When DSM-5 was published in 2013, several new terms were introduced in the section “Relational Problems,” which is part of “Other Conditions.” One of the new mental conditions in DSM-5 is child affected by parental relationship distress, explained as: “This category should be used when the focus of clinical attention is the negative effects of parental relationship discord (eg, high levels of conflict, distress, or disparagement) on a child in the family, including effects on the child’s mental or other medical disorders.”5 If a clinical or forensic practitioner finds that a child is experiencing a loyalty conflict that causes distress or dysfunction, the diagnosis may be child affected by parental relationship distress.
Internalized chronic stress
If the external stressors––especially, high conflict between the parents––continue for an extended period, the child’s symptoms may become internalized and develop into a more serious mental condition. Typically, the symptoms cluster to take the form of an anxiety disorder, a depressive disorder, or a somatic symptom disorder. An important recent study from Sweden showed that children of divorced parents had more sleeping problems, headaches, stomachaches, tenseness, and sadness than children in intact families.6
Regarding possible DSM-5 diagnoses, major depressive disorder and suicidality may develop in a child who grieves the loss of his previous family life or the loss of time with the noncustodial parent.5 If the child fears the loss of the custodial parent, he may develop separation anxiety disorder. Also, the child who repeatedly witnesses parental conflict during the “switching hour”––when the child transitions from one household to the other––may experience physical symptoms before, during, and after the transition. In that case, the diagnosis may be somatic symptom disorder.
Clinical personnel and forensic evaluators should consider the differential diagnosis presented here when they assess children of high-conflict divorce. This topic should be addressed in the training of MHPs. Trainees of all mental health disciplines (psychologists, psychiatrists, family therapists, nurse practitioners, social workers, school counselors) should learn how parental divorce affects children and what to do about it. The training of child forensic practitioners––who will conduct child custody evaluations and child maltreatment investigations––should address the theoretical bases and the identification of loyalty conflicts, parental estrangement, and parental alienation.
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