a relational problem (in Appendix B). The author provides thorough evidence for the validity, reliability, and prevalence of parental alienation, supporting its integration into DSM-5 while answering the critics of this concept. In addition, the author also addresses several controversies surrounding the diagnosis and answers several counterarguments appropriately. He provides several references and case examples to legitimize his proposal, which has been referenced in different places. The book contains approximately 600 citations about parental alienation; these certainly constitute one of the strengths of this book and make it a valuable tool for further research about this disorder.
Perhaps the most common criticism cited for such a diagnosis is the risk of having the diagnosis misused in the courtrooms, thereby causing conflicts within a custody battle over a child to be wrongfully given to an abusing parent if the latter states that he was wrongfully alienated from his child by the other parent. The author suggests that diagnostic clarity will make the diagnosis less likely to be misused and not the other way round.
Overall, the book is thorough and systematically covers all the reasons for inclusion of PAS in DSM-5. It is important to note, however, that this book is not intended to be a comprehensive source for the deeper psychological discussion of PAS or the psychosocial ramifications of including it as a diagnosis in everyday psychiatric practice.
Author affiliations: University of Virginia Health System, Charlottesville.
Potential conflicts of interest: Dr Madaan has been a consultant for NOW Foundation for Bipolar Disorder; has received research support from Pfizer, Otsuka, Eli Lilly, Shire, Forest, and Merck; has received honoraria from the American Psychiatric Association Focus Self-Assessment Editorial Board; and has been a speaker for the NOW Foundation for Bipolar Disorder. Dr Habib reports no potential conflict of interest relevant to this review.
J Clin Psychiatry 2013;74(3):e220 (doi:10.4088/JCP.12bk08344)
© Copyright 2013 Physicians Postgraduate Press, Inc.