Dispute about the diagnostic classification of PAS

PAS is not listed in the DSM-IV-TR and DSM-5. An increasing number of studies are devoted to PAS, and Bernet et al. [40] proposed to change PAS to parental alienation disorder (PAD) and include it in the DSM with a set of diagnostic criteria (Table 1). Until now, after 10 years of this suggestion, disputes between the pros and cons of including PAS/PAD in the DSM are still going on in legal, medical, and other related professionals.

Table 1Suggested Diagnostic criteria for Parental Alienation Disorder, by Bernet et al. [40]

A. The child—usually one whose parents are engaged in a high-conflict divorce—allies himself or herself strongly with one parent and rejects a relationship with the other, alienated parent without legitimate justification. The child resists or refuses contact or parenting time with the alienated parent.
B. The child manifests the following behaviors:
(1) A persistent rejection or denigration of a parent that reaches the level of a campaign.
(2) Weak, frivolous, and absurd rationalizations for the child’s persistent criticism of the rejected parent.
C. The child manifests two or more of the following six attitudes and behaviors:
(1) Lack of ambivalence.
(2) Independent-thinker phenomenon.
(3) Reflexive support of one parent against the other.
(4) Absence of guilt over exploitation of the rejected parent.
(5) Presence of borrowed scenarios.
(6) Spread of the animosity to the extended family of the rejected parent.
D. The duration of the disturbance is at least 2 months.
E. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
F. The child’s refusal to have contact with the rejected parent is without legitimate justification. That is, parental alienation disorder is not diagnosed if the rejected parent maltreated the child.


The rationales put forward by the opponents against defining PAS as PAD are largely as follows [41]: 1) there lacks empirical data to give the phenomenon of alienation a status of disease, 2) a formal diagnosis will complicate custody disputes and only increase confusion, 3) PAS does not need to be classified as a mental disease for the court to consider it during the divorce process, 4) children who are already suffering from parents’ divorce should not be labeled with mental illness, and 5) the offender’s attorney may use parental alienation (PA) to belittle the other’s claim [4,42].

The rationales for supporting the disease classification of PAS as PAD are largely as follows [43]: 1) there are ongoing qualitative and quantitative studies on the issue of PA, 2) among mental health professionals who have worked with children in divorced families, it is a widely accepted fact that there is a high prevalence of PA in children whose parents are in constant and intense conflict, 3) mental health trainees and clinicians should be trained on the prevalence and symptoms of PAS in order to enable the early detection of PAS in children and families, 4) the inclusion of PAD in the DSM and ICD will increase the awareness and understanding among clinicians, which would enhance the likelihood that children in divorced families will have healthy relationships with both parents, and 5) diagnosis-based consensus is an efficient way to prevent PA from being misused by the abusing parent. If PA has no diagnosis agreed upon or mental health professionals are not trained to detect and screen for PA, it will be easier for the abusing parent to make allegations that the child has been manipulated.

Despite these controversies, PAS is still an issue in custody disputes, and the professionals involved need to attain knowledge and competence to deal with the pros and cons of PAS, and become aware of and attend to the relevant areas of interest.


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