ArticlePDF Available

Parental alienation, DSM-5, and ICD-11



Parental alienation is an important phenomenon that mental health professionals should know about and thoroughly understand, especially those who work with children, adolescents, divorced adults, and adults whose parents divorced when they were children. We define parental alienation as a mental condition in which a child—usually one whose parents are engaged in a high-conflict divorce—allies himself or herself strongly with one parent (the preferred parent) and rejects a relationship with the other parent (the alienated parent) without legitimate justification. This process leads to a tragic outcome when the child and the alienated parent, who previously had a loving and mutually satisfying relationship, lose the nurture and joy of that relationship for many years and perhaps for their lifetimes. The authors of this article believe that parental alienation is not a minor aberration in the life of a family, but a serious mental condition. The child's maladaptive behavior—refusal to see one of the parents—is driven by the false belief that the alienated parent is a dangerous or unworthy person. We estimate that 1% of children and adolescents in the U.S. experience parental alienation. When the phenomenon is properly recognized, this condition is preventable and treatable in many instances. There have been scores of research studies and hundreds of scholarly articles, chapters, and books regarding parental alienation. Although we have located professional publications from 27 countries on six continents, we agree that research should continue regarding this important mental condition that affects hundreds of thousands of children and their families. The time has come for the concept of parental alienation to be included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), and the International Classification of Diseases, Eleventh Edition (ICD-11).
This article was downloaded by:
[VUL Vanderbilt University]
13 March 2010
Access details:
Access Details: [subscription number 917861922]
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-
41 Mortimer Street, London W1T 3JH, UK
The American Journal of Family Therapy
Publication details, including instructions for authors and subscription information:
Parental Alienation, DSM-V, and ICD-11
William Bernet
; Wilfrid von Boch-Galhau
; Amy J. L. Baker
; Stephen L. Morrison
Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
Private Practice, Würzburg, Germany
Vincent J. Fontana Center for Child Protection, New York, New
York, USA
Houston Police Department and Departments of Criminal Justice and Social Science,
University of Houston-Downtown, Houston, Texas, USA
Online publication date: 12 March 2010
To cite this Article Bernet, William, von Boch-Galhau, Wilfrid, Baker, Amy J. L. and Morrison, Stephen L.(2010) 'Parental
Alienation, DSM-V, and ICD-11', The American Journal of Family Therapy, 38: 2, 76 — 187
To link to this Article: DOI: 10.1080/01926180903586583
Full terms and conditions of use:
This article may be used for research, teaching and private study purposes. Any substantial or
systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or
distribution in any form to anyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation that the contents
will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses
should be independently verified with primary sources. The publisher shall not be liable for any loss,
actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly
or indirectly in connection with or arising out of the use of this material.
The American Journal of Family Therapy, 38:76–187, 2010
Copyright © Taylor & Francis Group, LLC
ISSN: 0192-6187 print / 1521-0383 online
DOI: 10.1080/01926180903586583
Parental Alienation, DSM-V, and ICD-11
Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
Private Practice, W
urzburg, Germany
Vincent J. Fontana Center for Child Protection, New York, New York, USA
Houston Police Department and Departments of Criminal Justice and Social Science,
University of Houston-Downtown, Houston, Texas, USA
Parental alienation is an important phenomenon that mental
health professionals should know about and thoroughly under-
stand, especially those who work with children, adolescents, di-
vorced adults, and adults whose parents divorced when they were
children. We define parental alienation as a mental condition in
which a child—usually one w hose parents are engaged in a high-
conflict divorce—allies himself or herself strongly with one par-
ent (the preferred parent) and rejects a relationship with the other
parent (the alienated parent) without legitimate justification. This
The authors appreciate very much the many colleagues who contributed to this proposal,
listed here: Jos
e M. Aguilar, Katherine Andre, E. James Anthony, Mila Arch Marin, Eduard
r, Paul Bensussan, Alice C. Bernet, Kristin Bernet, Barry S. Bien, J. Michael Bone,
Barry Bricklin, Andrew J. Chambers, Arantxa Coca Vila, Douglas Darnall, Gagan Dhaliwal,
Christian T. Dum, John E. Dunne, Robert A. Evans, Robert Bruce Fane, Bradley W. Free-
man, Prof. Guglielmo Gulotta, Anja Hannuniemi, Lena Hellblom Sj
ogren, Larry Hellmann,
Steve Herman, Adolfo Jarne Esparcia, Allan M. Josephson, Joseph Kenan, Ursula Kodjoe,
Douglas A. Kramer, Ken Lewis, Moira Liberatore, Demosthenes Lorandos, Ludwig F. Lowen-
stein, Dom
enec Luengo Ballester, James C. MacIntyre II, Jayne A. Major, Eric G. Mart, Kim
Masters, David McMillan, John E. Meeks, Steven G. Miller, Martha J. Morelock, Wade Myers,
Olga Odinetz, Jeff Opperman, Robert L. Sain, S. Richard Sauber, Thomas E. Schacht, Ul-
rich C. Schoettle, Jesse Shaver, Richard K. Stephens, Julie Lounds Taylor, Asunci
on Tejedor
Huerta, William M. Tucker, Benoit van Dieren, Hubert Van Gijseghem, James S. Walker,
Randy Warren, Monty N. Weinstein, Jack C. Westman, Katie Wilson, Robert H. Woody, and
Abe Worenklein.
Address correspondence to William Bernet, M.D., Department of Psychiatry, Vanderbilt
University School of Medicine, Vanderbilt Psychiatric Hospital, 1601 Twenty-third Avenue
South, Suite 3050, Nashville, TN 37212-7182. E-mail:
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 77
process leads to a tragic outcome when the child and the alienated
parent, who previously had a loving and mutually satisfying re-
lationship, lose the nurture and joy of that relationship for many
years and perhaps for their lifetimes. The authors of this article be-
lieve that parental alienation is not a minor aberration in the life
of a family, but a serious mental condition. The child’s maladap-
tive behavior—refusal to see one of the parents—is driven by the
false belief that the alienated parent is a dangerous or unworthy
person. We estimate that 1% of children and adolescents in the U.S.
experience parental alienation. When the phenomenon is properly
recognized, this condition is preventable and treatable in many
instances. There have been scores of research studies and hundreds
of scholarly articles, chapters, and books regarding parental alien-
ation. Although we have located professional publications from 27
countries on six continents, we agree that research should continue
regarding this important mental condition that affects hundreds of
thousands of children and their families. The time has come for
the concept of parental alienation to be included in the Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V),
and the International Classification of Diseases, Eleventh Edition
There is considerable international interest in the proposition that parental
alienation should be included in the official diagnostic systems for psychiatric
With regard to the Diagnostic and Statistical Manual of Mental Disor-
ders, Fifth Edition (DSM-V), a group of mental health and legal professionals
were invited to submit a formal proposal to the DSM-V Disorders in Child-
hood and Adolescence Work Group. The proposal, “Parental Alienation Dis-
order and DSM-V,” was submitted to the Work Group in August 2008. The
August 2008 formal proposal included more than 50 citations and quotations
from the mental health literature and more than 90 citations from the world
legal literature. The authors concluded that the diversity of these publications
supported the proposition that the concept of parental alienation is gener-
ally accepted by mental health and legal professionals. The August 2008
proposal was published in the American Journal of Family Therapy (Bernet,
After reviewing the August 2008 formal proposal, Daniel Pine, M.D.,
the chairman of the Disorders in Childhood and Adolescence Work Group,
replied that the proposal did not have enough information about the va-
lidity of parental alienation as a distinct mental condition, the reliability of
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
78 W. Bernet et al.
the diagnostic criteria, and the prevalence of this condition. Dr. Pine pro-
vided constructive criticism to the authors of the proposal and suggested
that we either locate or conduct additional research regarding this topic. Dr.
Pine indicated that the Work Group would be pleased to consider this addi-
tional research as they continue their deliberations regarding the child and
adolescent aspects of DSM-V.
With regard to the International Classification of Diseases, Eleventh Edi-
tion (ICD-11), of the World Health Organization, there is considerable interest
in coordinating as much as possible the content of DSM-V and ICD-11. With
that in mind, the authors were invited to submit a proposal regarding parental
alienation to the WHO International Advisory Group for the Revision of ICD-
10 Mental and Behavioural Disorders. This document—“Parental Alienation,
DSM-V, and ICD-11”—has being submitted both to the DSM-V Task Force
and the ICD-11 International Advisory Group. This document is based on
the August 2008 proposal, “Parental Alienation Disorder and DSM-V,” but is
longer and much more detailed. This document contains much more infor-
mation about the validity, reliability, and prevalence of parental alienation. It
also includes a comprehensive international bibliography regarding parental
alienation with more than 600 citations.
Although parental alienation has been described in the psychiatric literature
for at least 60 years, it has never been considered for inclusion in the Di-
agnostic and Statistical Manual of Mental Disorders (DSM). When DSM-IV
was being developed, nobody formally proposed that parental alienation be
included in that edition. Since the publication of DSM-IV in 1994, there have
been hundreds of publications (articles, chapters, books, court opinions)
regarding parental alienation in peer-reviewed mental health journals, l egal
literature, and the popular press. There has been controversy among mental
health and legal professionals regarding some aspects of parental alienation,
and at times the professional discourse resembled the hostility manifested
by entrenched and angry parents fighting over their children.
Regarding our proposed diagnostic criteria, we argue that the essential
feature of parental alienation is that a child—usually one whose parents are
engaged in a high-conflict divorce—allies himself or herself strongly with one
parent (the preferred parent) and rejects a relationship with the other parent
(the alienated parent) without legitimate justification. The primary behavioral
symptom is that the child refuses or resists contact with a parent, or has
contact with a parent that is characterized either by extreme withdrawal or
gross contempt. The primary mental symptom is the child’s irrational anxiety
and/or hostility toward the rejected parent. This anxiety and hostility may
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 79
have been brought about by the preferred parent or by other circumstances,
such as the child who avoids being caught between warring parents by
gravitating to one side and avoiding the other side of the conflict.
In this document, we differentiate the general concept of parental alien-
ation from parental alienation syndrome. Parental alienation refers to the
child’s strong alliance with one parent and rejection of a relationship with
the other parent without legitimate justification. Depending on the context,
we sometimes use the term parental alienation syndrome (PAS), which is
a more complex concept. When we refer to the research and published
literature, we use the term PAS if that was the terminology in the original
PAS typically refers to a child with parental alienation who manifests
some or all of the following eight characteristic behaviors: the child’s cam-
paign of denigration against the alienated parent; frivolous rationalizations
for the child’s criticism of the alienated parent; lack of ambivalence; the
independent-thinker phenomenon; reflexive support of the preferred par-
ent against the alienated parent; an absence of guilt over exploitation and
mistreatment of the alienated parent; borrowed scenarios; and spread of the
child’s animosity toward the alienated parent’s extended family (Gardner,
1992a). (These eight behaviors or symptoms are defined in Appendix A.)
Another difference between parental alienation and PAS is that the latter
typically includes the idea that one of the parents actively influenced the
child to fear and avoid the targeted parent. Although we believe that occurs
in many instances, it is not necessary to have an alienating parent for parental
alienation to occur. Parental alienation may occur simply in the context of
a high-conflict divorce in which the parents fight and the child aligns with
one side to get out of the middle of the battle, even with no indoctrination
by the favored parent.
Parental alienation and PAS do not describe or pertain to different
groups of children. On the contrary, we believe that the children who expe-
rience parental alienation are almost the same children who manifest PAS.
The latter is a subset of the former. We believe that the great majority of
children who experience parental alienation also manifest some or all of the
eight characteristic behaviors of PAS. In other words, parental alienation is
simply a general term that is not encumbered by the baggage associated with
PAS, i.e., the eight symptoms that constitute the syndrome and the role of
the alienating parent. In our use of these terms, parental alienation and PAS
are typically descriptors of the child. (For example, “For several years, Jimmy
lost the loving relationship he had with his mother because he experienced
parental alienation.”) However, the terms could be used to describe the tri-
adic relationship that involved two parents and a child. (For example, “Every
member of the Smith family was damaged by a severe degree of parental
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
80 W. Bernet et al.
We are explaining these definitions in detail because we realize that
some authors have given other meanings to “parental alienation.” For exam-
ple, some authors use “parental alienation” to describe the behaviors of the
alienating parent and “PAS” to describe the condition of the child. Also, some
authors use “parental alienation” to describe any estrangement between the
child and a parent (including situations in which the parent was abusive)
and “PAS” to describe the child’s unjustified rejection of a parent (i.e., when
the parent was not abusive).
When we refer to our proposal for DSM-V and ICD-11, we use the term
parental alienation disorder (because that is the terminology for mental
disorders in DSM-V) or parental alienation relational problem (because that
is the terminology for relational problems in DSM-V). See Appendix A for
the proposed criteria for parental alienation disorder. See Appendix B for the
proposed criteria for parental alienation relational problem. The proposed
criteria for parental alienation disorder and parental alienation relational
problem incorporate our definition of parental alienation and are partly based
on the definition of PAS.
We use the phrase contact refusal for the behavior of the child or
adolescent who adamantly avoids spending time with one of the parents.
Contact refusal is simply a symptom that could have a number of possible
causes, one of which is parental alienation. This terminology is similar to
school refusal, which is simply a symptom that could have a number of
possible causes.
Our proposal is that one of the following will occur with regard to
The text in Appendix A (regarding parental alienation disorder) will be
included in the main body of DSM-V.
OR, the text in Appendix A will be included in one of the appendices of
DSM-V, that is, Criteria Sets and Axes for Further Study.
OR, the text in Appendix B (regarding parental alienation relational prob-
lem) will be included in the chapter of DSM-V, Other Conditions That May
Be a Focus of Clinical Attention.
In addition to being included in DSM-V as either a mental disorder or a
relational problem, the concept of parental alienation should be mentioned
in the DSM-V differential diagnoses of certain disorders seen in children and
adolescents. For instance, parental alienation should be mentioned in the
differential diagnosis of separation anxiety disorder, since both conditions
can be manifested by an apparent fear of leaving one of the parents. Parental
alienation should be mentioned in the differential diagnosis of oppositional
defiant disorder, since both conditions can be manifested by the child’s
adamant refusal to follow a reasonable expectation of an adult.
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 81
We are making an analogous proposal regarding ICD-11:
The text in Appendix A (regarding parental alienation disorder) will
be included in the section of Chapter V called “Behavioural and emo-
tional disorders with onset usually occurring in childhood and ado-
OR, The text in Appendix B (regarding parental alienation relational prob-
lem) will be included in one of the sections of Chapter XXI. For ex-
ample, Chapter XXI includes a section called “Other problems related
to primary support group, including family circumstances” and another
section called “Problems related to other legal circumstances.” Parental
alienation relational problem would be appropriate for one of those
We believe there is almost uniform belief in the international mental
health community that parental alienation is a real phenomenon that affects
the life-long mental health of thousands of children and likewise the mental
health of their families. Parental alienation affects the quality of life of those
who are exposed to it. We believe there is enough research regarding valid-
ity, reliability, and prevalence to support the adoption of parental alienation
as a psychiatric diagnosis.
It is time to include parental alienation as a diagnosis in DSM-V and ICD-
11 for the following reasons. Most of these reasons are discussed in this
article, but some are not because of space limitations. The topics that are in
parentheses are not discussed in detail in this article, but will be addressed
in a subsequent publication (Bernet, in press).
Developmental factors are being considered for DSM-V. Attachment is
a very important developmental factor, and parental alienation can be
conceptualized as a disorder of attachment.
Relational disorders are being considered for DSM-V, and parental alien-
ation is a typical example of this type of mental condition.
(Dimensional diagnoses are being considered for DSM-V, and the descrip-
tions of parental alienation have had dimensional features since the early
(The phenomenon of parental alienation was described long before PAS
was formally defined.)
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
82 W. Bernet et al.
(Parental alienation is a valid concept. There has been considerable quali-
tative and quantitative research regarding parental alienation and PAS.)
Parental alienation is a valid concept. In the 1980s and 1990s, the phe-
nomenon was recognized and described independently by at least six
researchers or groups of researchers.
Parental alienation is a valid concept. After PAS was formally defined, many
researchers or groups of researchers were able to apply the definition to
their own subjects.
Parental alienation is a valid concept. Despite controversies regarding ter-
minology and etiology, the phenomenon is almost universally accepted by
mental health professionals who evaluate and treat children of high-conflict
Parental alienation is a valid concept. Parental alienation has been identi-
fied and studied in many countries.
(Parental alienation is a valid concept. Collateral research regarding re-
lated topics supports the contention that parental alienation is a real phe-
The diagnostic criteria for PAS are reliable. Systematic research indicates
the diagnostic criteria exhibit both test-retest and inter-rater reliability.
It is possible to estimate the prevalence of parental alienation. Systematic
research indicates the prevalence of parental alienation in the United States
is approximately 1% of children and adolescents.
Parental alienation and PAS have been discussed by professional
(Parental alienation and PAS have been discussed extensively by legal
(Parental alienation and PAS have been discussed extensively by the gen-
eral public.)
Parental alienation is a serious mental condition. It has a predictable course
that often continues into adulthood and can cause serious, long-term psy-
chological problems.
Establishing diagnostic criteria will make it possible to study parental alien-
ation in a systematic manner on a larger scale.
Establishing diagnostic criteria will be helpful for: clinicians who work with
divorced families; divorced parents, who are trying to do what is best for
their children; and children of divorce, who desperately need appropriate
treatment that is based on a correct diagnosis.
Establishing diagnostic criteria will reduce the opportunities for abusive
parents and unethical attorneys to misuse the concept of parental alienation
in child custody disputes.
(There are critics of parental alienation and PAS who oppose the use
of these concepts as a psychiatric diagnosis, but their arguments are not
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 83
Developmental Factors are Being Considered for DSM-V. Attachment
is a Very Important Developmental Factor, and Parental Alienation
Can Be Conceptualized as a Disorder of Attachment
Child and adolescent psychiatrists and other mental health professionals have
urged DSM-V personnel to take a developmental approach with regard to
the diagnoses that apply to children and adolescents and the criteria for
these diagnoses. For example, the criteria for some disorders are different,
depending on whether the patient is a child or an adult.
One of the most important aspects of child and adolescent develop-
ment is the concept of attachment, that is, the affective tie between a child
and a caregiver. There are several psychiatric conditions that directly affect
the child’s attachment to caregivers or reflect an aberration in the child’s
attachment. The most obvious disorders of attachment are reactive attach-
ment disorder (“markedly disturbed and developmentally inappropriate so-
cial relatedness in most contexts”) and separation anxiety disorder (“exces-
sive anxiety concerning separation from ... those to whom the individual
is attached”). There are other disorders that may be considered disorders
of attachment, such as feeding disorder of infancy or early childhood (be-
cause the condition may be caused by parent-child interaction problems)
and oppositional-defiant disorder (because the condition may be caused by
harsh, inconsistent, or neglectful child-rearing practices).
We recommend that, in DSM-V, attachment disorders be clustered in
the same way that pervasive developmental disorders and elimination dis-
orders are clustered in DSM-IV-TR. This new section would start with a
general overview of the significance of attachment as a developmental is-
sue, a brief discussion of typical attachment phenomena in childhood and
adolescence, and a general explanation of the problematic variations in at-
tachment. Parental alienation disorder can be conceptualized as a disorder of
attachment and included in this cluster of mental disorders. It is notable that
all of these disorders of attachment have something important in common,
that is, they are not predominantly genetic or constitutional, but are caused
primarily by what parents or caretakers do and say to their children.
Relational Problems Are Being Considered for DSM-V. Parental
Alienation Is a Typical Example of a Relational Problem Because
It Usually Involves the Interacting Attitudes of One Child
and Two Parents
In DSM-IV-TR, relational problems were included as V codes in the chapter,
Other Conditions That May Be a Focus of Clinical Attention. For example, one
of the relational problems in DSM-IV-TR is parent-child relational problem
(V61.20). According to DSM-IV-TR, “This category should be used when the
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
84 W. Bernet et al.
focus of clinical attention is a pattern of interaction between parent and child
... that is associated with clinically significant impairment in individual or
family functioning or the development of clinically significant symptoms in
parent or child” (American Psychiatric Association, 2000, page 737).
It is our understanding that relational problems will be addressed in a
more comprehensive manner in DSM-V. One way to organize DSM-V would
be to have a separate chapter called Relational Problems. That chapter could
explain the difference between mental disorders and relational problems
and also explain how relational factors are a consideration in many mental
Recent publications by DSM-V personnel emphasized the importance
of relational problems. For example, Michael First and his colleagues said,
“Relational disorders are painful, persistent behavioral problems that seri-
ously affect adjustment and should be considered for inclusion in the next
edition of the DSM” (First et al., 2002). Also, we agree with Steven Beach
and his colleagues that “disorder-specific relationship processes may prove
to be critical for understanding particular disorders or for distinguishing func-
tionally distinct types of disorders. Accordingly, a ... proposal for enhancing
the description of relationship processes in DSM-V would incorporate a ref-
erence to the presence or absence of disorder-specific relational processes
with relational specifiers” (Beach et al., 2006). Beach et al. gave examples
of diagnoses—feeding disorder of infancy and conduct disorder—that have
prominent relational characteristics.
In considering how relational problems will be presented in DSM-V,
parental alienation should be at the forefront of the discussion. Parental
alienation can be conceptualized simply as a mental disorder of the child,
who has a false belief that one of his or her parents is a dangerous or
contemptible or simply expendable person. Or, parental alienation can be
conceptualized as a complex relational problem in which: two parents have
a highly conflicted relationship; the child has a pathologically enmeshed
relationship with the preferred parent; and the child has an unfounded fear
or disregard of the alienated parent. Furthermore, all three parties contribute
in some way to the end result of the child’s false belief.
It is not a new idea that the concept of parent-child relational prob-
lem (V61.20) overlaps to some extent with the concept of parental alien-
ation. Richard Gardner commented on this topic in his article, “Does DSM-
IV have equivalents for the parental alienation syndrome (PAS) diagno-
sis?” Gardner thought that parent-child relational problem and PAS “have
some symptoms in common,” but they are not equivalent. He said, “In the
PAS situation there is a pathological dyad between the alienating parent
and the child and another pathological dyad between the alienated par-
ent and the child. ... Examiners using this criterion do well to emphasize
that two separate parent-child relational problems are manifested” (Gardner,
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 85
The Comprehensive Textbook of Psychiatry suggests that parent-child
relational problem includes the symptoms and behaviors that are typically
seen in parental alienation. In the chapter on Relational Problems, the author
said, “Substantial evidence indicates that marital discord leads to problems
in children, from depression and withdrawal to conduct disorder and poor
performance at school. This negative effect may be partly mediated through
triangulation of the parent-child relationships. Triangulation refers to the
process in which conflicted parents attempt to win the sympathy and support
of their child, who is recruited by one parent as an ally in the struggle with the
partner” (Dickstein, 2005, p. 2244). At least one medical insurance company
specifically states in its provider handbook that PAS is an example of parent-
child relational problem. The ValueOptions Provider Handbook states the
following example in the section regarding parent-child relational problem:
“Unresolved parental conflict (i.e., the constant devaluing of one parent by
the other) in divorced or estranged families resulting in parental alienation
syndrome” (ValueOptions, 2006).
The ICD already includes several conditions that are comparable to the
relational problems in DSM-IV. Chapter XXI of ICD-10 includes a section
called “Problems related to negative life events in childhood,” for example,
“Altered pattern of family relationships in childhood” (Z61.2). There is a
section called “Other problems related to primary support group, including
family circumstances,” for example, “Disruption of family by separation or
divorce” (Z63.5). In fact, disruption of family by separation or divorce has
an explanatory note that refers to “estrangement.” It is unclear what “es-
trangement” means in this context and whether the authors of ICD-10 have
already included the concept of parental alienation in their understanding
of disruption of family by separation or divorce. Finally, there is a section
called “Problems related to other psychosocial circumstances,” for example,
“Problems related to other legal circumstances” (Z65.3). The last category,
problems related to other legal circumstances, makes reference to “child
custody or support proceedings.”
Although both DSM and ICD allude to relational problems and although
parental alienation is a classic example of severe relational problems, neither
DSM nor ICD explicitly mentions parental alienation. We recommend that
the committees charged with coordinating DSM-V and ICD-11 find a way to
include parental alienation in both of these documents.
Parental Alienation Is a Valid Concept. In the 1980s and 1990s,
Parental Alienation Was Described Independently by at Least Six
Researchers or Groups of Researchers in the United States
A concept is a mental representation with meaning, and a valid concept
refers to one for which there is general agreement regarding the meaning or
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
86 W. Bernet et al.
definition of the concept. For example, is the term parental alienation disor-
der a valid mental representation of the condition that Gardner defined as “a
disturbance in which children were preoccupied with deprecation and criti-
cism of a parent–denigration that is unjustified and/or exaggerated” (Gardner,
1992a, p. 59)? One way to answer this question is to see whether various
professional observers independently collected similar data and arrived at
the same conclusions.
In the case of parental alienation, divorce researchers have consistently
identified a portion of children of divorce who become alienated from one
parent for no apparent reason, that is, the alienation was not due to abuse
or neglect by the rejected parent. At least six individuals or research groups
working independently during the 1980s and 1990s identified children of
separated or divorced parents who were severely alienated from one parent
without apparent justification.
In 1976, Judith Wallerstein and Joan B. Kelly, Ph.D., both psychologists,
identified a clinical phenomenon they called “pathological alignment,” which
sometimes occurred in their sample of divorcing families (Wallerstein and
Kelly, 1976).
In 1980, Wallerstein and Kelly published Surviving the Break-up: How
Children and Parents Cope with Divorce. In this important book, the au-
thors described their landmark, long-term study of 60 community families
of divorce from Northern California. Wallerstein and Kelly related that some
children of divorced parents became aligned with one parent against the
other. These children vehemently refused contact with one parent and ap-
peared to be unreasonably allied with the other. The authors referred to an
alliance between a narcissistically enraged parent and a particularly vulner-
able older child or adolescent, who “were faithful and valuable battle allies
in efforts to hurt and punish the other parent. Not infrequently, they turned
on the parent they had loved and been very close to prior to the marital
separation” (Wallerstein and Kelly, 1980, p. 77).
In 1989, Judith Wallerstein and Sandra Blakeslee published a follow-up
book, Second Chances: Men, Women, and Children a Decade After Divorce .
The authors did not use the term “parental alienation,” but they vividly related
how court-ordered visitation can “be entangled with Medea-like rage.” They
said, “A woman betrayed by her husband is deeply opposed to the fact
that her children must visit him every other weekend. ... She cannot stop
the visit, but she can plant seeds of doubt–‘Do not trust your father’–in the
children’s minds and thus punish her ex-husband via the children. She does
this consciously or unconsciously, casting the seeds of doubt by the way she
acts and the questions she asks. ... Fathers in similar circumstances make
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 87
use of techniques congenial to them, often conveying to the boy or girl that
the mother is depraved and dangerous” (Wallerstein and Blakeslee, 1989, p.
During the 1970s and early 1980s, Richard Gardner, a child and adolescent
psychiatrist, was called upon to conduct child custody evaluations, primarily
in the New York City area. As a custody evaluator, Gardner was in a position
to make observations, a role that was limited to those few mental health
professionals who did similar types of work. As Gardner conducted custody
evaluations, wrote reports, and prepared to testify in court, he made notes of
his observations. In the process of collecting and organizing the descriptions
of what he observed, Gardner was conducting qualitative research on the
phenomenon of parental alienation.
Drawing upon these observations, Gardner introduced in 1985 the term
“parental alienation syndrome” for a type of emotional child abuse almost
exclusively seen in separated and divorced families engaged in custody dis-
putes. Gardner said, “The parental alienation syndrome (PAS) is a disorder
that arises primarily in the context of child-custody disputes. Its primary
manifestation is the child’s campaign of denigration against the parent, a
campaign that has no justification. The disorder results from the combination
of indoctrination by the alienating parent and the child’s own contributions
to the vilification of the alienated parent” (Gardner, 1985).
As he continued to conduct custody evaluations and collect observa-
tional data, Gardner defined eight behaviors or symptoms as indicating the
presence of PAS. These behaviors–primarily manifested by children caught
between parents seeking custody during a high-conflict divorce–consisted
of the following: the campaign of denigration; weak, frivolous, and absurd
rationalizations for the deprecation; lack of ambivalence; the “independent-
thinker” phenomenon; reflexive support of the preferred parent in the
parental conflict; absence of guilt over cruelty to and/or exploitation of the
alienated parent; presence of borrowed scenarios; and spread of animosity
to the extended family of the alienated parent (Gardner, 1992a, pp. 63–82).
Gardner emphasized that in PAS, the child’s denigration of the alienated
parent is not justified. The child’s fear of the alienated parent is greatly out
of proportion to anything the alienated parent did. Gardner said, “When
true parental abuse and/or neglect are present, the child’s animosity may be
justified, and so the parental alienation syndrome explanation for the child’s
hostility is not applicable” (Gardner, 1998b).
Gardner identified hundreds of children with this condition. He thought
the dramatic increase in the prevalence of this condition occurred because,
in the late 1970s, it became much more common for fathers to seek custody
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
88 W. Bernet et al.
of their children and for courts to order joint custodial arrangements. This
created a climate in which parents would induce alienation in order to gain
the upper hand in court and foil the other parent’s claim for custody or
visitation. Also, some jurisdictions made it easier to obtain a divorce, thus
increasing the rate of divorce. Having observed the behaviors and symptoms
of PAS on numerous occasions, Gardner wrote about his observations related
to this topic in about 20 articles and four books (Gardner, 1987a, 1992a,
2001b; Gardner et al., 2006).
During the 1970s and 1980s, Leona Kopetski, a social worker, conducted
child custody evaluations in Colorado. At the time, she was unaware of the
work of Richard Gardner and the research of Stanley Clawar and Brynne
Rivlin. In describing the phenomenon of “Parent Alienation Syndrome,”
Kopetski said, “Alienating parents (who should know better) and their chil-
dren (who cannot be expected to know better) sometimes share a common
delusion that one and only one other human being, namely the alienating
parent, can provide the child with the relationship necessary for psycholog-
ical survival” (Kopetski, 1998a). She also pointed out, “Parent alienation is
not a gender-determined syndrome. Either the mother or father can alienate;
either can be alienated” (Kopetski, 1998b). Kopetski and her team identified
84 cases of severe alienation out of 413 court-ordered evaluations conducted
between 1976 and 1990 (Kopetski, 1998a, 1998b, 2006). Kopetski wrote de-
scriptions of her observations in an effort to assist other evaluators. Kopetski’s
own work led her “independently to conclusions that were remarkably sim-
ilar to Gardner’s conclusions regarding the characteristics of the syndrome”
(Kopetski, 1998a).
In 1991, Stanley Clawar, a sociologist, and Brynne Rivlin, a social worker,
who conducted child custody evaluations, published a study through the
American Bar Association titled Children Held Hostage.Anincreaseinchild
custody fights passing through the family court system created a concern
for how to better manage the conflict. I n their research, Clawar and Rivlin
followed 700 counseling cases over a 12-year period (apparently from the
mid 1970s to the late 1980s), primarily in Pennsylvania. Clawar and Rivlin
documented their observations over the course of their study, from which
they made conclusions. They found that in about 80% of the cases, there
was some element of parental programming in an effort to implant false
and negative ideas about the other parent with the i ntention of turning the
child against that other parent. Their work focused on emotional issues,
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 89
persistent programming, and brainwashing, which sometimes resulted in
severe parental alienation (Clawar and Rivlin, 1991).
In 1985, Janet R. Johnston, a sociologist, Linda E. G. Campbell, Ph.D., and
Sharon S. Mayes, Ph.D., reported the “distress and symptomatic behavior of
44 children, aged 6–12 years, ... who were the subject of post-separation
and divorce disputes over their custody and care.” The authors described
six primary responses of these children to their parents: “strong alliance,”
“alignment,” “loyalty conflict,” “shifting allegiances,” “acceptance of both”
with “avoidance of preferences,” and “rejection of both.” The authors’ defini-
tion of “strong alliance” was “a strong, consistent, overt (publicly stated)
verbal and behavioral preference for one parent together with rejection
and denigration of the other. It is accompanied by affect that is clearly
hostile, negative and unambivalent.” Of the 44 children studied, 7 (16%)
manifested this response (Johnston et al., 1985). It is notable that Gard-
ner described “parental alienation syndrome” and Johnston and her col-
leagues described children with a “strong alliance” in the same year. They
apparently were talking about the same phenomenon in different groups of
In 1993, Janet Johnston reported on two studies “of divorcing families
who represent the more ongoing and entrenched disputes over custody and
visitation.” Together, the two studies involved 140 divorcing parents disput-
ing the custody and visitation of 175 children. These families were referred
from family courts in the San Francisco Bay Area for counseling and media-
tion between 1982 and 1990. Some of these children demonstrated “strong
alignment” with one parent, which meant: “The child consistently denigrated
and rejected the other parent. Often, this was accompanied by an adamant re-
fusal to visit, communicate, or have anything to do with the rejected parent.”
Although Johnston’s research was undertaken independently of Gardner, she
observed, “Strong alignments are probably most closely related to the be-
havioral phenomenon Gardner referred to as parental alienation syndrome
... (Johnston, 1993).
In 1997, Janet Johnston and Vivienne Roseby published In the Name
of the Child, which addressed the assessment and treatment of high-conflict
divorcing families. In the chapter on “Parental Alignments and Alienation
among Children of High-Conflict Divorce,” they say, “Most children and
adolescents of divorce are eager to have an ongoing relationship with both
of their parents, and most are pained by loyalty conflicts and the fear that
they might have to choose one parent and lose the other. A minority of
children, however, will become enmeshed in the parental conflict to such a
degree that they are said to be aligned with one parent and alienated from
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
90 W. Bernet et al.
the other” (Johnston and Roseby, 1997, p. 193). A second edition of this
book was recently published (Johnston et al., 2009).
In 1998, Vivienne Roseby and Janet Johnston explained rather elo-
quently how parental alienation comes about. In a book chapter with a
dramatic title, “Children of Armageddon,” they said, “A central problem in
high-conflict divorce and protracted custody disputes involves the narcis-
sistic vulnerability of the divorcing parties. ... The other parent is seen as
irrelevant, irresponsible or even dangerous, whereas the self is seen as the
essential, responsible, and safe caretaker. These parents tend to selectively
perceive and distort the child’s concerns regarding the other parent. For
example, if a vulnerable woman has experienced her ex-spouse as emo-
tionally neglectful, she expects him to be neglectful with her child; if the
child comes back upset or depressed after spending time with the father, the
mother attributes the difficulty solely to the father’s lack of care. ... In this
way, vulnerable parents overidentify with elements of the child’s emotional
response that remind them of their own experience with the ex-spouse and
confirm the other parent’s ‘badness.’ Thus, such a mother will amplify and
distort her perception of the child’s sadness and anxiety, and run the risk of
distorting the child’s reality testing about his or her own feelings and ideas”
(Roseby and Johnston, 1998).
In 2001, Joan Kelly and Janet Johnston critiqued Gardner’s definition of
PAS and proposed an alternative framework for classifying alienated children.
Although Janet Johnston and Joan Kelly agree that parental alienation is a
real phenomenon, they do not agree with the concept of parental alienation
syndrome. Their work is sometimes referred to as the “reformulation” of
PAS, which meant that the focus of the assessment should be on the child,
not on the parent as embodied in the concept of PAS. Kelly and Johnston
believe that parental alienation is not necessarily caused primarily by an
alienating parent. Rather, they discussed alienation as a result of interrelated
systemic processes with contributing factors within the environment, within
each parent, and in the child to “create and/or consolidate alienation” of a
child from a once-loved parent (Kelly and Johnston, 2001).
Although they started with somewhat different assumptions about eti-
ology, both Gardner and Kelly and Johnston apparently identified the same
group of children. For example, Gardner thought that PAS consisted of eight
specific symptoms. In their alternative framework, Kelly and Johnston listed
almost the identical symptoms as features of what they called the “alienated
child.” For instance, Gardner’s list included “weak, absurd, or frivolous ratio-
nalizations for the deprecation” of a parent; Kelly and Johnston’s list included
“trivial or false reasons used to justify hatred” (Kelly and Johnston, 2001).
Also, Kelly and Johnston defined an alienated child as “one who expresses
freely and persistently unreasonable negative feelings and beliefs (such as
anger, hatred, rejection and/or fear) toward a parent that are significantly
disproportionate to the child’s actual experience with that parent.” Although
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 91
these authors do not agree with the concept of parental alienation syndrome,
they endorse the basic premise of parental alienation, that some children ally
with one parent against the other parent in the absence of abuse or neglect.
Johnston’s definition of an “alienated child” is almost exactly the same
as our concept of “parental alienation.” We also agree with Johnston’s state-
ment that “it is important to differentiate alienated children (who persis-
tently refuse visitation and stridently express unrealistic negative views and
feelings) from other children who also resist contact with a parent after
separation but for a variety of expectable reasons, including normal devel-
opmental preferences for one parent, alignments that are reactions to the
specific circumstances of the divorce, and estrangement from a parent who
has been neglectful or abusive” (Johnston, 2005, emphasis in original text).
Furthermore, we agree that there are various routes to becoming an alienated
child, as there are various causes of parental alienation. Since our definitions
and opinions seemed highly congruent, we have encouraged Janet Johnston
since October 2008 to participate with us in developing this proposal for
DSM-V and ICD-11; she has repeatedly declined our invitations.
One of Johnston’s reasons for not supporting either “the alienated child”
or “parental alienation” as a diagnostic entity is that sometimes it is hard to
tell the difference between alienation (which is unjustified) and estrangement
(which is justified because of the rejected parent’s neglectful or abusive
behaviors). However, in their own research, Johnston and her colleagues
studied the records of separating and divorced families and were able to
tell the difference between cases in w hich allegations of abuse were sub-
stantiated and those in which allegations of abuse were not substantiated.
They based their determinations on the type of information and documents
that are commonly collected in both clinical and forensic evaluations–such
as interviews of family members, observations of the interactions between
parents and children, information from collateral professionals and other
individuals, and written documentation provided by attorneys and parents
(Johnston, Lee, Olesen, and Walters, 2005).
From the mid 1960s to the present, Barry Bricklin, a psychologist, has con-
ducted child custody research, which was published in book chapters and
books (for example, Bricklin, 1995), as well as in peer-reviewed journals
and law reviews. Thousands of children and their parents were evaluated
and in some cases there have been seven years of follow-up data. Bricklin
studied children who voiced strongly-worded verbal opinions about par-
ents that were inconsistent with other information. In his research, Bricklin
called this phenomenon Not-Based-On-Actual-Interactions (NBOAI). That is,
a child made verbal statements that were likely not based on his or her
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
92 W. Bernet et al.
actual interactions with the person being spoken about, but rather on what
the child had been manipulated, bribed, or coerced into saying and possi-
bly believing. Children were most susceptible to these manipulations when
they viewed the parent doing the manipulating as needing help to survive
psychologically or needing retribution for some, usually imagined, wrong.
Bricklin identified four categories of NBOAI, one of which strongly
resembled the parental alienation syndrome as that entity was being dis-
cussed in the prevailing psychological literature. The signs for this category
of NBOAI were described as follows: (1) The child expressed a strong fa-
vorable verbal opinion of the parent he or she wished to live with, and a
strong negative verbal opinion of the parent he or she “never wanted to
see again.” (2) On a test in which it was consciously obvious to the child
whom he or she would be endorsing on each test item, all or almost all of
the endorsements were for the favored parent by huge and statistically rare
margins. (3) On a nonverbal test where it was not consciously obvious what
the statistically based responses meant, there were several endorsements for
the non-favored parent. (4) When the child was asked to give sense-based
real-life examples of negative endorsements, these examples were mostly
trivial or downright irrelevant to the issues supposedly involved.
It is important to note that these six groups of clinicians and
researchers–working during the same period of time–independently iden-
tified the same phenomenon. This is very strong evidence that the consistent
pattern of behaviors, which we are calling parental alienation, really exists
as a distinct clinical entity.
Parental Alienation Is a Valid Concept. After PAS Was Formally
Defined by Richard Gardner, Many Mental Health Researchers
Applied That Definition to Study Children of High-Conflict Divorces.
These Researchers Verified That Gardner’s Definition Could Be Used
to Identify Groups of Children Who Fulfilled the Diagnostic Criteria
of PAS
One way to establish the external and ecological validity of a concept is to
apply the criteria for the concept to other samples to see if similar individuals
are identified. Converging results from multiple samples allows for more
generalization and strengthens both external and ecological validity. After
the criteria for PAS were widely published and understood—for example,
through Gardner’s book, The Parental Alienation Syndrome: A Guide for
Mental Health and Legal Professionals (Gardner, 1992a)—researchers applied
these criteria to totally separate samples of children of divorced parents. They
found that Gardner’s criteria allowed them to identify parents and children
with a particular cluster of symptoms, which we call parental alienation.
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 93
Most of the research discussed in this section of the article was con-
ducted in the U.S. and Canada and published in English. See a subsequent
section for a discussion of many research studies that were conducted and
published in other countries. The research cited in this section was either
published in a peer-reviewed journal or was a dissertation written for a grad-
uate degree in psychology or a related field. Dissertation research is guided
by committees composed of experts at the doctoral level, which is analogous
to peer review. The following research studies are in chronological order.
In 1994, John Dunne, a child and adolescent psychiatrist, and Marsha
Hedrick, a psychologist, who worked in Seattle, published a study involving
16 cases of severe parental alienation which were very resistant to clinical
intervention. Using Gardner’s criteria for PAS, these authors found that the
syndrome can occur without reference to the length of the relationship prior
to the separation and can occur immediately following separation or not until
many years after the divorce. They also found that it can occur throughout
the age range, from very young children to teenagers who had previously
enjoyed a lengthy positive post-divorce relationship with the alienated par-
ent. In their study, PAS could involve all the children in a family or only
one. Although the alienating parent was most often the custodial mother,
alienation by non-custodial parents, usually fathers, also occurred. Dunne
and Hedrick thought that the motivations of the alienating parents were of-
ten out of their consciousness or colored in socially acceptable ways (Dunne
and Hedrick, 1994).
In 1997, Larry Nicholas, a forensic psychologist practicing in California, re-
ported on a survey of 21 custody evaluators. Nicholas sought to determine
whether there was a cluster of identifiable attitudes and behaviors in the
alienating parent, the target parent, and the child, which could be said to
constitute a syndrome as Gardner suggests. Parent alienating behaviors were
found to be highly correlated with children’s alienation symptoms and vice
versa. There were no significant correlations between the child’s alienation
symptoms and eight of ten target parent characteristics. Significant corre-
lations were found, however, between child alienation symptoms and two
target parent items: temporarily giving up on the child and becoming irritated
and angry with the child for exhibiting the alienating behaviors. The findings
of Nicholas’ survey support Gardner’s contention that the core dynamic in
PAS is between the alienating parent and child, and that the target parent’s
behavior is much less likely to be a major contributing factor (Nicholas,
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
94 W. Bernet et al.
Between 1997 and 2010, Deirdre Rand, Ph.D., a forensic psychologist practic-
ing in California, published “The Spectrum of Parental Alienation Syndrome”
in four parts. Part I discussed social changes, the etiology of PAS, and the
behaviors of parents who induce PAS (Rand, 1997a). Rand reviewed the de-
scriptions of parental alienation and PAS by Gardner (1987a, 1989a, 1992a),
Clawar and Rivlin (1991), Turkat (1994, 1995), and several other authors. Part
II described the behaviors of children after PAS had been introduced (Rand,
1997b). She also discussed other aspects of PAS, such as the contribution of
the targeted parent, the involvement of third parties, and the response of the
legal system to PAS. In Part III, Deirdre Rand and Randy Rand, Ed.D., joined
Leona Kopetski, MSSW (Rand et al., 2005). They sought to evaluate meth-
ods to therapeutically interrupt PAS in 45 custody evaluations and presented
the results of their research. Deirdre Rand has written another article (Rand,
in press) which discusses “critics of parental alienation syndrome and the
politics of science.”
In 1998, psychologists Jeffrey Siegel and J oseph Langford published an im-
portant paper, “MMPI-2 Validity Scales and Suspected Parental Alienation
Syndrome.” The authors said, “The present study is an attempt to gain un-
derstanding of parents who engage in alienating tactics through a statistical
examination of their MMPI-2 validity scales.” The study involved 34 female
subjects who completed the MMPI-2 in the course of child custody evalua-
tions. Of the total, 16 subjects met the criteria for classification as PAS parents;
18 were considered non-PAS parents. Siegel and Langford concluded, “The
hypothesis was confirmed for K and F scales, indicating that PAS parents are
more likely to complete MMPI-2 questions in a defensive manner, striving
to appear as flawless as possible. It was concluded that parents who engage
in alienating behaviors are more likely than other parents to use the psy-
chological defenses of denial and projection, which are associated with this
validity scale pattern” (Siegel and Langford, 1998).
In 1998, Jodi Stoner-Moskowitz completed a dissertation that examined the
relationship of children’s self-concept to four types of family structure, Intact,
Divorced, High Conflict, and Alienated families. Stoner-Moskowitz, using
Gardner’s definition of PAS to define the Alienated families, examined 141
children of divorced parents. Stoner-Moskowitz found that children in all four
groups had diminished self-concept; divorce conflict was inversely correlated
with self-concept (Stoner-Moskowitz, 1998).
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 95
In 1998, Jean-Guy Bellerose completed a thesis for graduate school. He
studied the phenomenon of parental alienation syndrome as defined by
Gardner. Bellerose said, “When, after a divorce, one is trapped in one’s
emotions, the result is an impasse, where parental alienation is but one
aspect of this impasse. This paper shows how an impasse grows and which
form the parental alienation syndrome takes” (Bellerose, 1998).
In 2001, Despina Vassiliou and Glenn Cartwright published a small, qualita-
tive study involving five fathers and one mother who had experienced PAS.
The data were collected via semistructured, open-ended interviews to deter-
mine if there were shared characteristics among alienated families, common
issues in the marital conflicts that contributed to the marriage dissolution, the
nature of the participants’ reports of alienation, similarities in the experience
of alienation, and what things a lost parent might do differently. Vassiliou
observed that a tactic used by the alienating parent is that of denigration
aimed at the targeted parent and that children aligned with the alienating
parent will join in the process. Overall, Vassiliou found that there are several
possible attributes that may be precursors or indicators of PAS (Vassiliou and
Cartwright, 2001).
In 2005, Vassiliou completed a dissertation for graduate school. The
purpose of this research was to find identifiable characteristics of PAS. Vas-
siliou examined targeted parents’ experiences with the legal system as their
cases passed through the family court. Vassiliou also compared PAS and false
allegations of abuse, and she sought to identify similarities and differences
and examine possible relationships between the two. Vassiliou found that
interference in visitation was a common tactic used for those inflicting PAS.
Also, she found that all participants left with negative perceptions of lawyers,
judges, and the family court system (Vassiliou, 2005).
In 2001, Janelle Burrill published significant research regarding PAS. Bur-
rill examined 30 families with 59 children, who were referred to her for
evaluation, therapy, or mediation. The selection criteria for her study were
intractable parental conflict and custody disputes, manifested by at least two
court appearances during a 24-month period commencing January 1998. Us-
ing the Gardner criteria for identifying and categorizing PAS, Burrill was able
to sort the parents—based on their PAS symptoms—into the mild, moderate,
and severe categories. She was able to sort the children—based on their PAS
symptoms—into the mild, moderate, and severe categories. Burrill compared
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
96 W. Bernet et al.
the number of symptoms manifested by the parents and the children in these
various groups. She found a correlation between the parents’ symptoms and
the children’s symptoms. She found a correlation between the alienating
parents’ behaviors and the child’s negative behaviors toward the alienated
parent. Burrill concluded, “The data from this study appear to support Dr.
Gardner’s observations of PAS published in 1985. ... In its severe form,
PAS is more distinctive than the mild form. PAS is destructive to a child’s
relationship with the alienated parent. Severe PAS can be irreversible in its
effects. Severe PAS is destructive irrespective of the gender of the alienating
parent. Children’s negative behaviors towards the alienating parent increase
in severity as the negative behaviors and hostility of the alienating parent
increases. The results of this data are significant” (Burrill, 2001, p. 78).
In 2003, Kristen Marie Carey completed a dissertation for graduate school.
She identified subjects in the San Francisco Bay area who had some degree
of parental alienation. Of the ten subjects, eight were found to have been
affected by PAS upon the divorce of their parents, and Carey was able to
categorize them as mild, moderate, or severe based on Gardner’s criteria.
The two remaining subjects manifested some degree of parental alienation,
but not PAS. It is notable that only six of the ten subjects had recovered their
relationship with the alienated parent. Although her sample size was small,
Carey confirmed the existence of the phenomenon of PAS (Carey, 2003).
In 2003, Jean Andrew Deters completed a dissertation for graduate school.
Deters’ research was based on the assumption that the phenomenon of PAS
existed. He sought to find methods for courts to deal with high-conflict
divorce and ongoing parental alienation. He described how models b ased
on “parent coordinating” would help courts deal with these issues (Deters,
2003). Since Deters conducted the research for his dissertation, many states
have adopted the role of “parenting coordinator” to help parents commu-
nicate in a constructive manner, reduce the conflict, and follow the court-
ordered parenting plan.
In 2004, Cynthia Raso completed a dissertation for graduate school, a qual-
itative study regarding the long term effects of PAS. Raso examined eleven
subjects who were self-identified as victims of PAS. After conducting detailed
interviews, Raso found, “The more severe the PAS, the more likely the child
will develop externalizing problems (drugs and alcohol, early sexual and
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 97
promiscuous sexual activity and disciplinary problems at school). ... The
more severe the PAS, the more likely the child will develop internalizing
problems (issues with trust, intimacy, and commitment). ... The more se-
vere the PAS, the more likely the child, if she/he becomes a parent and
goes through a divorce, will handle his/her divorce differently from the way
his/her parents did. ... The more severe the PAS, the more likely the non-
custodial parent-child relationship will be damaged for life.” Raso concluded
that PAS has detrimental effects for the alienated child and that the effects
continue into adulthood (Raso, 2004).
In 2005, Luisa Pederson Machuca completed a dissertation for graduate
school. Machuca used Gardner’s definition and eight symptoms of PAS. In
this research, Machuca evaluated a test instrument for determining presence
of PAS. She examined 329 students from Anchorage, Alaska, who were di-
vided into two groups, parents divorced and parents non-divorced. Machuca
assessed which of the eight symptoms of PAS contributed to the occurrence
of PAS; four were identified for mothers and three for fathers. Machuca
concluded her test instrument was valid to measure the presence of PAS
(Machuca, 2005). It is notable that Machuca identified some subjects as hav-
ing PAS, so her research confirmed the existence of the concept of PAS.
In 2006, Amy J. L. Baker, Ph.D., and Douglas Darnall, Ph.D., completed a
study of targeted parents who were asked to describe in detail the behaviors
exhibited by the alienating parents. Independent coding that achieved inter-
rater reliability identified the most common strategies. These strategies were
consistent with those identified by adults who as children were turned against
one parent by the other (Baker and Darnall, 2006).
In 2007, Baker and Darnall published a survey in which 97 targeted
parents were asked to rate the severity of the alienating parent’s alienation
strategies (na
ıve, active, obsessed) as well as the degree of the child’s alien-
ation (mild, moderate, severe). Although 90% of the parents were rated as
obsessed (defined as, “S/he has a mission to destroy the relationship between
the targeted parent and the child.”), only 44% of the children were rated as
severely alienated (defined as, “Your child professes to want nothing to do
with you. Visitation is minimal if at all.”). In other words, not all children
exposed to alienating behavior succumb to the pressure to choose sides. The
primary purpose of this study was to determine the extent to which targeted
parents describe their alienated children’s behavior as being consistent with
the eight behavioral manifestations of PAS as identified by Richard Gardner.
Although this was borne out in general, it was also discovered that even
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
98 W. Bernet et al.
the most alienated child will present some “crack in the armor” which can
be used as a window of opportunity by targeted parents for countering the
alienation (Baker and Darnall, 2007).
In 2007, Baker published the results of an empirical investigation into
the beliefs and practices of custody evaluators. Baker found that over 70%
of survey respondents reported that they “very much” believed that it was
possible for a parent to turn a child against the other parent in the absence of
abuse, neglect, or abandonment (essentially a restatement of the core idea of
PAS), and 75% said that they “very much” thought it was important to assess
the presence of parental alienation in custody evaluations (Baker, 2007a).
Also in 2007, Baker published a book describing the results of in-depth
interviews with adults who believed that when they were children they
had been turned against one parent by the other. These data presented the
first look at the phenomenon of parental alienation from the perspective
of the children who lived through it and provided compelling validation
that parents are able to emotionally manipulate children to reject a parent
that they would otherwise have no reason or desire to reject. The study
also provided harrowing accounts of the negative lifelong impact of this
experience for the child victims (Baker, 2007b).
A very recent collaborative study between the Vincent J. Fontana Center
for Child Protection and New York University revealed that about 28% of
adults in a community sample (i.e., not selected because of a precondition
related to divorce or custody) reported that when they were children one
parent tried to turn them against the other. These data are striking in that
a significant portion of the sample was probably raised in an intact family.
Not surprisingly, the proportion who reported that they had been exposed
to parental alienation (defined in the study as one parent trying to turn the
child against the other parent) was higher in the subsample of individuals
who had been raised by a stepparent, at 44%. Thus, it would fair to estimate
that in 40% to 80% of all divorcing families, one parent exhibits parental
alienation tactics, at least periodically (Baker, 2010).
In 2007, Kathleen M. Reay completed a dissertation for graduate school. Reay
conducted a quantitative study designed to answer the following question:
“Do adult children of divorce with different levels of PAS show corresponding
levels of psychological distress.” Reay used Gardner’s concept of PAS and the
symptoms of PAS to conduct her study. She collected data from 150 adults
from a Canadian community, who had been selected based on specified
criteria. Based on responses to questionnaires, Reay determined the level
of PAS for each subject as mild, moderate, or severe. Next, Reay used a
separate questionnaire to determine each respondent’s present psychological
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 99
distress. Upon analyzing the data for correlations, Reay found, “As the level
of PAS increased, so did the measurable level of psychological distress.”
Reay concluded that her research lends support to Richard Gardner’s theory
of PAS, with a lifetime of mental health issues observed to occur for those
victimized by PAS. Reay thought her data analysis supported the scientific
validity of PAS (Reay, 2007).
In 2007, Melissa Colarossi completed a dissertation for graduate school. She
conducted a small qualitative study regarding the impact of marital separation
and divorce on individuals. Colarossi examined twelve subjects and found
two cases of PAS. She found that the two individuals who had experienced
PAS manifested sadness because their ex-wives were making sure they would
not be able to spend time with their children. Colarossi noted that alienating
parents strive to cut off contact between the targeted parent and the children
(Colarossi, 2007).
In 2008, Robert Gordon, Ronald Stoffey, and Jennifer Bottinelli published
important research regarding the use of objective psychological testing—the
Minnesota Multiphasic Personality Inventory-2 (MMPI-2)—with families in-
volved in custody disputes. The authors collected the MMPI-2 results from
the parents who had been seen in 158 court-ordered custody evaluations.
Of these cases, 76 were PAS cases and 82 were custody cases without PAS
(controls). The subjects were identified as alienating parent, target parent
and control parent. Two different MMPI-2 indexes were used to measure
primitive defenses: L + KFand(L+ Pa + Sc)–(Hy + Pt). The authors
found that mothers and fathers who were alienators had higher scores (in
the clinical range), indicating primitive defenses such as splitting and pro-
jective identification, than control mothers and fathers (scores in the normal
range). The scores of target parents were mostly similar to the scores of
control parents. Overall, this study strongly supported Gardner’s definition
of PAS (Gordon et al., 2008).
In 2009, James N. Bow, Jonathan W. Gould, and James R. Flens published
their research in which they surveyed 448 mental health and legal profes-
sionals about their knowledge of parental alienation and PAS. They found
their subjects, as a group, to be knowledgeable about parental alienation
and aware of the controversies regarding this topic. The authors found that
on the average, their respondents had attended five conferences and read
ten books or articles that addressed parental alienation (Bow et al., 2009).
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
100 W. Bernet et al.
Parental Alienation Is a Valid Concept. Despite Controversies
Regarding Terminology and Etiology, the Phenomenon of Parental
Alienation Is Almost Universally Accepted by Psychiatrists,
Psychologists, Social Workers, and Family Counselors Who Evaluate
and Treat Children of High-Conflict Divorces
During the 1990s and into the 2000s–after Gardner and other authors de-
scribed the features of parental alienation–hundreds and perhaps thousands
of mental health professionals in North America, South America, Europe,
Africa, Australia, and Asia identified the same constellation of symptoms in
children of parents who were embroiled in high-conflict divorces. Psycholo-
gists, psychiatrists, family counselors, and other mental health professionals
have described individual cases and small groups of divorcing families that
manifested the same pattern of parental alienation. This extensive literature
has provided a wealth of observations regarding this phenomenon. The fol-
lowing citations do not constitute systematic research, but they reflect the
widespread acceptance of the concept of parental alienation among mental
health professionals. These articles and chapters are discussed in chronolog-
ical order.
In 1990, Frank S. Williams, a child and adolescent psychiatrist and family ther-
apist who practiced in Los Angeles, gave the keynote address at the annual
meeting of the National Council for Children’s Rights in Washington, D.C.
Williams’ address was titled “Preventing Parentectomy Following Divorce.”
He said, “Parentectomy is the removal, erasure, or severe diminution of a
caring parent in a child’s life, following separation or divorce. Parentectomy
covers a large range of parent removal from partial parentectomy, ‘You may
visit your Daddy or Mommy every other Sunday’; to total parentectomy, as
in Parental Alienation Syndrome, described by Gardner; or complete parent
absence or removal. The victims of parentectomy are the children and the
parents so severed from each other’s lives. A parentectomy is the most cruel
infringement upon children’s rights to be carried out against human children
by human adults. Parentectomies are psychologically lethal to children and
parents” (Williams, 1990).
In 1993, Glenn F. Cartwright, a psychologist, published “Expanding the Pa-
rameters of Parental Alienation Syndrome” (Cartwright, 1993). Cartwright is
a professor in the Department of Educational and Counseling Psychology at
McGill University in Canada. He frequently lectures on PAS and maintains
an Internet web site that provides information regarding PAS to the public.
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 101
Since 1994, Ira Daniel Turkat, a clinical psychologist practicing in Florida,
has written about PAS (Turkat, 1995, 1997, 2000, 2005). He conceptualized
PAS as being a feature or a condition of one of the parents, not the child.
For instance, Turkat said, “In certain cases, child visitation interference is
a direct result of a custodial parent suffering from a Parental Alienation
Syndrome. Here, the custodial parent engages in a variety of direct and
indirect methods designed to alienate the child from his or her nonresidential
parent. The result is that the child becomes preoccupied with unjustified
criticism and hatred of the nonresidential parent” (Turkat, 1994). Most writers
have conceptualized PAS as being a feature or a condition of the child.
Subsequently, in “Parental alienation syndrome: A review of critical issues,”
Turkat discussed the spectrum of PAS and the problems and difficulties faced
by social researchers studying this topic (Turkat, 2002).
In 1994, Carla Garrity and Mitchell Baris published Caught in the Middle:
Protecting the Children of High-Conflict Divorce. Although not exclusively
about PAS, the authors discussed that topic. They said, “Parental alienation
is very real. It occurs when one parent convinces the children that the other
parent is not trustworthy, lovable, or caring—in short, not a good parent.
This persuasion may be consciously malicious and intended to destroy the
children’s relationship with the other parent. Or it may take a more insidious,
even unconscious form arising from the personality issues as yet unresolved
in the childhood of one parent” (Garrity and Baris, 1994, p. 66). These
authors introduced the concept of the parenting coordinator, who had two
tasks: “(1) translating the visitation plan into a conflict-reduction plan tailored
specifically to the dynamics of the divorce impasse and (2) assisting parents
to implement it on an ongoing basis” (Garrity and Baris, 1994, p. 120).
Parenting coordination has become an important intervention for children
who manifest mild and moderate degrees of parental alienation.
In 1995, William Bernet published the first edition of Children of Divorce: A
Practical Guide for Parents, Attorneys, and Therapists (Bernet, 1995). Bernet
described “parental alienation through indoctrination” (consistent with the
Gardner definition of PAS) and “parental alienation without indoctrination”
(when the child gravitates to one parent or the other simply to get out of the
war zone of parental battles). Bernet, a child and adolescent psychiatrist, also
described the phenomenon of PAS in an article, “Child Custody Evaluations”
(Bernet, 2002) and in a major reference book, the Handbook of Child and
Adolescent Psychiatry (Bernet, 1998).
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
102 W. Bernet et al.
In 1996, Waldron and Joanis described parental alienation syndrome as a
family dynamic that can have long-term deleterious effects on the child be-
cause the child learns that “hostile, obnoxious behavior is acceptable in
relationships and that deceit and manipulation are a normal part of relation-
ships” (Waldron and Joanis, 1996).
J. M
In 1997 and 1999, J. Michael Bone, a psychotherapist and family law me-
diator, and Michael R. Walsh, a marital and family law lawyer, published
articles regarding PAS in a legal journal in Florida. Bone and Walsh based
their writings on Gardner’s definition of PAS. They said, for example, “The
strategies utilized by the [alienating parent] to alienate the children and the
other parent vary from the most subtle to the most obvious. They all, how-
ever, have a consistent theme: any opportunity for the [alienating parent] to
control access and contact or the sharing of major decisions with reference
to the child is apt to be exploited” (Walsh and Bone, 1997). Bone and Walsh
also identified “four very specific criteria that can be used to identify po-
tential PAS”: one parent actively blocks access or contact between the child
and the absent parent; false or unfounded accusations of abuse against the
absent parent; a deterioration in the relationship between the children and
the absent parent following the parents’ separation; the children’s fear in
displeasing or disagreeing with the potentially alienating parent (Bone and
Walsh, 1999).
In 1998, Douglas Darnall, a clinical psychologist with over 25 years of experi-
ence, published Divorce Casualties: Protecting Your Children from Parental
Alienation, which discussed the spectrum of parental alienation. Darnall
used the term “parental alienation” for the adult behaviors and processes
that cause PAS. He proposed a three-tier classification system, now in com-
mon use, that distinguishes between na
ıve, active and obsessed alienators.
ıve alienators make negative comments about the other parent but without
serious intent to undermine the child’s relationship with that parent. Their
negative comments tend to be careless remarks, and, in general, na
ıve alien-
ators support the child’s relationship with the other parent. Active alienators
are more consistent and determined in their alienating behaviors. There is an
intentional desire to criticize and undermine the targeted parent. Deep down,
however, active alienators realize that what they are doing is wrong and
potentially harmful to the child. By contrast, obsessed alienators are deter-
mined to destroy the child’s relationship with the targeted parent. Obsessed
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 103
alienators are extremists. They pressure the child to adopt their own negative
view of the targeted parent, put much pressure on the child to emphatically
reject the targeted parent, and cannot tolerate a good relationship between
the child and the targeted parent. Also, Darnall created a 49-item question-
naire to help determine the presence of behaviors that induce PAS (Darnall,
1998, pp. 18–22).
In 2000, Elizabeth Ellis published Divorce Wars: Interventions with Families
in Conflict. Ellis discussed parental alienation extensively in this book and
said, “Although the term [PAS] has not gained formal acceptance by the
American Psychiatric Association, it has come to be accepted by clinicians
working with families involved in postdivorce conflict. Definitions for PAS
have been unclear, because clinicians still confuse the child’s symptoms with
the parent’s behavior and the qualities of the relationship between the child
and the alienating parent” (Ellis, 2000, page 227). Ellis conceptualized PAS
as a mild form of folie
adeuxand she proposed DSM-style criteria for its
diagnosis. Ellis suggested that the diagnosis of PAS should require that the
child or adolescent manifest nine of the following twelve criteria: the child
maintains a delusion of being persecuted by a parent; the child uses the
mechanism of splitting to reduce ambiguity; the child denies any positive
feelings for the targeted parent; the attribution of negative qualities to the
targeted parent may take on a quality of distortion or bizarreness; the child
states “recollections” of events that occurred out of the child’s presence;
the child’s sense of persecution by the targeted parent has the quality of a
litany; the child, when faced with contact with the targeted parent, displays
a reaction of extreme anxiety; the child has a dependent and enmeshed
relationship with the alienating parent; the child is highly cooperative with
all adults other than the targeted parent; the child views the alienating parent
as a victim; the child maintains a complete lack of concern about the targeted
parent; and the child’s belief system is particularly rigid, fixed, and resistant to
traditional methods of intervention (adapted from Ellis, 2000, pp. 229–232).
In 2001, Richard Warshak published Divorce Poison, perhaps the best-known
book for both professionals and the general public regarding the topic of
parental alienation (Warshak, 2001a). A clinical professor at the Univer-
sity of Texas Southwestern Medical Center, Warshak has over 30 years of
experience in evaluating and treating children, adolescents, and families.
Warshak—among others—provided an explanation that we believe supports
the acceptance of PAS as an official diagnosis. He said, “PAS fits a basic pat-
tern of many psychiatric syndromes. Such syndromes denote conditions in
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
104 W. Bernet et al.
which people who are exposed to a designated stimulus develop a certain
cluster of symptoms. ... These diagnoses carry no implication that everyone
exposed to the same stimulus develops the condition, nor that similar symp-
toms never develop in the absence of the designated stimulus. ... Similarly,
some, but not all, children develop PAS when exposed to a parent’s neg-
ative influence. Other factors, beyond the stimulus of an alienating parent,
can help elucidate the etiology for any particular child” (Warshak, 2006).
In 2001, Diana Mercer and Marshal Kline Pruett published Your Divorce Advi-
sor: A Lawyer and a Psychologist Guide You Through the Legal and Emotional
Landscape of Divorce. Although this book is not exclusively devoted to PAS,
it does address this topic. The authors said, “The field of law and psychology
has created a term for when a child does not want to visit the nonresidential
parent, and expresses that refusal with venom and vehemence. The child
shows disregard for the parent, maybe even hatred. The term is Parental
Alienation Syndrome (PAS). PAS occurs when children become allied with
one parent to a degree that they refuse to have any contact with the other
parent. The hatred they express often reflects the feelings of their primary
parent. They become echoes of one parent’s disdain for the other. This may
be communicated directly to the children, until that parent cultivates negative
feelings in the children that become deep-rooted and unmalleable” (Mercer
and Pruett, 2001, p. 256).
In 2003, Philip M. Stahl, a psychologist who practiced in Arizona, explained
that pathological alienation is caused by the attitudes and behaviors of all
three parties, the aligned parent, the rejected parent, and the child. He also
emphasized, “When children are caught up in the midst of this conflict and
become alienated, the emotional response can be devastating to the child’s
development. The degree of damage to the child’s psyche will vary depend-
ing on the intensity of the alienation and the age and vulnerability of the
child. However, the impact is never benign because of the fact of the child’s
distortions and confusions” (Stahl, 2003). Stahl published extensively regard-
ing child custody evaluations and parenting children of divorce, including
three books (Stahl, 1994, 1999a, 2007).
In 2008, Michael Brock, a forensic mental health professional in private
practice, and Samuel Saks, an attorney, published Contemporary Issues in
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 105
Family Law and Mental Health. This book was part of the American Series in
Behavioral Science and Law. Although not exclusively about PAS, the authors
discussed this topic. They said, “The motivation behind a pattern of alienation
is not difficult to discover if one considers all the surrounding circumstances.
Yet it does require mental health professionals to undertake a thorough
investigation of the situation and not merely accept the presenting parent’s
perspective. ... False allegations of abuse represent the most extreme form
of alienation” (Brock and Saks, 2008, p. 87).
In 2009, Wiley InterScience published The Wiley Encyclopedia of Forensic
Science, described as “the defining major reference work for forensic sci-
entists and the legal profession.” This encyclopedia includes an entry on
parental alienation syndrome in which the authors said, “This article sum-
marizes parental alienation, a child’s rejection of an appropriate parent in
the context of a high conflict divorce. Mental health professionals are often
asked to evaluate children of separated or divorced parents for the presence
of parental alienation. This article explains the psychodynamics and etiology
of parental alienation. Custody recommendations and treatment strategies
are discussed to aid custody evaluators, judges, and lawyers, and guide fam-
ilies to address this very difficult problem that can destroy families and hurt
children” (Kenan and Bernet, 2009).
Numerous mental health practitioners and social researchers have ob-
served PAS and published their observations. Hundreds of articles have been
published in peer-reviewed mental health and legal journals. (See the com-
prehensive bibliography beginning on page 143 of this document.) The con-
sistency and redundancy of these observations have confirmed the existence
of “a disturbance in which children were preoccupied with deprecation and
criticism of a parent—denigration that was unjustified and or exaggerated”
(Gardner, 1992a, page 59). Drawing from the numerous collective observa-
tions, we consider parental alienation and PAS to be valid concepts.
Parental Alienation Is a Valid Concept. Although It Was Originally
Described in the U.S., Parental Alienation Has Been Identified and
Studied in Many Countries
Parental alienation was originally described in the United States indepen-
dently by six different researchers or research groups, as discussed earlier
in this article. Parental alienation has been studied extensively in the United
States, where many mental health and legal professionals have written about
it. However, it is extremely important to note that practitioners in many other
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
106 W. Bernet et al.
countries have recognized the same phenomenon. In some cases, these pro-
fessionals heard about Richard Gardner’s criteria for PAS, and they found
it helpful to apply those criteria to their own patients and clients. In other
cases, the mental health and legal professionals in other countries noticed a
particular pattern among the children of high-conflict divorces, and they sub-
sequently realized that these children met the Gardner criteria for PAS. The
bibliography of this article cites publications from the professional literature
of twenty-seven countries.
The most exhaustive single volume regarding PAS is The International
Handbook of Parental Alienation Syndrome (Gardner et al., 2006), which
was part of the American Series in Behavioral Science and Law published
by Charles C. Thomas. More than thirty mental health professionals wrote
chapters for this book, including authors from Australia, Canada, the Czech
Republic, England, Germany, Israel, Sweden, and the United States. This
book received positive reviews. Pressmann (2007) said, The International
Handbook of Parental Alienation Syndrome is a powerful volume that pro-
vides therapists and justices a wealth of knowledge and wisdom that may
positively impact the lives of children who have become fodder in marital
and custodial conflicts.” Dunkley (2007) said, “The strengths of this volume
are its comprehensiveness and its clinical components. There is much to
learn from the contributions about how children are manipulated in the af-
termath of separation, and how to prevent and repair the damage. I would
recommend it to any child welfare professional, particularly those involved
in residency and contact disputes.”
In 1993, the legislature of Argentina adopted a law (Ley 24270) that provides
criminal penalties for “a parent or a third person who illegally prevents or ob-
structs contact of a minor with his or her nonresidential parent.” This law has
been used to prosecute parents who alienate their children against the other
parent. A book by Graciela N. Manonelles, Responsabilidad penal del padre
obstaculizador, La. Ley 24270. Sindrome de alienaci
on parental (SAP) (Crim-
inal Responsibility of the Obstructing Parent, Law 24270. Parental Alienation
Syndrome [PAS]), explains the concept of PAS and also discusses legal cases
and prosecution of alienators (Manonelles, 2005).
In 2008, two Argentines, Delia Susana Pedrosa and Jos
e Bouza, pub-
lished an important book, S
ındrome de Alienaci
on Parental. Proceso de ob-
on del v
ınculo entre los hijos y uno de sus progenitors (Parental Alien-
ation Syndrome: The Process of Obstructing the Bond between the Child and
Parent) (Pedrosa and Bouza, 2008). It is notable that this book received a
favorable review in the publication of the National Academy of Sciences of
Buenos Aires.
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 107
Sandra S. Berns, Ph.D., a professor at Griffith Law School, Brisbane, has
written extensively on family law. She conducted research regarding divorce
judgments in Brisbane, Australia, and found that parental alienation syn-
drome was present in 29% of cases (Berns, 2001). In commenting on the
role of PAS in family courts in Australia, Berns said, “Although the Australian
Family Court will admit evidence of PAS in appropriate cases ... and has
given that evidence weight in decision making, the intense politicization of
PAS remains a significant problem for the court. Injudicious statements both
by those advocating full legal recognition of PAS and by those opposing
such recognition have created a climate in which the courts and the legal
profession are skeptical and reluctant to move too far in advance of settled
legal and psychiatric opinion” (Berns, 2006).
Several mental health professionals in Belgium have observed and written
about PAS. A Belgian journal for mental health professionals, Divorce &
eparation, devoted its June 2005 issue to the topic of parental alienation. For
instance, that issue of the journal included an article by Didier Erwoine, M.A.,
a Belgian clinical psychologist, “Les traitements du Syndrome d’Ali
Parentale” (“Treatments of the Parental Alienation Syndrome”). Erwoine said
that one of the most dramatic elements of PAS was its often “incurable
and irreversible” aspect. In Erwoine’s opinion, it is absolutely essential to
combine psychotherapeutic treatment with court ordered measures in order
to reverse the PAS inducing process (Erwoine, 2005).
Benoit van Dieren, Ph.D., a psychologist, family therapist, family media-
tor, and expert, identified PAS in some of the families he assessed in Brussels.
He has started to educate mental health and legal professionals regarding
this topic. Van Dieren reported, “I have always perceived this ‘disorder’ as a
systemic problem, that is, a problem that can be understood only i f we con-
sider the complex and dynamic relationships between at least three poles:
the child, the father, and the mother, plus the other elements gravitating
around these poles such as the extended families, friends, new partners, and
the judicial and psychosocial systems.” In Belgium, van Dieren has helped
to organize a multidisciplinary group (a magistrate, a lawyer, a mediator,
and a psychologist) to study how to detect PAS and how to intervene when
it occurs. They have promoted an approach that is combined (both judicial
and psychological functions), coordinated, and rapid.
Jean Yves Hayez, M.D., Ph.D., a child psychiatrist at the Catholic Uni-
versity of Louvain, wrote a cautionary article, “L’Alienation Parentale, un
a haut risque” (“Parental Alienation: A high risk concept”) (Hayez
and Kinoo, 2005). Hayez thought the concept of parental alienation should
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
108 W. Bernet et al.
be limited to cases in which the toxicity of the guardian parent is evident,
for example, in psychotic or highly disturbed parents.
Finally, in 2008, Jean-Emile Vanderheyden, M.D., a neuropsychiatrist,
edited and published an important book, Approcher le divorce conflictuel
(Approaching Conflicting Divorces). This is a multidisciplinary book that
discusses high-conflict divorce from a number of perspectives. The chap-
ter authors include judges, lawyers, family mediators, social workers, neu-
ropsychiatrists, and psychologists. The book includes poignant statements by
mothers and fathers who experienced loss of their children through parental
alienation. There are discussions of the misdiagnosis of parental alienation
and the mismanagement of it by the justice system. The authors make various
suggestions ranging from the training of competent judges to the designation
of “a special day in the calendar” in order to improve societal awareness of
parental alienation.
Maria Berenice Dias is a distinguished appellate judge who has been a
leader in the Brazilian women’s movement, particularly fighting against
domestic violence. Judge Dias has been active—both in Brazil and
internationally—in teaching and writing about family law. Her website
( includes a notable article, “S
ındrome da
ao parental, o que
e isso?” (“Parental alienation syndrome, what is
it?”) (Portuguese). Judge Dias said, “Certainly everyone involved in the study
of family conflict and violence in interpersonal relationships has come across
a phenomenon that is not new, but that has been identified by more than
one name. Some call it ‘parental alienation syndrome,’ others refer to it as
‘implantation of false memories.’” After citing the work of “the American
psychiatrist, Richard Gardner,” Judge Dias said, “The child, who loves his
parent, is taken away from a father who also loves him. This generates a
conflict of feelings and a destruction of the bond between them. ... In this
game of manipulation, all weapons are used, including the assertion of the
child having been the victim of sexual abuse. ...The child cannot always dis-
cern that he is being manipulated and ends up believing what he was told in
such an insistent and repeated manner. Over time, even the mother cannot
distinguish the difference between truth and falsehood. Her truth becomes
the truth for the son, who lives with false characters of a false existence,
resulting then in false memories being implanted in his mind” (Dias, 2006).
Priscilla Maria Pereira Corr
ea da Fonseca, Ph.D., a law professor, pub-
lished an article in a pediatric journal, “S
ındrome de alienac¸
ao parentale”
(“Parental alienation syndrome”). She discussed the causes of PAS and how
to identify it. Corr
ea da Fonseca (2006) concluded, “To identify the parental
alienation and prevent this harmful process from affecting the child and con-
verting into a syndrome are tasks for the Justice. The family law lawyer must
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 109
prioritize the child and adolescent even when the alienating parents de-
mand their rights, including the refusal to support the cause of the alienating
parent.” Igor Nazarovicz Xax
a wrote a dissertation at Universidade Paulista,
ılia, which was titled, A S
ındrome de Alienac¸
ao Parentale eo Poder Ju-
ario (The Parental Alienation Syndrome and the Judiciary). Xax
a, who
apparently was himself an alienated or targeted parent, described how resis-
tant Brazilian officials were to appreciating the serious consequences of PAS
a, 2008). There is now a movement in the National Congress of Brazil
to adopt measures (Bill Number 4053) that address parental alienation and
seek to protect children and adolescents from this type of abuse.
Mental health and legal professionals in Canada have been familiar with
the concept of parental alienation for many years. Perhaps the earliest dis-
cussion of PAS in the professional literature in Canada was a 1991 arti-
cle by Anne-France Goldwater in a law journal, “Le syndrome d’ali
parentale” (Goldwater, 1991). In 1992, Abe Worenklein, Ph.D., a clinical
and forensic psychologist, published “Custody Litigation and Parental Alien-
ation” (Worenklein, 1992). More recently, Gold-Greenberg and Worenklein
(2001) published “L’ali
enation Parentale, un D
efi L
egal et Clinique pour les
Psychologues” (“Parental Alienation, a Legal and Clinical Challenge for Psy-
Hubert Van Gijseghem, Ph.D., a professor at the University Montreal,
has conducted research and written extensively regarding parental alien-
ation (Van Gijseghem, 2002, 2004, 2005b, 2009). For instance, he reported
his attempts to calculate the prevalence of parental alienation in metropoli-
tan Montreal in an interesting article, “L’Ali
enation parentale: Points con-
es” (“Parental alienation: Controversial points”). In this article, Van
Gijseghem acknowledged that the concept of parental alienation is not ac-
cepted by everybody, and he commented on the emotional debates regard-
ing this topic. He concluded, “That the phenomenon does exist, there is no
doubt, but we will have to wait another decade to resolve several aspects of
the controversy” (Van Gijseghem, 2005a). Van Gijseghem has also organized
training workshops regarding parental alienation for professionals in Canada
and European countries.
Marie H
ene Gagn
e, Ph.D., and Sylvie Drapeau, Ph.D., psychologists
at Laval University, Quebec, published “L’ali
enation parentale est-elle une
forme de maltraitance psychologique?” (“Is parental alienation a form of
psychological abuse?”). The authors proposed to use the conceptual and
theoretical frame of psychological abuse to study parental alienation. They
defined both concepts and described the conceptual links between them
e and Drapeau, 2005).
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
110 W. Bernet et al.
In 2008, Barbara Jo Fidler, Ph.D., Nicholas Bala, Rachel Birnbaum, Ph.D.,
and Katherine Kavassalis published Challenging Issues in Child Custody As-
sessments: a Guide for Legal and Mental Health Professionals. Fidler and
Birnbaum are mental health professionals; Bala and Kavassalis are lawyers.
In the chapter titled “Understanding Child Alienation and Its Impact on Fam-
ilies,” the authors said, “Children from separated and divorced families who
vigorously resist or refuse contact with one parent frequently are referred for
child custody assessments. ... There is significant debate in the mental health
and legal literature about the conceptualization and etiology of parent-child
contact problems, and about the most appropriate mental health interven-
tions and judicial remedies relating to them. Although most authors agree
that the phenomenon exists, finding an appropriate name for the problem is
also a subject of debate” (Fidler et al., 2008a, p. 203).
The Canadian Symposium for Parental Alienation Syndrome (CS-PAS)
is an international, educational conference for mental health professionals,
family law attorneys and other professionals dedicated to the prevention
and treatment of parental alienation and PAS. The CS-PAS conferences oc-
curred in March 2009 and October 2009 in Toronto. Additional information
is available at
Eduard Bakal
r, C.Sc., is a psychologist who began assessing custody dis-
putes for the Municipal Court in Prague in 1967. He has noted the occurrence
of parental alienation in the Czech Republic, where mental health profession-
als have published articles regarding this topic. Bakal
r also reported that
the phenomenon of parental alienation has been described in the Ukraine
and Russia, but the mental health professionals have no name for it because
they are not familiar with the literature and research published elsewhere.
r wrote extensively regarding parental alienation, including
ete proti druh
emu rodi
ci” (“Inciting the child against the other
parent” (Bakal
ak, 1996) and “Syndrom zavr
ı rodi
ce: P
oza, terapie” (“Parental alienation syndrome: Etiology, diagnostics, ther-
apy) (Bakal
r, 2006b). In his book, Pr
uvodce otcovstv
ım (A Guide through
Fatherhood), Bakal
r included a chapter regarding parental alienation syn-
drome i n the Czech Republic (Bakal
r, 2002). In another book chapter,
r discussed the psychodynamics of PAS. He said, “Competition and
narcissism may play a part in the rivalry between some parents who con-
sciously or unconsciously wish that their children will look like, act like,
and think like they do. ... Neurotic egotistical projection on the part of at
least one parent can cause the child to favor a point of view and take sides
when the child observes parental conflict and separation of the household”
r, 2006a, p. 302).
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 111
A Danish judge who has written extensively about family law, Svend
Danielsen, recently published Forældres Pligter–B
orns Rettigheder (Parents’
Duties—Children’s Rights). This judge was commissioned by Nordisk Minis-
ad (the Nordic Council of Ministers) to compare family law in English-
speaking countries (England, Scotland, Australia, and Canada) with the
Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) to look
for possible ideas for Nordic reforms. In this book, PAS was mentioned and
the phenomenon of parental alienation was discussed: “It can be that the res-
idential parent has such strong rejections against visiting rights for the other
parent that the child is affected. In English justice it is called ‘implacable hos-
tility.’ Another concept and manifestation of conflict is ‘parental alienation
syndrome.’ ... Generally it is unlucky to capitulate because of ill-disposed
parents, resulting in no visitation. ... If one of the parents makes the contact
difficult or impossible, a decision on residence for the child can be altered,
but this has to be the last way out, and the possibility cannot be used for
solving a relatively mild contact problem” (Danielsen, 2004, pp. 210–211).
The Danish organization, Foreningen Far til Støtte for Børn og Forældre
(Fathers in Support of Children and Parents) was established in 1977. This
organization convened a conference on parental alienation in 2002, and lec-
tures regarding parental alienation and PAS were presented by Erik Kofod
and Lena Hellblom Sj
ogren, Ph.D., a Swedish psychologist. The proceed-
ings of this conference were published in the organization’s yearbook, “On
Visitation and Parents’ Responsibility,” in September 2002.
Anja Hannuniemi, LL.Lic.—a lawyer, licentiate of law, and medical law
researcher—has conducted research and taught criminal law and medical
law at the University of Helsinki for twenty years. She is preparing a doctor’s
thesis about PAS. Hannuniemi has acted as an attorney, expert witness, and a
judge in very difficult cases involving children. When she heard about PAS in
2000, Hannuniemi immediately realized that PAS had been a factor in all of
the longest and most difficult custody disputes and compulsory guardianship
cases that she had been working on as an attorney. (“Compulsory guardian-
ship” means that the municipality becomes the custodian of the child instead
of the parents.) Hannuniemi thought that in many of these cases, PAS was
induced or made much worse by social workers involved with the divorced
families. Hannuniemi has worked hard to educate the judiciary in Finland
regarding PAS. For instance, in a lengthy article published in a Finnish legal
journal, she noted, “Alienation syndrome does not result only from the close
parent intentionally, semi-intentionally, or subconsciously acting to alienate
the child from the other parent, but its clinical picture also includes the part
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
112 W. Bernet et al.
of the child, in which he/she—following his/her sense of loyalty to the close
parent—is susceptible to the indoctrination practiced by that parent, and
actively alienates oneself from the distant parent” (Hannuniemi, 2007).
There is considerable interest in PAS among both mental health profession-
als and child advocates in France. An advocacy organization, Association
Contre L’ali
enation Parentale (ACALPA) (The Association against Parental
Alienation) was founded in 2004. This organization engages in extensive
education of parents, legal professionals, and mental health professionals
regarding PAS. ACALPA also organizes national programs for training police
and gendarmerie officers regarding PAS.
French psychiatrists have studied PAS and published papers regarding
this topic. Paul Bensussan, M.D., for example, a psychiatric expert for the
French courts, has specialized in cases of parental alienation and false allega-
tions of child sexual abuse. In 15 years, he has studied more than 800 cases
of high conflict divorce. In a recent article in a medical journal, “L’ali
parentale: vers la fin du d
eni?” (“Parental alienation: Toward the end of the
denial?”), Bensussan commented that PAS “arouses polemics and controver-
sies.” He said in the abstract, “Some go as far as denying the very existence
of the phenomenon itself, arguing that it is still absent from the international
classifications of psychiatric disorders (European or American). ... The au-
thor describes the difficulties encountered, by judges as well as by experts,
to evaluate the quality of the relationship before the split and to suggest
adequate solutions, in as much as the field of action is severely restricted
with such determined children or teenagers” (Bensussan, 2009).
Another psychiatric expert, Jean-Marc Delfieu, M.D., published in a le-
gal journal “Syndrome d’ali
enation parentale—Diagnostic et prise en charge
edico-juridique” (“Parental alienation syndrome—Diagnosis and medical-
legal management”). In this article, Delfieu described the recent increase
of cases with severe mental manipulation of children, which he saw in di-
vorce cases. He described the psychopathology, psychodynamics, and clini-
cal manifestation of PAS, with case examples. He proposed joint therapeutic
and judicial interventions (Delfieu, 2005).
Mireille Lasbats, Ph.D., a clinical psychologist and forensic expert,
published an article in an important legal journal, “Etude du syndrome
enation parentale
a partir d’une expertise civile” (“Study of the parental
alienation syndrome starting from a civil expertise”). Lasbats described the
identification of PAS in high-conflict divorces. With clinical cases she ex-
plained how to recognize this phenomenon and the risks to which the
alienated child, as well as the rejected parent, are exposed. Consistent with
Richard Gardner’s concept of PAS, Lasbats said the factors contributing to
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 113
this condition are the manipulation by a parent and the contribution of the
child to the denigration of the rejected parent (Lasbats, 2004).
Also, Jacques Tr
emintin, M.A., a social worker, published an article,
“Quand l ’enfant se retrouve pi
enation parentale” (“When the child
finds himself/herself trapped—Parental alienation”). Tr
emintin said, “The
concept of parental alienation seems to be very helpful to better understand
what is going on in certain families and work out intervention strategies for
professionals” (Tr
emintin, 2005).
A large number of German mental health and legal professionals have stud-
ied and commented on PAS. The first mention of “Parental Alienation Syn-
drome (PAS)” in the German professional literature was in 1995 by Wolf-
gang Klenner, Ph.D., a forensic psychologist, in an important article, “Rituale
der Umgangsvereitelung bei getrennt lebenden oder geschiedenen Eltern”
(“Rituals of contact refusal from parents in separation or divorce”). Klenner
mentioned PAS—when a child has been heavily manipulated by one parent
on whom it is dependent—as one of the possible causes of contact refusal
(Klenner, 1995).
In 1998, Ursula Kodjoe, M.A., a forensic psychologist, family therapist,
and mediator, and Peter Koeppel, J.D., a family law attorney, published
papers regarding PAS in Germany (Kodjoe and Koeppel, 1998a, 1998b,
1998c). These articles prompted an intensive discussion among mental health
and legal professionals in Europe regarding the phenomenon of parental
alienation and the diagnosis of parental alienation syndrome. Subsequently,
Kodjoe said, “Experts need to have several theories and concepts at their
disposal–amongst others, the PAS concept as an explanation for the refusal
of contact for manipulative reasons. Experts who equate any form of contact
refusal and the PAS concept did not understand the concept and must there-
fore reject it. The ‘estranged child’ is left out as a consequence. Manipulated
against the other by the care-taking parent, seldom by the visiting parent
and at the worst by both parents, the child internalizes the enemy image
and behaves accordingly. This emotional abuse seems to be a taboo and is
denied even by experts” (Kodjoe, 2003b).
Walter Andritzky, Ph.D., a forensic psychologist and sociologist, studied
PAS phenomena and published book chapters and articles in professional
journals regarding this topic (Andritzky, 2002a, 2002b, 2002c, 2003a, 2003b,
2003c). He published two book chapters regarding PAS in English, “Behav-
ioral Patterns and Personality Structure of Alienating Parents: Psychosocial
Diagnostic and Orientation Criteria for Intervention” (Andritzky, 2003d) and
“The Role of Medical Reports in the Development of Parental Alienation
Syndrome” (Andritzky, 2006). Andritzky described the behavioral patterns of
alienated children and the personality structure of alienating parents, as well
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
114 W. Bernet et al.
as the “natural” and “induced” symptoms of children affected by high conflict
separation or divorce. His articles assist professionals and institutions of the
health and legal systems to understand the psychodynamic and diagnostic
criteria of PAS and to make appropriate clinical and legal decisions in cases
involving PAS.
Wilfrid von Boch-Galhau, M.D., a psychiatrist and psychotherapist, and
Ursula Kodjoe studied adult survivors of PAS in Germany. In a book chapter
in English, they said, “The induction of PAS in the child must be considered
a form of psychological/emotional abuse. It can be connected with trau-
matizing long-term effects in the child that endure into adulthood. It is dif-
ficult to understand that this phenomenon—despite corresponding clinical
findings and despite relevant results of recent traumatology and victimol-
ogy research—is still trivialized, denied, or even opposed by many experts”
(Boch-Galhau and Kodjoe, 2006b, p. 310). They also published their find-
ings in a French journal, Synapse, Journal de Psychiatrie et Syst
eme Nerveux
Central (Boch-Galhau and Kodjoe, 2006a).
Also, Boch-Galhau, Kodjoe, Koeppel, and Andritzky organized the Inter-
national Conference on PAS that was held in Frankfurt, Germany, in October
2002. Richard Gardner presented a lecture at that conference. The proceed-
ings of this conference were published in their book, Das Parental Alienation
Syndrom: Eine interdisziplin
are Herausforderung f
ur scheidungsbegleitende
Berufe (The Parental Alienation Syndrome: An Interdisciplinary Challenge
for Professionals Involved with Divorce) (Boch-Galhau et al., 2003). Informa-
tion regarding this conference can be found on
Astrid Camps, M.D., a child psychiatrist in Germany, said, “Gardner’s
PAS concept proves helpful in child psychiatric practice. If the PAS problem
for the child of divorce is not solved, the psychiatric and psychosomatic
long-term consequences can be dramatic and for the child patient may be
accompanied by great suffering (Camps, 2003, p. 155).
Uwe Jopt, Ph.D., and Katharina Behrend, Ph.D., forensic psychologists
from the University of Bielefeld, published a well known pair of articles
regarding PAS. They described PAS as consisting of two stages. In the first
stage, the specific conditions for the development of PAS are met (instru-
mentalization and parentification of the child, denigration of the other parent,
with the custodial parent expecting the child to align to herself). In the sec-
ond stage, the syndrome is solidified. There occurs a reduction of cognitive
dissonance, a l ack of empathy, internal and external reinforcement. The au-
thors discussed possible methods of intervention by the various professions
(family court, social services, psychological experts, and lawyers) (Jopt and
Behrend, 2000a, 2000b).
In Germany, mental health and legal professionals, institutions, and
agencies use an important handbook, Kindesmisshandlung und Ver-
assigung (Child Abuse and Neglect). This book refers to the “Parental
Alienation Syndrome” as a particular kind of psychological violence against
Downloaded By: [VUL Vanderbilt University] At: 03:50 13 March 2010
Parental Alienation, DSM-V, and ICD-11 115
children in the context of custody and visitation conflicts (Deegener and
orner, 2005, pp. 684 and 694).
Daniel J. Gottleib, Psy.D., is a clinical psychologist who has served as a
court-appointed expert in child custody and adoption cases. In a book chap-
ter, Gottleib said, “In the Hebrew literature, PAS is referred to by different
names: syndrome nikur hori (parental alienation syndrome), hitnakrut he-
horeh (alienation from a parent), or sarvanut kesher (contact