Lena Hellblom Sjögren som i dag den 27 juli 2002 , när den viktiga nyheten om ett högt antal av barn utsätts för barnfridsbrott, vidaresänder ett väl underbyggt förslag av William Bernet och Amy Baker

/forwarding today a well founded suggestion by William Bernet and Amy Baker July 27, 2022, when the important Swedish news about a high number of children exposed to domestic violence is presented.

 Proposal for Parental Alienation Relational Problem to be Included in

“Other Conditions That May Be a Focus of Clinical Attention” _in DSM-5-TR

Submitted by William Bernet, M.D., and Amy J. L. Baker, Ph.D.

June 27, 2022

IDENTIFYING INFORMATION

William Bernet, M.D.

Professor Emeritus

Vanderbilt University School of Medicine

Nashville, Tennessee, USA

Cell phone: 001-615-330-0124

Email: william.bernet@vumc.org

Amy J. L. Baker, Ph.D.

Teaneck, New Jersey

Cell phone: 001-201-321-9874

Email: amyjlbaker@aol.com

BRIEF DESCRIPTION OF PROPOSED CHANGE

This document proposes that parental alienation be considered a relational problem in the chapter of DSM-5-T_R_,_ _“O_t_h_e_r_ _C_o_n_d_i_t_i_o_n_s_ _T_h_a_t_ _M_a_y_ _B_e_ _a_ _F_o_c_u_s_ _o_f_ _C_l_i_n_i_c_a_l_ _A_t_t_e_n_t_i_o_n_._” _This is the proposed wording for parental alienation relational problem (PARP):

Z62.898 Parental Alienation Relational Problem

This category may be used when a child—usually one whose parents are engaged in a high-conflict separation or divorce—allies strongly with one parent and rejects a relationship with the other parent without a good reason. The diagnosis of parental alienation relational problem usually requires five criteria: the child actively avoids, resists, or refuses a relationship with a parent; the presence of a prior positive relationship between the child and the now rejected parent; the absence of abuse or neglect or seriously deficient parenting on the part of the now rejected parent; the use of multiple alienating behaviors by the favored parent; and the manifestation of behavioral signs of alienation by the child. Parental Alienation Relational Problem, page 2

JUSTIFICATIONS FOR THE PROPOSED CHANGE

Rationale for Proposed Change

P_A_R_P_ _i_s_ _a_ _s_e_r_i_o_u_s_ _m_e_n_t_a_l_ _c_o_n_d_i_t_i_o_n_ _t_h_a_t_ _s_o_m_e_t_i_m_e_s_ _o_c_c_u_r_s_ _w_h_e_n_ _a_ _c_h_i_l_d_’s_ _p_a_r_e_n_t_s_ _a_r_e_ _e_n_g_a_g_e_d_ _in a high-conflict separation or divorce. For the child, it is painful to be caught in the battle-ground between their parents. For the alienated parent, it is humiliating, traumatic, and extremely frustrating to be irrationally rejected by a child, with whom they previously had an enjoyable, loving relationship. Both clinicians and forensic practitioners need to be able to: identify this condition when it is presented in both evaluation and therapy sessions; take steps to prevent its progression when it is mild in severity; and devise appropriate interventions when it is at a moderate or severe level of intensity.

Historical Context for This Proposal

The concept of PARP has been around for centuries in legal literature1 p 284 and for decades in mental health literature.2 p 153, 3 p 63 T_h_e_ _p_h_e_n_o_m_e_n_o_n_ _o_f_ _P_A_R_P_ _h_a_s_ _b_e_e_n_ _c_a_l_l_e_d_ _t_h_e_ _“i_n_t_e_r_d_e_-_p_e_n_d_e_n_t_ _t_r_i_a_d_,_”4 pp 48–49 “c_r_o_s_s_-g_e_n_e_r_a_t_i_o_n_a_l_ _c_o_a_l_i_t_i_o_n_,_”5 p 102 t_h_e_ _“M_e_d_e_a_ _s_y_n_d_r_o_m_e_,_”6 pp 195–196 “p_r_o_g_r_a_m_m_i_n_g_” _a_n_d_ _“b_r_a_i_n_w_a_s_h_i_n_g_,_”7 p 8 “n_o_t_-based-on-actual-i_n_t_e_r_a_c_t_i_o_n_,_”8 p 105 “d_i_v_o_r_c_e_-re-l_a_t_e_d_ _m_a_l_i_c_i_o_u_s_ _p_a_r_e_n_t_ _s_y_n_d_r_o_m_e_,_”9 p 96 “a_n_ _a_l_i_e_n_a_t_e_d_ _c_h_i_l_d_,_”10 p 251 a_n_d_ _“r_e_s_i_s_t_/_r_e_f_u_s_e_ _d_y_-_n_a_m_i_c_._”11 p 424

I_n_ _1_9_8_5_,_ _R_i_c_h_a_r_d_ _G_a_r_d_n_e_r_ _i_n_t_r_o_d_u_c_e_d_ _t_h_e_ _t_e_r_m_ _“p_a_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_o_n_ _s_y_n_d_r_o_m_e_” _(_P_A_S_)_._12 In recent years, most writers have stopped using the w_o_r_d_ _“s_y_n_d_r_o_m_e_” _a_n_d_ _s_i_m_p_l_y_ _r_e_f_e_r_r_e_d_ _t_o_ _t_h_i_s_ _p_h_e_-_n_o_m_e_n_o_n_ _a_s_ _“p_a_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_o_n_._” _F_o_r_ _p_u_r_p_o_s_e_s_ _o_f_ _t_h_i_s_ _p_r_o_p_o_s_a_l_,_ _w_e_ _a_r_e_ _u_s_i_n_g_ _t_h_e_ _t_e_r_m_ _“p_a_r_e_n_-_t_a_l_ _a_l_i_e_n_a_t_i_o_n_ _r_e_l_a_t_i_o_n_a_l_ _p_r_o_b_l_e_m_._” _

When DSM-5 was being developed, a group of scholars proposed in a lengthy journal article13 and a book14 t_h_a_t_ _t_h_i_s_ _c_l_i_n_i_c_a_l_ _e_n_t_i_t_y_ _b_e_ _i_n_c_l_u_d_e_d_ _a_s_ _e_i_t_h_e_r_ _“p_a_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_o_n_ _d_i_s_o_r_d_e_r_” _o_r_ _“p_a_-_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_o_n_ _r_e_l_a_t_i_o_n_a_l_ _p_r_o_b_l_e_m_._” _(Complimentary copies of the book, Parental Alienation, DSM-5, and ICD-11, are available for the DSM-5 Screening Committee upon request.)

During the development of DSM-5, the author of this proposal (WB) corresponded with members of the DSM-5 Task Force, including David J. Kupfer, M.D., Darrel A. Regier, M.D., William E. Nar-row, M.D., Roger Peele, M.D., Daniel S. Pine, M.D., and David Shaffer, M.D. All these individuals agreed on the reality of parental alienation phenomena. Most of them repeatedly said, both publicly and privately, that parental alienation could not be considered a mental disorder because parental alienation does not “reside i_n_s_i_d_e_” _t_h_e_ _d_e_s_i_g_n_a_t_e_d_ _p_a_t_i_e_n_t_._ _I_n_s_t_e_a_d_,_ _t_h_e_y_ _s_a_i_d_ _t_h_a_t_ _p_a_-_rental alienation was a mental condition—specifically, a relational problem—because it occurs between the designated patient (usually a child) and another person (usually a parent). Parental Alienation Relational Problem, page 3

For example, Darrel A. Regier wrote:

Dear Dr. Bernet:

Many thanks for your follow-up letter to Dr. Kupfer, Dr. Pine, and me regarding the proposed criteria for Parental Alienation Syndrome (PAS). You are correct in your understanding of our rationale behind excluding PAS from DSM-5. As you note, we consider this primarily a relational problem covered under the V-codes in ICD-9-CM and Z-codes in ICD-10-CM. It is not a health-r_e_l_a_t_e_d_ _c_o_n_d_i_t_i_o_n_ _t_h_a_t_ _r_e_s_i_d_e_s_ _w_i_t_h_i_n_ _a_n_ _i_n_d_i_v_i_d_u_a_l_._ _… _Therefore, it does not meet our standar_d_ _d_e_f_i_n_i_t_i_o_n_ _o_f_ _a_ _m_e_n_t_a_ _d_i_s_o_r_d_e_r_._ _… _T_h_a_n_k_ _y_o_u_ _again for reaching out to us about these matters.

Best regards,

Darrel A. Regier, M.D., M.P.H.

(Letter from Darrel A. Regier to William Bernet, October 12, 2012)

A_l_t_h_o_u_g_h_ _t_h_e_ _a_c_t_u_a_l_ _w_o_r_d_s_ _“p_a_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_o_n_” _w_e_r_e_ _n_o_t_ _i_n_c_l_u_d_e_d_ _i_n_ _D_S_M_-5, the concept of PARP w_a_s_ _i_n_c_l_u_d_e_d_ _i_n_ _t_h_r_e_e_ _d_i_f_f_e_r_e_n_t_ _d_i_a_g_n_o_s_e_s_ _i_n_ _t_h_e_ _c_h_a_p_t_e_r_ _o_n_ _“O_t_h_e_r_ _C_o_n_d_i_t_i_o_n_s_.” _Each of these diagnoses paraphrased the meaning of PARP in their respective definitions:

• • _Child affected by parental relationship distress (CAPRD) =_ _“… _n_e_g_a_t_i_v_e_ _e_f_f_e_c_t_s_ _o_f_ _p_a_-_rental relationship discord (e.g., high levels of conflict, distress, or disparagement) o_n_ _a_ _c_h_i_l_d_ _i_n_ _t_h_e_ _f_a_m_i_l_y_._” _

• • _Parent–child relational problem =_ _“n_e_g_a_t_i_v_e_ _a_t_t_r_i_b_u_t_i_o_n_s_ _o_f_ _t_h_e_ _o_t_h_e_r_’s_ _i_n_t_e_n_t_i_o_n_s_,_ _h_o_s_t_i_l_i_t_y_ _t_o_w_a_r_d_ _t_h_e_ _o_t_h_e_r_,_ _a_n_d_ _u_n_w_a_r_r_a_n_t_e_d_ _f_e_e_l_i_n_g_s_ _o_f_ _e_s_t_r_a_n_g_e_m_e_n_t_._” _

• • _Child psychological abuse =_ _“h_a_r_m_i_n_g_/_a_b_a_n_d_o_n_i_n_g_ _p_e_o_p_l_e_ _o_r_ _things that the child c_a_r_e_s_ _a_b_o_u_t_._” _

Practitioners were advised that if they identified a case of parental alienation, they could use one or more of those terms to classify the client, depending on the focus of attention. That is, CAPRD was appropriate if the focus was on the mental condition of the child; parent-child relational problem was appropriate if the focus was on the relationship between the child and the rejected parent, and child psychological abuse was appropriate if the focus was on the alienating behaviors of the favored parent.

Following the publication of DSM-5, Bernet, Wamboldt, and Narrow15 published an article, “C_h_i_l_d_ _A_f_f_e_c_t_e_d_ _b_y_ _P_a_r_e_n_t_a_l_ _R_e_l_a_t_i_o_n_s_h_i_p_ _D_i_s_t_r_e_s_s_,_” _i_n_ _t_h_e_ _Journal of the American Academy of Child and Adolescent Psychiatry. They said that CAPRD is a heterogeneous concept that covers at least four family scenarios: children exposed to intimate partner distress; children exposed to Parental Alienation Relational Problem, page 4

intimate partner violence; children experiencing intense loyalty conflict; and children experiencing parental alienation (see Appendix A).

Possible Negative Consequences of Proposed Change

Critics of the concept of parental alienation have claimed that abusive fathers assert that their children avoid having a relationship with them because their mothers have alienated the children against them. In this way, fathers are allegedly using the concept of parental alienation as a_ _w_a_y_ _t_o_ _d_e_f_l_e_c_t_ _r_e_s_p_o_n_s_i_b_i_l_i_t_y_ _f_o_r_ _t_h_e_ _c_h_i_l_d_’s_ _r_e_j_e_c_t_i_o_n_ _o_f_ _t_h_e_m_._ _Of course, any psychiatric diagnosis that finds its way into legal proceedings may be abused by inept expert witnesses and un-principled attorneys. For example, it has been said that posttraumatic stress disorder (PTSD) is the most widely misused psychiatric concept in legal settings. That does not mean that PTSD and PARP should be disallowed or dismissed, but that these terms should be used correctly by clinicians, forensic practitioners, lawyers, and judges.

Controversies or Disagreements among Researchers and Clinicians

Even the most vocal critics of PARP agree that the phenomenon occurs. For example, Madelyn S. Milchman, Robert Geffner, and Joan S. Meier16 said:

One more important distinction must be made: None of the authors of this article dispute the need to identify, assess, and treat parent-child relationship problems where a parent may have manipulated a child to reject the other p_a_r_e_n_t_._ _… _H_o_w_e_v_e_r_,_ _w_e_ _s_t_r_o_n_g_l_y_ _object to using the label_ _“a_l_i_e_n_a_t_i_o_n_” _a_s_ _a_ _d_i_a_g_n_o_s_t_i_c_,_ _s_c_i_e_n_t_i_f_i_c_,_ _o_r_ _p_s_y_c_h_o_-legal construct in place of an objective and comprehensive causal assessment, whether that assessment is done as a child custody evaluation or as a careful review of the facts by judges or other decisionmakers. (p. 342)

F_o_r_ _s_o_m_e_ _r_e_a_s_o_n_,_ _t_h_e_s_e_ _a_u_t_h_o_r_s_ _w_a_n_t_ _t_o_ _u_s_e_ _t_h_e_ _g_e_n_e_r_i_c_ _t_e_r_m_ _“b_a_d_ _p_a_r_e_n_t_i_n_g_” _f_o_r_ _t_h_e_ _a_c_t_i_v_i_t_i_e_s_ _t_h_a_t_ _m_o_s_t_ _w_r_i_t_e_r_s_ _r_e_f_e_r_ _t_o_ _a_s_ _“a_l_i_e_n_a_t_i_n_g_ _b_e_h_a_v_i_o_r_s_._” _T_h_e_ _t_e_r_m_ _“b_a_d_ _p_a_r_e_n_t_i_n_g_” _m_i_s_s_e_s_ _t_h_e_ _i_n_t_e_n_-_tionality and toxicity of typical alienating behaviors. Of course, everyone agrees that a custody e_v_a_l_u_a_t_i_o_n_ _s_h_o_u_l_d_ _c_o_n_s_i_s_t_ _o_f_ _“o_b_j_e_c_t_i_v_e_ _a_n_d_ _c_o_m_p_r_e_h_e_n_s_i_v_e_” _p_r_o_c_e_d_u_r_e_s_._ _

Some widely held opinions of critics of PARP are simply misunderstandings or misinformation regarding parental alienation theory. Critics have repeatedly made the false claim that proponents of parental alienation theory assume that every instance of contact refusal was caused by the alienating behaviors of the favored parent. That idea is misinformation that has been repeated over and over again in journal articles and book chapters by parental alienation critics.17 Instead, parental alienation theory holds that not all instances of contact refusal are caused by alienating behaviors of the favored parent; and alienating behaviors by Parent A do not always cause children to reject Parent B. Parental Alienation Relational Problem, page 5

The great majority of practitioners (who are familiar with parental alienation) agree on the basic principles of the theory. (See research described below.) There are relatively minor disagreements regarding diagnosis and interventions for PARP. There may be disagreements on how to distinguish mild, moderate, and severe levels of PARP. There may be disagreements regarding the interventions for these levels of severity.

MAGNITUDE OF PROPOSED CHANGE

W_e_ _u_n_d_e_r_s_t_a_n_d_ _t_h_a_t_ _t_h_e_ _a_d_d_i_t_i_o_n_ _o_f_ _a_ _n_e_w_ _c_o_n_d_i_t_i_o_n_ _t_o_ _“O_t_h_e_r_ _C_o_n_d_i_t_i_o_n_s_ _T_h_a_t_ _M_a_y_ _B_e_ _a_ _F_o_c_u_s_ _o_f_ _C_l_i_n_i_c_a_l_ _A_t_t_e_n_t_i_o_n_” _i_s_ _c_o_n_s_i_d_e_r_e_d_ _a_ _s_u_b_s_t_antial change. Although PARP may represent a substantial change with regard to DSM nosology, it is not a large change with respect to the public awareness of this condition, the use of this concept by mental health practitioners, and the activities of researchers.

Harman et al.18 recently published a comprehensive review of parental alienation literature. They identified more than one thousand articles and books that pertained primarily to parental alienation theory. They excluded the material that contained no data; they ultimately reviewed in detail 207 empirical research studies described in articles and books (see Appendix B). The following graph demonstrates how qualitative and quantitative research regarding parental alienation theory has grown over time:

More than 100 books have been published regarding PARP, most of them written by psychiatrists, psychologists, and other mental health professionals; some were written by alienated Parental Alienation Relational Problem, page 6

parents or formerly alienated children describing their lived experiences (see Appendix C).

The exact threshold for the requirement of em_p_i_r_i_c_a_l_ _r_e_s_e_a_r_c_h_ _t_o_ _b_e_ _i_n_c_l_u_d_e_d_ _i_n_ _“O_t_h_e_r_ _C_o_n_d_i_-_t_i_o_n_s_” _i_s_ _u_n_c_l_e_a_r_. There has been an overwhelming amount of qualitative and quantitative research regarding PARP; only a fraction of those studies is explicitly noted in this proposal. Ironically, the novel diagnosis of CAPRD was added to t_h_e_ _c_h_a_p_t_e_r_ _o_n_ _“O_t_h_e_r_ _C_o_n_d_i_t_i_o_n_s_” _i_n_ _DSM-5 even though there had never been a single peer-reviewed article regarding that condition prior to the publication of DSM-5 in 2013.

SUMMARY OF DATA ON CLINICAL UTILITY

Summary of Information Regarding the Clinical Utility in Several Populations

There is vast professional literature regarding PARP, which relates qualitative research from diverse national, cultural, and ethnic groups. After parental alienation was described by Gardner a_n_d_ _o_t_h_e_r_ _w_r_i_t_e_r_s_ _i_n_ _t_h_e_ _1_9_9_0_’s_ _a_n_d_ _2_0_0_0_’s_,_ _p_s_y_c_h_i_a_t_r_i_s_t_s_ _a_n_d_ _p_s_y_chologists in countries on six continents reported that the same mental condition occurred in children and families in their own practices. Most of these articles constituted case reports of this mental condition; some authors commented on the intransigence of alienating parents and the difficulties encountered in trying to help alienated children have a good relationship with both parents.

Peer-reviewed publications regarding PARP have appeared in professional literature in more than 50 countries (see Table 1). Of course, the implications regarding clinical utility are that practitioners and researchers in many countries will benefit from standardized definitions and diagnostic criteria for this mental condition. If practitioners understand PARP, they will be able to help children and families who are struggling with this mental condition. Parental Alienation Relational Problem, page 7

__________________________________________________________________

Table 1. Parental alienation has been described in the mental health literature of the following countries:

Algeria

Argentina

Australia

Austria

Belgium

Brazil

Canada

Columbia

Chile

Costa Rica

Croatia

Cuba

Czech Republic

Denmark

Ecuador

Finland

France

Germany

Hong Kong

India

Indonesia

Ireland

Israel

I_t_a_l_y_ _

J_a_p_a_n_ _

K_o_r_e_a_ _

L_a_t_v_i_a_ _

Lithuania

Malaysia

Malta

Mexico

Morocco

Netherlands

New Zealand

Norway

Peru

Poland

Portugal

Romania

Russia

South Africa

S_p_a_i_n_ _

S_w_e_d_e_n_ _

S_w_i_t_z_e_r_l_a_n_d_ _

T_a_i_w_a_n_ _

T_u_r_k_e_y_ _

U_k_r_a_i_n_e_ _

U_n_i_t_e_d_ _K_i_n_g_d_o_m_ _

S_c_o_t_l_a_n_d_ _

W_a_l_e_s_ _

N_o_r_t_h_e_r_n_ _I_r_e_l_a_n_d_ _

U_n_i_t_e_d_ _S_t_a_t_e_s_ _

P_u_e_r_t_o_ _R_i_c_o_ _

U_r_u_g_u_a_y_

____________________________________________________________________

Empirical Studies Regarding Validity and Reliability

In addition to the qualitative research described above, there has been quantitative research that addressed the validity and reliability of PARP. The diagnosis of PARP is based on the following five specific factors19, 20 (see Appendix D):

• • _O_n_e_:_ _T_h_e_ _c_h_i_l_d_ _a_c_t_i_v_e_l_y_ _a_v_o_i_d_s_,_ _r_e_s_i_s_t_s_,_ _o_r_ _r_e_f_u_s_e_s_ _a_ _r_e_l_a_t_i_o_n_s_h_i_p_ _w_i_t_h_ _a_ _p_a_r_e_n_t_._ _
• • _Two: Presence of a prior positive relationship between the child and the now rejected parent.
• • _Three: Absence of abuse or neglect or seriously deficient parenting on the part of the now rejected parent.
• • _F_o_u_r_:_ _U_s_e_ _o_f_ _m_u_l_t_i_p_l_e_ _a_l_i_e_n_a_t_i_n_g_ _b_e_h_a_v_i_o_r_s_ _b_y_ _t_h_e_ _f_a_v_o_r_e_d_ _p_a_r_e_n_t_._ _
• • _Five: Exhibition of many or all of the eight behavioral manifestations of alienation by the child.

Parental Alienation Relational Problem, page 8

The validity of Factors One, Two, and Three are untestable. They simply comprise the definition of PARP, so they are required for the diagnosis of this mental condition. There may be rare exceptions. For example, Factor Two (prior positive relationship) may not be present if Parent A withheld the child from Parent B starting with the birth of the child. Factor Three (absence of abuse or neglect) may not apply if domestic violence occurred many years previously and the child subsequently enjoyed a healthy relationship with the formerly abusive parent.

The validity of Factor Four was established in the following studies:

Baker and Darnall (2006).21 Ninety-seven self-reported targeted parents completed a survey about the actions and attitudes of the other parent. Over 1,300 specific behaviors were mentioned, which were independently coded by the two authors. They were reduced to eleven categories of parental alienation behaviors.

Baker (2007).22 Baker was one of the first psychologists to conduct systematic research regarding parental alienation syndrome and parental alienation. In this research project, Baker collected the life stories of adults who had previously experienced parental alienation syndrome as children.

Baker and Chambers (2011).23 One hundred five undergraduate or graduate students completed a survey regarding their recollections of exposure to parental alienating behaviors by a parent during their childhood. Results revealed that 80% of the sample reported some exposure and those whose parents were divorced reported statistically significant higher levels of exposure.

Baker and Verrocchio (2013).24 Two hundred fifty-seven undergraduate students completed a survey, the Baker Strategies Questionnaire (BSQ) about their recollection of their childhood exposure to alienating behaviors by a parent as well as measures of current functioning. Results revealed statistically significant associations between exposure to parental alienating behaviors and current self-esteem, depression, alcohol abuse, self-direction, and cooperation.

Baker and Eichler (2014).25 One hundred fifty-seven college students completed a survey about their recollections of childhood exposure to alienating behaviors by their parents. Those whose parents were separated/divorced reported higher levels as did those who reported that their pa_r_e_n_t_s_’ _m_a_r_r_i_a_g_e_ _w_a_s_ _p_o_o_r_ _q_u_a_l_i_t_y_._ _T_h_e_ _h_i_g_h_e_r_ _t_h_e_ _r_a_t_e_ _o_f_ _e_x_p_o_s_u_r_e_,_ _t_h_e_ _g_r_e_a_t_e_r_ _t_h_e_ _r_e_p_o_r_t_ _o_f_ _psychological maltreatment.

Verrocchio, Baker, and Bernet (2016).26 Exposure to alienating behaviors was associated with maltreatment, which was associated with parental bonding, which was associated with each of the three mental health outcomes: depression, state anxiety, and trait anxiety. The authors Parental Alienation Relational Problem, page 9

conclude that exposure to alienating behaviors in childhood represents a risk factor for subsequent poor mental health.

The validity of Factor Five was established in the following studies:

Baker and Darnall (2007).27 Sixty-eight parents were surveyed about the behaviors of their children from whom they reported to be alienated. Results revealed general support for the presence of the eight behavioral manifestations of alienation as well as windows of opportunity w_h_e_n_ _e_v_e_n_ _t_h_e_ _m_o_s_t_ _a_l_i_e_n_a_t_e_d_ _c_h_i_l_d_r_e_n_ _d_e_m_o_n_s_t_r_a_t_e_ _“c_r_a_c_k_s_ _i_n_ _t_h_e_ _a_r_m_o_u_r_,_” _p_o_i_n_t_i_n_g_ _t_o_w_a_r_d_ _avenues for intervention.

Baker and Eichler (2014).28 One hundred fifty-seven college students completed a survey about their recollections of childhood exposure to alienating behaviors by their parents. Those whose parents were separated/divorced reported higher levels as did those who reported that their pa_r_e_n_t_s_’ _m_a_r_r_i_a_g_e_ _w_a_s_ _p_o_o_r_ _q_u_a_l_i_t_y_._ _T_h_e_ _h_i_g_h_e_r_ _t_h_e_ _r_a_t_e_ _o_f_ _e_x_p_o_s_u_r_e_,_ _t_h_e_ _g_r_e_a_t_e_r_ _t_h_e_ _r_e_p_o_r_t_ _o_f_ _psychological maltreatment.

The reliability of the diagnostic criteria for PARP was addressed in the following studies:

Rueda (2004).29 This was a small study of inter-rater reliability (14 participants for the test and 10 for the re-test). Rueda presented 5 case vignettes, some of which had 8 signs characteristic of parental alienation. He found that the manifest behaviors were recognizable and reliable for identifying parental alienation.

Morrison (2006).30 Morrison replicated the Rueda (2004) study using the same vignettes. He concluded that the 8 manifest behaviors are reliable in identifying parental alienation. The sample size consisted of 32 raters for the test and 20 for the re-test.

Baker (2018).19 Sixty-eight mental health professionals completed surveys, which addressed the Four-Factor Model for the identification of parental alienation. Baker reported that reliability was quite high across the vignettes, coders, and factors. There was agreement that when all four factors are present the case is alienation and when one or no factor is present it is not alienation. (The Four-Factor Model evolved to the Five-Factor Model used in this proposal. The only difference is the addition of the new Factor One, the requirement that the child manifests contact refusal.)

Morrison and Ring (2021).31 Six vignettes related to parental alienation were presented to a panel of mental health professionals; the number of respondents ranged between 34 and 61 f_o_r_ _e_a_c_h_ _v_i_g_n_e_t_t_e_._ _T_h_e_ _a_u_t_h_o_r_s_ _s_a_i_d_,_ _“The Intraclass Correlation Coefficient indicated reliability with an average of 0.923 for all vignettes. The Cronbach Alpha values indicate consistency, with a_n_ _a_v_e_r_a_g_e_ _o_f_ _0_._9_2_6_._” _T_h_u_s_,_ _t_h_e_ _F_i_v_e_-Factor Model was determined to be a reliable assessment Parental Alienation Relational Problem, page 10

tool for parental alienation.

Parameters of Clinical Utility Such as_ _U_s_e_r_ _A_c_c_e_p_t_a_b_i_l_i_t_y_,_ _C_l_i_n_i_c_i_a_n_s_’ _A_b_i_l_i_t_y_ _t_o_ _A_p_p_l_y_ _D_i_a_g_n_o_s_t_i_c_ _Criteria Accurately, C_l_i_n_i_c_i_a_n_s_’ _A_d_h_e_r_e_n_c_e_ _t_o_ _P_r_a_c_t_i_c_e_ _G_u_i_d_e_l_i_n_e_s_ _

The acceptability of the concept of PARP can be addressed in four tiers: (1) the acceptance of the general concept of PARP by large professional organizations; (2) the publication of information regarding parental alienation in major textbooks and reference works; (3) the acceptance of the general concept of PARP by groups of practitioners; and (4) the acceptance of the definitions of specific components of parental alienation theory by groups of practitioners.

American Academy of Child and Adolescent Psychiatry (AACAP). In 1997, AACAP published Practice Parameters for Child Custody Evaluation, a_n_ _“A_A_C_A_P_ _O_f_f_i_c_i_a_l_ _A_c_t_i_o_n_” _t_h_a_t_ _w_a_s_ _a_d_o_p_t_e_d_ _by the governing body of the organization. The practice parameters explicitly referred to and e_x_p_l_a_i_n_e_d_ _t_h_i_s_ _t_o_p_i_c_ _u_n_d_e_r_ _t_h_e_ _h_e_a_d_i_n_g_,_ _“P_a_r_e_n_t_a_l_ _A_l_i_e_n_a_t_i_o_n_._”32

Association of Family and Conciliation Courts (AFCC). In 2005, AFCC published Guidelines for Parenting Coordination, which included a discussion of “F_a_m_i_l_y_ _D_y_n_a_m_i_c_s_ _i_n_ _S_e_p_a_r_a_t_i_o_n_ _a_n_d_ _D_i_-_vorce.” _The AFCC document addressed topics such as “d_e_a_l_i_n_g_ _w_i_t_h_ _h_i_g_h_ _c_o_n_f_l_i_c_t_ _p_a_r_e_n_t_s_” _a_n_d_ _“t_h_e_ _d_y_n_a_m_i_c_s_ _o_f_ _c_h_i_l_d_ _a_l_i_g_n_m_e_n_t_s_,_ _e_s_t_r_a_n_g_e_m_e_n_t_s_ _a_n_d_ _a_l_i_e_n_a_t_i_o_n_._”33 p 18 In 2019, AFCC published Guidelines for Parenting Coordination. That document addressed the “c_o_n_t_i_n_u_u_m_ _o_f_ _p_a_r_-_ent–child contact problems (e.g., affinity, alignments, realistic estrangement, alienation, hybrid) and levels of severity in cases involving resist-r_e_f_u_s_e_ _d_y_n_a_m_i_c_s_._”34 p 3 In 2022, AFCC published Guidelines for Parenting Plan Evaluations in Family Law Cases. In discussing the education, t_r_a_i_n_i_n_g_,_ _a_n_d_ _c_o_m_p_e_t_e_n_c_e_ _o_f_ _c_u_s_t_o_d_y_ _e_v_a_l_u_a_t_o_r_s_,_ _t_h_a_t_ _d_o_c_u_m_e_n_t_ _s_t_a_t_e_d_:_ _“B_e_c_a_u_s_e_ _o_f_ _t_h_e_ _m_a_n_y_ _complex issues that arise in family law cases, evaluators should have education and training in the following foundational areas: (9) parent-child contact problems and resist-refuse dynamics, i_n_c_l_u_d_i_n_g_ _p_o_s_s_i_b_l_e_ _u_n_d_e_r_l_y_i_n_g_ _c_a_u_s_s_e_s_ _s_u_c_h_ _a_s_ _p_a_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_n_g_ _b_e_h_a_v_i_o_r_s_ _…”35 p 10

American Academy of Matrimonial Lawyers (AAML). In 2015, AAML published Child Centered Residential Guidelines. That document do_e_s_ _n_o_t_ _i_n_c_l_u_d_e_ _t_h_e_ _w_o_r_d_s_ _“p_a_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_o_n_,_” _b_u_t_ _c_l_e_a_r_l_y_ _d_e_s_c_r_i_b_e_s_ _t_h_e_ _p_r_o_b_l_e_m_:_ _“A_ _c_h_i_l_d_ _m_a_y_ _a_l_s_o_ _r_e_s_i_s_t_ _p_a_r_e_n_t_i_n_g_ _d_u_e_ _t_o_ _c_o_n_t_r_i_v_e_d_ _o_r_ _m_a_g_n_i_f_i_e_d_ _concerns regarding a parent that may be supported by the non-rejected parent. In cases where the concerns are unsupported or exaggerated, early and ongoing Court intervention is imperative to halt the conduct of the parent and to provide immediate consequences for the violation of cour_t_ _o_r_d_e_r_s_._” _The AAML Guidelines also lists several alienating behaviors.36 p 36–37

American Academy of Pediatrics (AAP). In 2016, the AAP published a clinical report called “H_e_l_p_i_n_g_ _C_h_i_l_d_r_e_n_ _a_n_d_ _F_a_m_i_l_i_e_s_ _D_e_a_l_ _w_i_t_h_ _D_i_v_o_r_c_e_ _a_n_d_ _S_e_p_a_r_a_t_i_o_n_._” _T_h_a_t_ _r_e_p_o_r_t_ _s_a_i_d_,_ _“A_l_i_e_n_a_t_i_o_n_ _of the child and the targeted parent is a frequent problem that needs practical professional input to correct the negative e_f_f_e_c_t_s_ _o_n_ _a_l_l_ _p_a_r_t_i_e_s_._”37 Parental Alienation Relational Problem, page 11

National and international meetings and educational programs. Many professional organizations have accepted papers and symposiums regarding parental alienation at conferences for mental health and legal professionals:

• • _American Academy of Child and Adolescent Psychiatry (2010, 2012, 2017)
• • _A_m_e_r_i_c_a_n_ _A_c_a_d_e_m_y_ _o_f_ _F_o_r_e_n_s_i_c_ _S_c_i_e_n_c_e_s_ _(_2_0_1_0_,_ _2_0_1_2_,_ _2_0_1_9_)_ _
• • _A_m_e_r_i_c_a_n_ _A_c_a_d_e_m_y_ _o_f_ _P_s_y_c_h_i_a_t_r_y_ _a_n_d_ _t_h_e_ _L_a_w_ _(_2_0_1_0_,_ _2_0_1_4_)_ _
• • _A_m_e_r_i_c_a_n_ _C_o_l_l_e_g_e_ _o_f_ _F_o_r_e_n_s_i_c_ _P_s_y_c_h_o_l_o_g_y_ _(_2_0_1_3_)_ _
• • _American Psychiatric Association (2011, 2013, 2022)
• • _American Psychological Association (2011, 2016)
• • _Association of Family and Conciliation Courts (2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2016, 2017, 2018, 2019, 2020)
• • _A_s_s_o_c_i_a_t_i_o_n_ _S_u_i_s_s_e_ _P_o_u_r_ _l_a_ _C_o_p_a_r_e_n_t_a_l_i_t_é _(_S_w_i_t_z_e_r_l_a_n_d_,_ _2_0_2_2_)_ _
• • _European Association of Parental Alienation Practitioners (Czech Republic, 2017; United Kingdom, 2018).
• • _VI Congreso Nacional de Psicologia Juridica y Forense (Spain, 2011)
• • _V_I_ _C_o_n_g_r_e_s_s_o_ _L_u_s_o_b_r_a_s_i_l_e_i_r_o_ _A_l_i_e_n_a_c_a_o_ _P_a_r_e_n_t_a_l_ _(_B_r_a_z_i_l_,_ _2_0_2_2_)_ _
• • _European Association for Forensic Child & Adolescent Psychiatry (Switzerland, 2010; Italy, 2018)
• • _International Association for Relationship Research (Canada, 2016; USA 2018; UK, 2019)
• • _International Conference on Shared Parenting (USA, 2018; Greece, 2019; Canada, 2020
• • _I_n_t_e_r_n_a_t_i_o_n_a_l_ _C_o_n_g_r_e_s_s_ _o_f_ _P_s_y_c_h_o_l_o_g_y_ _(_J_a_p_a_n_,_ _2_0_1_6_)_ _
• • _I_n_t_e_r_n_a_t_i_o_n_a_l_ _C_o_n_g_r_e_s_s_ _o_n_ _F_o_r_e_n_s_i_c_ _P_s_y_c_h_o_l_o_g_y_ _(_B_r_a_z_i_l_,_ _2_0_2_2_)_ _
• • _International Congress on Law and Mental Health (The Netherlands, 2013; Czech Re-public, 2017; Italy, 2019; France, 2022)
• • _International Society for Interpersonal Acceptance and Rejection (India, 2013; Spain, 2016; United States, 2022)
• • _International Conferences of Parental Alienation Study Group (United States, 2017; Sweden, 2018; United States, 2019; Belgium 2021).
• • _W_o_r_l_d_ _C_o_n_g_r_e_s_s_ _o_f_ _P_s_y_c_h_i_a_t_r_y_ _(_S_p_a_i_n_,_ _2_0_1_4_)_._ _

Authoritative textbooks and encyclopedias. The topic of parental alienation has been discussed and explained in the following publications:

• • _P_s_y_c_h_i_a_t_r_y_ _i_n_ _L_a_w_ _/_ _L_a_w_ _i_n_ _P_s_y_c_h_i_a_t_r_y_ _
• • _P_r_i_n_c_i_p_l_e_s_ _a_n_d_ _P_r_a_c_t_i_c_e_ _o_f_ _C_h_i_l_d_ _a_n_d_ _A_d_o_l_e_s_c_e_n_t_ _F_o_r_e_n_s_i_c_ _M_e_n_t_a_l_ _H_e_a_l_t_h_ _
• • _S_a_l_e_m_ _H_e_a_l_t_h_ _P_s_y_c_h_o_l_o_g_y_ _a_n_d_ _M_e_n_t_a_l_ _H_e_a_l_t_h_ _

Parental Alienation Relational Problem, page 12

• • _C_u_l_t_u_r_a_l_ _S_o_c_i_o_l_o_g_y_ _o_f_ _D_i_v_o_r_c_e_:_ _A_n_ _E_n_c_y_c_l_o_p_e_d_i_a_ _
• • _The Handbook of Forensic Psychology
• • _W_i_l_e_y_ _E_n_c_y_c_l_o_p_e_d_i_a_ _o_f_ _F_o_r_e_n_s_i_c_ _S_c_i_e_n_c_e_ _
• • _T_h_e_ _E_n_c_y_c_l_o_p_e_d_i_a_ _o_f_ _C_l_i_n_i_c_a_l_ _P_s_y_c_h_o_l_o_g_y_ _
• • _C_o_m_p_r_e_h_e_n_s_i_v_e_ _T_e_x_t_b_o_o_k_ _o_f_ _P_s_y_c_h_i_a_t_r_y_ _
• • _K_a_p_l_a_n_ _a_n_d_ _S_a_d_o_c_k_’s_ _Comprehensive Textbook of Psychiatry
• • _P_r_i_n_c_i_p_l_e_s_ _a_n_d_ _P_r_a_c_t_i_c_e_ _o_f_ _F_o_r_e_n_s_i_c_ _P_s_y_c_h_i_a_t_r_y_._ _

K_e_i_l_i_n_ _a_n_d_ _B_l_o_o_m_ _(_1_9_8_6_)_._38 T_h_e_ _a_u_t_h_o_r_s_ _s_u_r_v_e_y_e_d_ _8_2_ _m_e_n_t_a_l_ _h_e_a_l_t_h_ _p_r_o_f_e_s_s_i_o_n_a_l_s_._ _T_h_e_y_ _r_a_t_e_d_ _o_n_ _a_ _9_-_p_o_i_n_t_ _s_c_a_l_e_ _t_h_e_ _i_m_p_o_r_t_a_n_c_e_ _o_f_ _2_1_ _f_a_c_t_o_r_s_ _i_n_ _s_h_a_p_i_n_g_ _c_u_s_t_o_d_y_ _r_e_c_o_m_m_e_n_d_a_t_i_o_n_s_,_ _o_n_e_ _o_f_ _t_h_e_m_ _w_a_s_ _r_e_l_a_t_e_d_ _t_o_ _p_a_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_o_n_:_ _“P_a_r_e_n_t_ _o_f_t_e_n_ _a_t_t_e_m_p_t_s_ _t_o_ _a_l_i_e_n_a_t_e_ _t_h_e_ _c_h_i_l_d_ _f_r_o_m_ _t_h_e_ _o_t_h_e_r_ _p_a_r_e_n_t_ _b_y_ _n_e_g_a_t_i_v_e_l_y_ _i_n_t_e_r_p_r_e_t_i_n_g_ _t_h_e_ _o_t_h_e_r_ _p_a_r_e_n_t_’s_ _b_e_h_a_v_i_o_r_._” _T_h_i_s_ _w_a_s_ _t_h_e_ _s_e_c_o_n_d_ _h_i_g_h_e_s_t_ _r_a_n_k_-_i_n_g_ _f_a_c_t_o_r_,_ _c_l_e_a_r_l_y_ _i_n_d_i_c_a_t_i_n_g_ _e_n_d_o_r_s_e_m_e_n_t_ _o_f_ _t_h_e_ _c_o_n_c_e_p_t_._ _

A_c_k_e_r_m_a_n_ _a_n_d_ _A_c_k_e_r_m_a_n_ _(_1_9_9_6_)_._39 T_h_e_ _a_u_t_h_o_r_s_ _s_u_r_v_e_y_e_d_ _o_v_e_r_ _2_0_0_ _m_e_n_t_a_l_ _h_e_a_l_t_h_ _p_r_o_f_e_s_s_i_o_n_a_l_s_ _a_n_d_ _t_h_e_ _r_a_n_k_i_n_g_ _o_f_ _t_h_e_ _p_a_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_o_n_ _i_t_e_m_ _i_n_c_r_e_a_s_e_d_ _o_v_e_r_ _t_i_m_e_,_ _i_n_d_i_c_a_t_i_n_g_ _d_e_ _f_a_c_t_o_ _s_u_p_p_o_r_t_ _f_o_r_ _t_h_e_ _c_o_n_c_e_p_t_._ _

Q_u_i_n_n_e_l_l_ _a_n_d_ _B_o_w_ _(_2_0_0_1_)_._40 T_h_e_ _a_u_t_h_o_r_s_ _s_u_r_v_e_y_e_d_ _c_l_o_s_e_ _t_o_ _2_0_0_ _c_u_s_t_o_d_y_ _e_v_a_l_u_a_t_o_r_s_ _a_n_d_ _f_o_u_n_d_ _v_e_r_y_ _h_i_g_h_ _e_n_d_o_r_s_e_m_e_n_t_ _o_f_ _t_h_e_ _c_o_n_c_e_p_t_ _o_f_ _“T_h_e_ _w_i_l_l_i_n_g_n_e_s_s_ _a_n_d_ _a_b_i_l_i_t_y_ _o_f_ _e_a_c_h_ _o_f_ _t_h_e_ _p_a_r_t_i_e_s_ _t_o_ _f_a_c_i_l_i_t_a_t_e_ _a_n_d_ _e_n_c_o_u_r_a_g_e_ _a_ _c_l_o_s_e_ _a_n_d_ _c_o_n_t_i_n_u_i_n_g_ _p_a_r_e_n_t_-_c_h_i_l_d_ _r_e_l_a_t_i_o_n_s_h_i_p_ _b_e_t_w_e_e_n_ _t_h_e_ _c_h_i_l_d_ _a_n_d_ _t_h_e_ _o_t_h_e_r_ _p_a_r_e_n_t_,_” _w_h_i_c_h_ _o_f_ _c_o_u_r_s_e_ _i_s_ _t_h_e_ _i_n_v_e_r_s_e_ _o_f_ _p_a_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_o_n_._ _

B_a_k_e_r_ _(_2_0_0_7_)_._41 T_h_e_ _a_u_t_h_o_r_ _s_u_r_v_e_y_e_d_ _o_v_e_r_ _1_0_0_ _c_u_s_t_o_d_y_ _e_v_a_l_u_a_t_o_r_s_,_ _9_5_%_ _o_f_ _w_h_o_m_ _s_a_i_d_ _t_h_a_t_ _t_h_e_y_ _a_s_s_e_s_s_ _f_o_r_ _p_a_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_o_n_ _s_o_m_e_t_i_m_e_s_,_ _o_f_t_e_n_,_ _o_r_ _a_l_w_a_y_s_._ _1_0_0_%_ _s_a_i_d_ _t_h_a_t_ _i_t_ _w_a_s_ _s_o_m_e_w_h_a_t_ _o_r_ _v_e_r_y_ _m_u_c_h_ _p_o_s_s_i_b_l_e_ _f_o_r_ _a_ _p_a_r_e_n_t_ _t_o_ _t_u_r_n_ _a_ _c_h_i_l_d_ _a_g_a_i_n_s_t_ _t_h_e_ _o_t_h_e_r_ _p_a_r_e_n_t_._ _

B_a_k_e_r_,_ _J_a_f_f_e_,_ _B_e_r_n_e_t_,_ _a_n_d_ _J_o_h_n_s_t_o_n_ _(_2_0_1_1_)_._42 T_h_e_ _a_u_t_h_o_r_s_ _s_u_r_v_e_y_e_d_ _p_a_r_t_i_c_i_p_a_n_t_s_ _a_t_ _t_h_e_ _p_a_r_e_n_t_a_l_ _a_l_i_e_n_a_t_i_o_n_ _p_l_e_n_a_r_y_ _s_e_s_s_i_o_n_ _o_f_ _t_h_e_ _2_0_1_0_ _A_F_C_C_ _c_o_n_f_e_r_e_n_c_e_._ _N_e_a_r_l_y_ _9_8_%_ _o_f_ _r_e_s_p_o_n_d_e_n_t_s_ _e_n_d_o_r_s_e_d_ _t_h_e_ _q_u_e_s_t_i_o_n_,_ _“D_o_ _y_o_u_ _t_h_i_n_k_ _t_h_a_t_ _s_o_m_e_ _c_h_i_l_d_r_e_n_ _a_r_e_ _m_a_n_i_p_u_l_a_t_e_d_ _b_y_ _o_n_e_ _p_a_r_e_n_t_ _t_o_ _i_r_r_a_t_i_o_n_a_l_l_y_ _a_n_d_ _u_n_j_u_s_t_i_f_i_a_b_l_y_ _r_e_j_e_c_t_ _t_h_e_ _o_t_h_e_r_ _p_a_r_e_n_t_?_” _Of course, that question was intended to convey the essence of parental alienation.

B_e_r_n_e_t_,_ _B_a_k_e_r_,_ _a_n_d_ _A_d_k_i_n_s_ _(_2_0_2_2_)_._43 T_h_e_ _a_u_t_h_o_r_s_ _s_u_r_v_e_y_e_d_ _1_1_6_ _c_u_s_t_o_d_y_ _e_v_a_l_u_a_t_o_r_s_ _r_e_g_a_r_d_i_n_g_ _1_1_ _k_e_y_ _d_e_f_i_n_i_t_i_o_n_s_ _i_n_ _t_h_e_ _f_i_e_l_d_ _o_f_ _P_A_,_ _i_n_c_l_u_d_i_n_g_ _t_e_r_m_s_ _s_u_c_h_ _a_s_ _“a_l_i_e_n_a_t_i_o_n_,_” _“e_s_t_r_a_n_g_e_m_e_n_t_,_” _“a_l_i_e_n_a_t_-_i_n_g_ _b_e_h_a_v_i_o_r_s_,_” _a_n_d_ _t_h_e_ _“F_i_v_e_-_F_a_c_t_o_r_ _M_o_d_e_l_._” _T_h_e_r_e_ _w_a_s_ _v_e_r_y_ _l_i_t_t_l_e_ _d_i_s_a_g_r_e_e_m_e_n_t_ _w_i_t_h_ _a_n_y_ _o_f_ _t_h_e_ _1_1_ _d_e_f_i_n_i_t_i_o_n_s_._ _Parental Alienation Relational Problem, page 13

Data Regarding Clinical Outcomes

Interventions for PARP depend on whether the case is mild, moderate, or severe in intensity:

• • _Mild PARP: The child complains about spending time with the rejected parent, but goes and has a good time. In cases of mild PARP, the mental health professional may strongly admonish the parents to stop exposing their child to conflict and stop un-d_e_r_m_i_n_i_n_g_ _c_h_i_l_d_’s_ _r_e_l_a_t_i_o_n_s_h_i_p_ _w_i_t_h_ _t_h_e_ _o_t_h_e_r_ _p_a_r_e_n_t_._ _

• • _Moderate PARP: The child complains about spending time with the rejected parent and is oppositional during much of the time with the rejected parent, although there may be some opportunities for enjoyable activities between the child and the rejected parent. In cases of moderate PARP, it is usually recommended to design a comprehensive approach to help the favored parent, the rejected parent, and child to change their attitudes and behaviors. In some cases of moderate PARP, it is necessary to remove child from the influence of the favored parent.

• • _Severe PARP: The child adamantly refuses to see the rejected parent and may threaten to run away f_r_o_m_ _t_h_e_ _r_e_j_e_c_t_e_d_ _p_a_r_e_n_t_’s_ _h_o_u_s_e_h_o_l_d_._ _T_h_e_ _c_h_i_l_d_’s_ _h_o_s_t_i_l_e_ _o_r_ _i_n_-_different behavior may persist for months or years. Also, some children who have parenting time with the rejected parent may still be considered severe if: the child is persistently oppositional; the child manifests most or all of the behavioral signs of PARP; the favored parent continues alienating behaviors; and/or there has been no improvement after a traditional therapeutic intervention. In cases of severe PARP, it is almost always necessary to remove the child from the influence of the favored parent.

• • _Extreme PARP: Occasionally, the feelings associated with PARP become so intense that one of the participants of the pathological triad kills themself and/or another family member: an alienated child killed their alienated parent44; an alienating par-ent killed the child and themself45; an alienated child (or alienated parent) may become so hopeless and frustrated that they kill themself.46 Of course, there is no intervention for these tragic cases; our only hope is to prevent the onset of PARP and intervene before the cases progress to severe and extreme levels of intensity.

There have been peer-reviewed publications regarding interventions for PARP, which are listed in chronological order:

Warshak (2010).47 The author found: “B_y_ _t_h_e_ _c_o_n_c_l_u_s_i_o_n_ _o_f_ _t_h_e_ _w_o_r_k_s_h_o_p_,_ _2_2_ _o_f_ _t_h_e_ _2_3_ _c_h_i_l_-_dren, all of whom were severely alienated at the outset, and had prior failed experiences with counseling, had restored a positive relationship with the rejected parent as evidenced by the Parental Alienation Relational Problem, page 14

c_h_i_l_d_r_e_n_’s_ _o_w_n_ _s_t_a_t_e_m_e_n_t_s_,_ _b_y_ _t_h_e_ _o_b_s_e_r_v_a_t_i_o_n_s_ _o_f_ _t_h_e_ _p_a_r_e_n_t_ _a_n_d_ _w_o_r_k_s_h_o_p_ _l_e_a_d_e_r_s_,_ _a_n_d_ _b_y_ _t_h_e_ _o_b_s_e_r_v_a_t_i_o_n_s_ _o_f_ _t_h_e_ _a_f_t_e_r_c_a_r_e_ _s_p_e_c_i_a_l_i_s_t_._” _

Reay (2015).48 The author reported that:_ _“T_h_e_ _p_i_l_o_t_ _r_e_v_e_a_l_e_d_ _a_ _9_5_%_ _s_u_c_c_e_s_s_ _r_a_t_e_ _(_2_1_ _o_f_ _t_h_e_ _2_2_ _children) in reestablishing a relationship between the children and their once-rejected parents between the second and third day of the retreat as evidenced by the_ _c_h_i_l_d_r_e_n_’s_ _s_t_a_t_e_m_e_n_t_s_,_ _p_a_r_e_n_t_s_’ _s_t_a_t_e_m_e_n_t_s_,_ _a_n_d_ _o_b_s_e_r_v_a_t_i_o_n_s_ _o_f_ _t_h_e_ _m_u_l_t_i_d_i_s_c_i_p_l_i_n_a_r_y_ _t_e_a_m_ _a_t_ _t_h_e_ _r_e_t_r_e_a_t_._” _

Walters and Friedlander (2016).49 This article examines the guidelines both in and out of court for dealing with resist/refuse dynamics in families. It explains in detail the intervention called Multi-Modal Family Intervention, which they found to be appropriate for mild and some moderate cases of PARP.

Richard Warshak (2018).50 This study involved 83 participants._ _A_t_ _t_h_e_ _w_o_r_k_s_h_o_p_’s_ _c_o_n_c_l_u_s_i_o_n_,_ _parents rated 99% of relationships improved; professionals rated 94% of relationships im-p_r_o_v_e_d_;_ _c_h_i_l_d_r_e_n_ _r_a_t_e_d_ _7_4_%_ _o_f_ _r_e_l_a_t_i_o_n_s_h_i_p_s_ _i_m_p_r_o_v_e_d_._” _“I_m_p_r_o_v_e_d_” _m_eant “m_u_c_h_ _b_e_t_t_e_r_” _p_l_u_s_ _“s_o_m_e_w_h_a_t_ _b_e_t_t_e_r_._” _NOTE: In both Warshak studies, some children later relapsed, usually be-cause of premature contact with the favored parent.

Jennifer J. Harman, Luke Saunders, and Tamara Afifi (2022).51 T_h_e_ _a_u_t_h_o_r_s_ _s_a_i_d_,_ _“Improvements in the parent-child relationships were noted, and the TPFF helped to improve family m_e_m_b_e_r_s_’ _c_o_m_m_u_n_a_l_ _c_o_p_i_n_g_ _s_c_o_r_e_s_._ _P_a_r_t_i_c_i_p_a_t_i_o_n_ _d_i_d_ _n_o_t_ _l_e_a_d_ _t_o_ _n_e_g_a_t_i_v_e_ _c_h_a_n_g_e_s_ _o_n_ _a_n_y_ _measure. This preliminary evidence indicates that TPFF, similar to other therapeutic structural i_n_t_e_r_v_e_n_t_i_o_n_s_,_ _i_s_ _a_ _s_a_f_e_ _a_n_d_ _e_f_f_e_c_t_i_v_e_ _t_r_e_a_t_m_e_n_t_ _o_p_t_i_o_n_ _f_o_r_ _s_e_v_e_r_e_l_y_ _a_l_i_e_n_a_t_e_d_ _c_h_i_l_d_r_e_n_._” _

SUMMARY OF DATA ON PREVALENCE OF PARP

Alienating behaviors (the activities of the alienating parent) are much more common than PARP (the mental condition of the child and their relationship with the rejected parent); most children who are exposed to alienating behaviors do not develop parental alienation.

Harman, Leder-Elder, and Biringen (2019)52 reported on three online surveys from the United States and Canada to determine the mental health impact of parental alienating behaviors. These surveys built on a state-level survey published in 2016 by the same authors. They found, again, that between 35% and 39% of parents in the U.S. reported being targets of parental alienating behaviors.

Bernet (2010)14 pp 96–98 and (2020)53 pp 19–20 estimated that between 0.5% and 1.0% of children and adolescents in the United States experience PARP. Parental Alienation Relational Problem, page 15

SUMMARY OF DATA ON RELIABILITY WITH WHICH PARP CAN BE IDENTIFIED

Distinguishing PARP from Other DSM-5-TR Diagnoses

There are several DSM-5-TR diagnoses that may be confused with PARP in some circumstances, although these conditions can be distinguished in a careful clinical evaluation:

Child affected by parental relationship distress (CAPRD). The definition of CAPRD includes “… _negative effects of parental relationship discord (e.g., high levels of conflict, distress, or dispar-a_g_e_m_e_n_t_)_ _o_n_ _a_ _c_h_i_l_d_ _i_n_ _t_h_e_ _f_a_m_i_l_y_._” _However, CAPRD is a broad, heterogeneous concept that covers at least four family scenarios: children exposed to intimate partner distress; children exposed to intimate partner violence; children experiencing intense loyalty conflict; and children experiencing parental alienation (see Appendix A). On the other hand, PARP is a narrow concept with specific criteria for its diagnosis. If a practitioner is assessing a child who is displaying contact refusal, the initial diagnosis might be CAPRD, which encompasses several possible explanations for the contact refusal. As the evaluation progresses, it should be possible to clarify t_h_e_ _u_n_d_e_r_l_y_i_n_g_ _r_e_a_s_o_n_ _f_o_r_ _t_h_e_ _c_h_i_l_d_’s_ _c_o_n_t_a_c_t_ _r_e_f_u_s_a_l_,_ _w_h_i_c_h_ _m_i_g_h_t_ _b_e_ _P_A_R_P or might be some other issue within the family.

Parent-child relational problem. The definition of this mental condition includes: “n_e_g_a_t_i_v_e_ _a_t_-_t_r_i_b_u_t_i_o_n_s_ _o_f_ _t_h_e_ _o_t_h_e_r_’s_ _i_n_t_e_n_t_i_o_n_s_,_ _h_o_s_t_i_l_i_t_y_ _t_o_w_a_r_d_ _t_h_e_ _o_t_h_e_r_,_ _a_n_d_ _u_n_w_a_r_r_a_n_t_e_d_ _f_e_e_l_i_n_g_s_ _o_f_ _e_s_-_t_r_a_n_g_e_m_e_n_t_._” _However, parent-child relational problem is a broad, heterogeneous concept that covers numerous difficulties that may occur between a child and their parent(s). If a practitioner is assessing a child who is displaying persistent conflict with one or both parents, the initial diagnosis might be parent-child relational problem, which encompasses several possible explanations for the persistent conflict. As the evaluation progresses, it should be possible to clarify the underlying reason for the persistent conflict, which might be PARP or might be some other issue within the family.

Child psychological abuse. The definition for this mental condition includes: “h_a_r_m_i_n_g_/_ _aban-doning p_e_o_p_l_e_ _o_r_ _t_h_i_n_g_s_ _t_h_a_t_ _t_h_e_ _c_h_i_l_d_ _c_a_r_e_s_ _a_b_o_u_t_._” _However, child psychological abuse is a broad, heterogeneous concept that covers numerous methods by which a parent might engage in child maltreatment. In cases of severe PARP, it is likely that the persistent alienating behaviors of the favored parent constitute child psychological abuse. In such a case, it would be appropriate to diagnose PARP (with respect to the relationship between the child and the rejected parent) and child psychological abuse (with respect to the activities of the favored or alienating parent).

Delusional symptoms in the context of relationship with an individual with prominent delusions. This is DSM-5-TR terminology for the mental disorder that previously was called Parental Alienation Relational Problem, page 16

shared psychotic disorder and folie à deux. In some cases of severe PARP, the underlying explanation might be a delusional disorder in the favored parent, which that parent repeatedly discussed with the child and which the child ultimately adopted as their own. In such a case, the best practice would be to diagnose the child with both PARP and delusional symptoms in the context of relationship with an individual with prominent delusions. It is remarkable that the earliest description of PARP in the American Journal of Psychiatry w_a_s_ _“M_o_t_h_e_r_–Son Folie à Deux: A Case of At_t_e_m_p_t_e_d_ _P_a_t_r_i_c_i_d_e_” _(_1_9_7_7_)_._54 That case report clearly described PARP, long before the introduction of the term parental alienation.

Employing Objective Tests to Distinguish PARP from Other Conditions

Several psychological tests have been found to reliably distinguish alienated from nonalienated children. Some of these instruments were developed specifically for this task; others were older, established psychological tests that were newly applied to cases involving PARP. The following are listed in chronological order:

Baker, Burkhard, and Albertson-Kelly (2012)55 The Baker Alienation Questionnaire (BAQ) is intended to identify alienated children using a paper-and-pencil measure that is short, easy to administer, and easy to score objectively. The authors found that the BAQ discriminated between alienated and nonalienated children at an 87.5% accuracy rate. See principal results below:

Rowlands (2019).56 The Rowlands Parental Alienation Scale (RPAS) was administered to 592 parents along with measures of convergent and discriminant validity. The RPAS consists of six factors: campaign of denigration toward the alienated parent; independent thinker phenomenon; reflexive support of favored parent; presence of borrowed scenarios; spread of animosity to extended family of rejected par-ent; and lack of positive affect toward the rejected parent. Parents who reported either that a court evaluation or court findings had confirmed the presence of parental alienation scored significantly higher on all six RPAS factors as well as on the overall RPAS score.

Bernet et al. (2018)57 and (2020).58 The Parental Acceptance-Rejection Questionnaire (PARQ) was administered to 45 severely alienated children and 71 nonalienated children in Canada. It was found that severely alienated children engage in an extreme level of splitting, i.e., perceive the favored parent in very positive terms and the rejected parent in exclusively negative terms. Parental Alienation Relational Problem, page 17

Th_e_ _P_A_R_Q_ _G_a_p_ _(_t_h_e_ _d_i_f_f_e_r_e_n_c_e_ _b_e_t_w_e_e_n_ _t_h_e_ _c_h_i_l_d_’s_ _P_A_R_Q_:_ _M_o_t_h_e_r_ _a_n_d_ _P_A_R_Q_:_ _F_a_t_h_e_r_ _s_c_o_r_e_s_)_ _w_a_s_ _99% accurate in distinguishing alienated from nonalienated children. See principal results below:

Blagg and Godfrey (2018).59 The Bene–Anthony Family Relations Test (BAFRT) was administered to 16 alienated children and 17 nonalienated children in the United Kingdom. Children in the alienated group expressed almost exclusively negative feelings toward the rejected parent while expressing almost exclusively positive feelings toward their preferred parent. See principal results below:

SUMMARY OF DELETERIOUS CONSEQUENCES

Potentially Deleterious Consequences of Absence of PARP in DSM-5-TR

In the United States, there are hundreds of thousands of children and families that have experienced PARP. Occasionally, this amounts to a mild condition that resolves after a simple intervention accomplished by a mental health professional or perhaps a judge. In many cases, however, moderate and severe levels of PARP are extremely painful and damaging for the affected children and the alienated or rejected parent. It is our belief that most of these cases of PARP go undetected and untreated simply because this serious mental condition is not well known among psychiatrists, psychologists, social workers, and other mental health professionals and Parental Alienation Relational Problem, page 18

because of the misinformation that has been disseminated about it. In some instances, the process of alienation is even encouraged by naïve and poorly informed therapists and lawyers. This unfortunate state of affairs will continue until PARP is recognized by leading mental health organizations and then filtered down to front-line practitioners. The most direct method for accomplishing that goal is for PARP to be accepted as a relational problem in DSM-5-TR, which will quickly lead to educational programs for graduate students and trainees, as well as pertinent continuing education for practicing mental health and legal professionals.

Potentially Deleterious Consequences of Adding PARP to the section on Other Conditions That May Be a Focus of Clinical Attention

The authors of this proposal predict that there will be unpleasant short-term reactions when this proposal is submitted for public comment and, subsequently, if PARP becomes a relational problem in DSM-5-TR. That is, a cadre of critics of parental alienation theory will strenuously object to any formal recognition of PARP. They will say that if PARP receives any kind of official status within the DSM system, abusive fathers will use this diagnosis in legal settings as a way to remove t_h_e_i_r_ _c_h_i_l_d_r_e_n_ _f_r_o_m_ _“p_r_o_t_e_c_t_i_v_e_” _m_o_t_h_e_r_s_ _i_n_ _o_r_d_e_r_ _t_o_ _c_o_n_t_i_n_u_e_ _t_h_e_i_r_ _a_b_u_s_i_v_e_ _p_r_a_c_t_i_c_e_s_._ _Although this concern has been repeated many times for at least 20 years, there has not been objective, systematic research demonstrating that phenomenon, and strong peer-reviewed scientific research indicates that the opposite outcome tends to happen: any allegation of abuse made by a parent (particularly mothers), substantiated or not, tends to result in their getting sole custody of children rather than lose it.60, 61

The most severe critics of parental alienation theory back down when challenged. For example, Paul J. Fink, M.D., former president of the American Psychiatric Association, wrote a regular column for Clinical Psychiatry News. In 2010, Fink famously discussed controversies involving the development of DSM-5:

One such area is parental alienation syndrome (PAS). I am personally involved opposing the inclusion of this bit of junk science invented by a psychiatrist in the 1980s, the late Dr. Richard A. Gardner. … _I_n_ _r_e_c_e_n_t_ _y_e_a_r_s_,_ _t_h_e_ _b_a_l_l_ _h_a_s_ _b_e_e_n_ _p_i_c_k_e_d_ _u_p_ _b_y_ _“f_a_t_h_e_r_’s_ _r_i_g_h_t_s_” _g_r_o_u_p_s_ _w_h_o_ _d_o_n_’t_ _l_i_k_e_ _t_o_ _b_e_ _i_n_t_e_r_f_e_r_e_d_ _w_i_t_h_ _w_h_e_n_ _t_h_e_y_ _a_r_e_ _s_e_x_u_a_l_l_y_ _a_b_u_s_i_n_g_ _t_h_e_i_r_ _children. This group has petitioned the DSM task force to include PAS in the publication.62 p 6

Several readers wrote to the editor of Clinical Psychiatry New a_n_d_ _c_o_m_p_l_a_i_n_e_d_ _a_b_o_u_t_ _F_i_n_k_’s_ _ex-tremely inappropriate and irresponsible remarks. Fink quickly apologized and corrected his published statements, saying:

I apologize for suggesting that all fathers who accuse mothers of PAS are sexually abusing their children. That was clearly an o_v_e_r_s_t_a_t_e_m_e_n_t_ _t_h_a_t_ _I_ _r_e_t_r_a_c_t_._ _… _I_ _h_a_d_ _a_b_s_o_l_u_t_e_l_y_ _n_o_ _Parental Alienation Relational Problem, page 19

i_n_t_e_n_t_i_o_n_ _o_f_ _i_m_p_u_g_n_i_n_g_ _D_r_._ _B_e_r_n_e_t_,_ _h_i_s_ _c_o_l_l_e_a_g_u_e_s_,_ _o_r_ _F_a_t_h_e_r_s_ _&_ _F_a_m_i_l_i_e_s_ _i_n_ _a_n_y_ _w_a_y_._ _… _I_ _do not deny that parental alienation occurs and that a lot of people are hurt when there is an alienator.63 p 10

We_ _a_g_r_e_e_ _w_i_t_h_ _D_r_._ _F_i_n_k_ _t_h_a_t_ _“a_ _l_o_t_ _o_f_ _p_e_o_p_l_e_ _a_r_e_ _h_u_r_t_ _w_h_e_n_ _t_h_e_r_e_ _i_s_ _a_n_ _a_l_i_e_n_a_t_o_r_._” _W_e_ _believe that in the long-term, there will be minimal negative consequences of including PARP as a relational problem in DSM-5-TR. We predict, instead, that in the future the various factions that have opinions about PARP—the proponents, the opponents, practitioners, researchers, legal scholars—will come together to share their respective expertise. They will find ways to study PARP in a collaborative manner in order to more fully understand the psychopathology of this condition, methods for its diagnosis, interventions for varying levels of severity, and perhaps ultimately its prevention. W_e_ _a_g_r_e_e_,_ _i_n_ _f_a_c_t_,_ _w_i_t_h_ _D_r_._ _F_i_n_k_’s_ _s_u_m_m_a_t_i_o_n_:_ _

I hope we can all come to an agreement about what constitutes alienation, how to deal with PAS, and how to proceed in court hearings when someone alleges that one or another parent is an alienator or an abuser.61 p 10

THE PROBLEM OF MISINFORMATION

An unusual feature of this topic is the unusual amount of misinformation that has been created by critics of parental alienation theory over many years. This misinformation—which was expressed in various forms—has been methodically clarified and refuted by proponents of parental alienation theory in book chapters64, 65, and in peer-reviewed journals.17, 66, 67, 68

A particularly dramatic example of chronic misinformation is illustrated in the figure below (Bernet, unpublished data). In this research, citation analysis was used to demonstrate a pattern of recurrent misinformation in journal articles, books, presentations, government documents, and legal briefs. In this diagram, 87 publications and other materials are indicated in chronological order from left (1994) to right (2022). Node size indicates the number of times an item is cited by subsequent items. Arrow direction of the edges represents the direction of the misinformation. Thus, the earliest example of misinformation (Wood 1994) only has outgoing edges; the most recent examples (e.g., Doughty 2022) only have incoming arrows. Parental Alienation Relational Problem, page 20

Or course, this type of bibliometric research has implications for the proposal that PARP be added to DSM-5-TR. Critics of parental alienation theory are likely to protest vigorously to this proposal. We urge DSM personnel to consider the writings of parental alienation critics in a careful and somewhat skeptical manner—and to distinguish factual material from the false information and misinformation that may be found there.

[REFERENCES WILL GO HERE IN FINAL VERSION] Parental Alienation Relational Problem, page 21

ENDORSEMENTS

This proposal has been endorsed by the following mental health practitioners, researchers, advocacy groups, and professional organizations.

Research Groups

Mandy Mathewson, Ph.D., and the Family and Interpersonal Relationships Lab, University of Tasmania, Hobart, Tasmania, Australia.

Ronald P. Rohner, Ph.D., Professor Emeritus, and Director of the Center for the Study of Inter-personal Acceptance and Rejection, University of Connecticut, Storrs, Connecticut, USA.

Advocacy Groups

Family Access – _F_i_g_h_t_i_n_g_ _f_o_r_ _C_h_i_l_d_r_e_n_’s_ _R_i_g_h_t_s_,_ _N_o_r_t_h_ _C_a_r_o_l_i_n_a_,_ _U_S_A_ _- brings awareness and education of alienation as well as support to alienated family members, http://www.familyaccessfighting-forchildrensrights.com.

H_e_r_o_’s_ _C_i_r_c_l_e_ _

Mothers Against Child Abuse

Parental Alienation Study Group, Nashville, Tennessee, USA – _900 members (mental health and legal professionals and alienated parents and grandparents) from 65 countries, http://www.pasg.info.

Victim to Hero Institute

Professional Organizations

International Society for Interpersonal Acceptance-Rejection (ISIPAR), Storrs, Connecticut, USA – _supports and encourages research and practice worldwide related to issues of interpersonal acceptance and rejection, https://isipar.uconn.edu/. Parental Alienation Relational Problem, page 22

Individual Researchers

Sumbleen Ali, Ph.D., Assistant Professor, Human Development and Family Studies, State University of New York – _Oneonta, New York, USA

Amy J. L. Baker, Ph.D., Teaneck, New Jersey, USA

William Bernet, M.D., Professor Emeritus, Department of Psychiatry and Behavioral Sciences, Vanderbilt University, Nashville, Tennessee, USA

Jennifer J. Harman, PhD. Associate Professor, Colorado State University, Fort Collins, CO, USA

Demosthenes Lorandos, Ph.D., J.D., Private Practice, PsychLaw, Ann Arbor, Michigan, USA

Stephen Lee Morrison, Ph.D., Houston, Texas, USA

Vincenzo Paolo Senese, Ph.D., Associate Professor, Department of Psychology, University of Campania, Caserta, Italy.

Individual Practitioners

Les Linet, M.D., Clinical Associate Professor, College of Health Professionals, Pace University, New York, New York, USA

Alan D. Blotcky, Ph.D., Birmingham, Alabama USA

Individual Child Advocates Parental Alienation Relational Problem, page 23

APPENDICES

Appendix A: Bernet W, Wamboldt MZ, Narrow WE: Child affected by parental relationship distress. Journal of American Academy of Child and Adolescent Psychiatry, 2016; 55(7):571–579.

Appendix B: Harman JJ, Warshak RA, Lorandos D, Florian MJ: Developmental psychology and the scientific status of parental alienation. Developmental Psychology, 2022; https://doi.org/10.1037/dev0001404

Appendix C: Two_ _d_o_c_u_m_e_n_t_s_:_ _“Eighty-Five Important Books and Book Chapters Regarding P_a_r_e_n_t_a_l_ _A_l_i_e_n_a_t_i_o_n_ _b_y_ _M_e_n_t_a_l_ _H_e_a_l_t_h_ _a_n_d_ _L_e_g_a_l_ _P_r_o_f_e_s_s_i_o_n_a_l_s_” _a_n_d_ _“S_e_v_e_n_t_y_ _I_m_p_o_r_t_a_n_t_ _B_o_o_k_s_ _R_e_g_a_r_d_i_n_g_ _P_a_r_e_n_t_a_l_ _A_l_i_e_n_a_t_i_o_n_ _b_y_ _P_a_r_e_n_t_s_ _a_n_d_ _f_o_r_ _P_a_r_e_n_t_s_._” _

Appendix D: Bernet W, Greenhill L: The Five-Factor Model for the Diagnosis of Pa-rental Alienation. Journal of American Academy of Child and Adolescent Psychiatry, 2022; 61(5):591–594. Parental Alienation Relational Problem, page 24

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If you agree with the proposal and wish to endorse it, contact Mandy Matthewson if you are an …•    Individual Researcher•    Individual Practitioner•    Individual Child Advocate – such as an alienated parent or grandparent. When you contact Mandy, send your name, professional degree (if any), academic affiliation (if any), and location. Contact Mandy at mmatthewson@salamancapsychology.com.au. Contact Jennifer Harman if you represent a …•    Research Group•    Advocacy Group•    Professional Organization. Send Jennifer the name of the group or organization, its location, and its website. Also, include a very brief description of the group, such as its size and its mission. Contact Jennifer at jennifer.harman@colostate.edu. If you have questions about the content of the proposal or if you have suggestions or corrections, send them to me at william.bernet@vumc.org.  This is a very important project. As always, thanks for your support and your help.  Please forward this message to friends and colleagues. Best Wishes, William Bernet, M.D.President, PASG Proposal, 2022-06-30.pdf Download F