C. A. CHILDRESS, Psy.D.

LICENSED CLINICAL PSYCHOLOGIST, PSY 18857

547 S. MARENGO DR., STE 105 PASADENA, CA 91101 (909) 821-5398

DSM-5 Diagnosis of Parental Alienation Processes Parental Psychopathology The family relationship processes that have classically been described as parental alienation represent the artificially induced suppression of the normal-range functioning of the childs attachment system (a neuro-biologically embedded primary motivational system) toward one parent (i.e., the targeted/rejected parent) as a consequence of aberrant and distorted parenting practices emanating from the other parent (i.e., the favored/allied parent). The aberrant and distorted parenting practices of the favored/allied parent falsely define for the child that the parenting practices of the other parent, the targeted/rejected parent, represent a threat to the child. Typically the alleged threat is characterized as being one of emotional or psychological abuse of the child, supposedly as a consequence of the fundamental parental inadequacy of the targeted/rejected parent, although occasionally the characterization of potential threat is elevated to one of possible physical or sexual abuse of the child by the targeted/rejected parent. The origin of the favored/allied parents false perception of threat is the misattribution of meaning (Bowlby, 1980)1 by the favored/allied parent regarding an authentically experienced intense anxiety that is the product of insecure, severely anxious- disorganized/anxious-preoccupied attachment patterns representing the internal working models of the favored/allied parents attachment system organization. The severely anxious-disorganized/anxious-preoccupied internal working models of the favored/allied parents attachment system coalesced during childhood development into pathological personality structures (Bowlby, 1973) involving a self-experience of primal inadequacy and an experience of others as abandoning (Batholomew, 1990; Jellema, 2000). The distorted parenting of the favored/allied parent represents a role-reversal relationship (Bacciagaluppi, 1985; Stepp, Whalen, Pilkonis, Hipwell, & Levine, 2011) in which the favored/allied parent is inducing the childs symptomatic rejection of the other
1

In discussing the cognitive misattributions that can result from distorted internal working models of attachment, Bowlby (1980) described the processes involved with the misidentification of the interpersonal situation eliciting a response(p. 65). In this description, the emotional and behavioral responses of the person who is responding to attachment system patterns may become disconnected cognitively from the interpersonal situation that is eliciting it, leaving him unaware of why he is responding as he is so that he may mistakenly identify some other person (or situation) as the one who (which) is eliciting his responses and he may dwell so insistently on the details of his own reactions and sufferings that he has no time to consider what the interpersonal situation responsible for his reactions may actually be. (p. 65) Millon (2011) also describes this process of attributional distortion relative to the narcissistic personality, Owing to their excessive use of fantasy mechanisms, they [narcissists] are disposed to misinterpret events and to construct delusional beliefs. Unwilling to accept constraints on their independence and unable to accept the viewpoints of others, narcissists may isolate themselves from the corrective effects of shared thinking. Alone, they may ruminate and weave their beliefs into a network of fanciful and totally invalid suspicions. (p. 407)

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parent in order to regulate the favored parents own emotional and psychological processes that are originating in the parents own attachment-mediated, personality disorder anxiety associated with primal self-inadequacy and abandonment fears that were triggered into active experience by the divorce and relationship loss experience (Mikulincer, Gillath, & Shaver, 2002). In normal-range and healthy parent-child relationships, parents meet the psychological and emotional needs of the child. In a role- reversal parent-child relationship, the child is used by the parent to meet the emotional and psychological needs of the parent. A role-reversal parent-child relationship, in which a parent uses a child to regulate the emotional and psychological needs of the parent, is associated with an insecure anxious-disorganized pattern of attachment (Lyons-Ruth, Bronfman, & Parsons, 1999), which is considered the most pathological of the attachment patterns, and which is extremely damaging to the childs emotional and psychological development (Baciagaluppi, 1985; Lyons-Ruth, Bronfman, & Parsons, 1999; Moor & Silvern, 2006). The role-reversal parent-child relationship is a product of the internal working models of the favored/allied parents attachment system (Bowlby, 1969) that are creating a primal experience of core-self inadequacy (which induces a compensatory defensive narcissistic inflation of self; i.e., narcissistic personality disorder traits), and an intense fear of abandonment (i.e., borderline personality disorder processes). These personality disorder processes represent the constellated product of the internal working models of the favored/allied parents insecure, severely anxious-disorganized/anxious-preoccupied attachment system networks that produce both the primal experience of core-self inadequacy and the intense fear of abandonment (Bowlby, 1973; Brennan & Shaver, 1998; Jellema, 2000; Levy, 2005; Lyddon & Sherry, 2001). The childs symptomatic display of a suppressed attachment bonding with the targeted/rejected parent represents the induced product of the trans-generational transmission of distorted attachment patterns from the personality disordered parent to the child, resulting in the childs disrupted ability to form a normal-range attachment bond with the other parent, the targeted/rejected parent. The trans-generational transmission of distorted attachment system dynamics is mediated through a role-reversal parent-child relationship and the distorted communication and parenting practices of the narcissistic/borderline personality disordered favored/allied parent (Benoit & Parker, 1994; Brennan & Shaver, 1998; Bretherton, 1990; Cohen, 1998; Dutton, Denny-Keys, & Sells, 2011; Fonagy & Target 2005; Fruzzetti, Shenk, & Hoffman, 2005; Holmes, 2004; Krugman, 1987; Linehan, & Koerner, 1993; Lyons-Ruth, Bronfman, & Parsons, 1999; Stepp et al., 2011; van Ijzendoorn, 1992). DSM-5 Diagnosis The DSM-5 diagnosis for the childs induced symptomatology that is the consequent product of the distorted communication and parenting practices emanating from a narcissistic/borderline parent, representing the trans-generational transmission of attachment system distortions from the personality disordered parent to the childs attachment bonding with the targeted/rejected parent (a process classically referred to as parental alienation), would be:

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DSM-5 Diagnosis 309.4 Adjustment Disorder with mixed disturbance of emotions and conduct V61.20 Parent-Child Relational Problem V61.29 Child Affected by Parental Relationship Distress The DSM-5 (APA, 2013) describes the range of potential Adjustment Disorder stressors, The stressor may be a single event (e.g., a termination of a romantic relationship), or there may be multiple stressors (e.g., marked business difficulties and marital problems). Stressors may be recurrent (e.g., associated with seasonal business crises, unfulfilling sexual relationships) or continuous (e.g., persistent painful illness with increasing disability, living in a crime-ridden neighborhood). Stressors may affect a single individual, an entire family, or a larger group or community (e.g., a natural disaster). Some stressors may accompany specific developmental events (e.g., going to school, leaving a parental home, reentering a parental home, getting married, becoming a parent, failing to attain occupational goals, retirement) (p. 267). With regard to the childs induced symptomatic rejection of a relationship with a parent (the targeted/rejected parent), the stressor (Criterion A) is the continuous exposure of the child to the distorted communications and parenting practices of a personality disordered parent that is producing chronic spousal and family conflict subsequent to the divorce and familys dissolution, and into which the child is being triangulated (Haley, 1977; Mann, Borduin, Heneggeler, & Blaske, 1990; Minuchin, 1974), producing an artificially induced suppression of the childs attachment system functioning relative to the childs relationship bonding with the targeted/rejected parent. The functional impairment caused by the childs symptoms (Criterion B) is that they are out of proportion to what would be considered normal-range post-divorce family conflict and the childs symptoms are out of proportion to the essentially normal-range parenting behaviors of the targeted/rejected parent, so that the childs exposure to the continuous stressor of the distorted communications and parenting practices of the personality disordered parent is resulting in a significant impairment to the childs capacity for normal-range family functioning. Additional Diagnostic Consideration An additional DSM-5 diagnostic consideration, would be V995.51 Child Psychological Abuse, Suspected/Confirmed

The DSM-5 criteria relative to the application of this additional diagnostic consideration is somewhat mixed. The diagnosis of Child Psychological Abuse would be warranted based on the first sentence of the DSM-5 criteria description, "Child psychological abuse is non-accidental verbal or symbolic acts by a child's parent or caregiver that result, or have a reasonable potential to result, in significant psychological harm to the child" (p. 719).

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The research regarding the psychologically damaging effects on children of narcissistic and borderline parenting (cf., Stepp et al., 2011) and parental failure of empathy (cf., Moor & Silvern, 2006) would indicate that the distorted parenting practices of the narcissistic/borderline parent that result in a suppression to the childs normal-range attachment bonding to the other parent would have a reasonable potential of resulting in psychological harm to the child, thereby meeting the criteria for the DSM-5 diagnosis of Child Psychological Abuse. Theodore Millon (2011) discusses Mastersons view of the damaging effects of borderline personality parenting on the childs development, which may itself lead to the development of borderline personality traits in the child, The ideas proposed by J. Masterson (1972, 1976) draw heavily on the developmental theses of Bowlby and of Mahler. Stressing the belief that the mother may have been borderline herself, Masterson sees the child as being encouraged to continue symbiotic clinging, while the mother threatens to withdraw love should the child persist in striving for autonomy. Relating to mothers who are intensely conflicted about their childs growing independence, these youngsters are faced with a dilemma: Becoming autonomous will mean a loss of maternal love. This ambivalence creates an intrapsychic schism; any form of assertiveness threatens abandonment. This deep template within the future borderlines psyche sets the groundwork for unstable relationships, repeated intrapsychic ruptures, fruitless searches for idealized unions, and periodic states of emptiness and depression. (Millon, p. 901) Linehan and Koerner (1993) discuss the damaging effects on the childs emotional and psychological development of the invalidating environment associated with borderline personality processes, A defining characteristic of the invalidating environment is the tendency of the family to respond erratically or inappropriately to private experience and, in particular, to be insensitive (i.e., nonresponsive) to private experience Invalidating environments contribute to emotional dysregulation by: (1) failing to teach the child to label and modulate arousal, (2) failing to teach the child to tolerate stress, (3) failing to teach the child to trust his or her own emotional responses as valid interpretations of events, and (4) actively teaching the child to invalidate his or her own experiences by making it necessary for the child to scan the environment for cues about how to act and feel. (p. 111-112) Fruzetti, Shenk, and Hoffman, (2005) elaborate on the negating effects of the invalidating environment created by the personality disordered parent on the childs capacity for authentic self-experience, In extremely invalidating environments, parents or caregivers do not teach children to discriminate effectively between what they feel and what the caregivers feel, what the child wants and what the caregiver wants (or wants the child to want), what the child thinks and what the caregiver thinks. (p. 1021)

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When the effect of this parentally created invalidating environment is to induce an artificial suppression of the childs normal-range motivations for attachment bonding to the other parent, the potential for long-term negative psychological consequences for the child would be reasonably anticipated (Dutton, Denny-Keys, & Sells, 2011; Millon, 2011; Stepp, et al., 2011) In their research on child abuse, Moor and Silvern (2006) found that the long-term negative impact of child abuse is mediated by parental failure of empathy, and that the parental failure of empathy associated with narcissistic parenting represents a form of developmental trauma in and of itself, Only insofar as parents fail in their capacity for empathic attunement and responsiveness can they objectify their children, consider them narcissistic extensions of themselves, and abuse them. It is the parents view of their children as vehicles for satisfaction of their own needs, accompanied by the simultaneous disregard for those of the child, that make the victimization possible. (p. 104; emphasis added) An empathically responsive environment precludes abuse and objectification of children. Correspondingly, the act of child abuse by parents is viewed in itself as an outgrowth of parental failure of empathy and a narcissistic stance towards ones own children. Deficiency of empathic responsiveness prevents such self-centered parents from comprehending the impact of their acts, and in combination with their fragility and need for self-stabilization, predisposes them to exploit children in this way. (p. 94-95; emphasis added) The indication that posttraumatic symptoms were no longer associated with child abuse, across all categories, after statistically controlling for the effect of perceived parental empathy might appear surprising at first, as trauma symptoms are commonly conceived of as connected to specifically terrorizing aspects of maltreatment (e.g., Wind & Silvern, 1994). However, this finding is, in fact, entirely consistent with both Kohuts (1977) and Winnicotts (1988) conception of the traumatic nature of parental empathic failure. In this view, parental failure of empathy is predicted to amount to a traumatic experience in itself over time, and subsequently to result in trauma-related stress. Interestingly, even though this theoretical conceptualization of trauma differs in substantial ways from the modern use of the term, it was still nonetheless captured by the present measures. (p. 107; emphasis added) Shaw (2010) also notes the traumatic impact of narcissistic parenting for the child and the potential for this relational trauma to be transmitted to later generations, Exposure to parental narcissistic pathology constitutes cumulative relational trauma, which subverts the development of intersubjective [i.e., psychologically intimate] relating capacities in the developing child. This trauma is inherited and bequeathed intergenerationally. (p. 46; emphasis added) The research evidence regarding the severe psychological and developmental harm inflicted on the child by narcissistic/borderline parenting practices (Dutton, Denny-Keys, & Page 5 of 10

Sells, 2011; Fruzzetti, Shenk, & Hoffman, 2005; Millon, 2011; Moor & Silvern, 2006; Shaw, 2010; Stepp, Whalen, Pilkonis, Hipwell, & Levine, 2011) would merit both child protection concerns and a diagnostic identification of the distorted parenting practices associated with narcissistic and borderline personality disordered parenting as representing a form of psychological child abuse. The profound failure of parental empathy and the role-reversal parent-child relationship associated with the narcissistic/borderline parenting that is responsible for the induced suppression of the normal-range functioning of the childs attachment bonding to the other parent (a family relationship process that has traditionally been referred to as parental alienation) creates for the child a false definition that the childs other parent represents a threat to the child. This parentally induced co-creation of a false definition of the other parent as being a threat to the child represents a role-reversal parent-child relationship with the narcissistic/borderline parent in which the childs symptomatic rejection of the targeted parent is serving the psychological and emotional function for the narcissistic/borderline parent of regulating the parents own intense core-self inadequacy (narcissistic processes) and fear of abandonment (borderline processes) that are the coalesced product of insecure attachment relationship patterns (insecure anxious- disorganized/anxious-preoccupied internal working models of attachment) that were reactivated for the narcissistic/borderline parent by the interpersonal loss experience associated with the divorce and familys dissolution. This role-reversal relationship and induced false definition of the childs other parent as representing a threat to the child has the effect of inducing an artificial suppression of the child's normal-range attachment system bonding to the targeted parent, resulting in the loss for the child of a normal-range relationship with a nurturing and supportive parent (i.e., the targeted/rejected parent) as a consequence of the disordered psychopathology of the narcissistic/borderline parent. The induced distortion to the normal-range functioning of the childs attachment system bonding with the targeted parent can result in the subsequent entrenchment of these attachment system distortions within the childs own attachment networks (i.e., the trans-generational transmission of attachment patterns) that can potentially contribute to the ultimate development of narcissistic and borderline personality processes for the child (Bowlby, 1980, Millon, 2011, Shaw, 2010; Stepp, et al., 2011) Therefore, the aberrant and distorted parenting practices of the narcissistic/borderline parent could reasonably represent a "symbolic" act within that parents own trauma reenactment (Trippany, Helm, & Simpson, 2006; van der Kolk, 1989) of attachment system distortions (i.e., the personality disorder processes involving a self-experience of primal inadequacy and an intense fear of abandonment) that has the potential to result in significant psychological harm to the child because of the induced distortions to the normal-range functioning of the child's attachment system development in which the child loses a relationship with a normal-range and nurturing parent (i.e., the targeted/rejected parent) as a consequent result of the narcissistic/borderline parents psychopathology, and which can potentially result in the development of prominent distortions to the childs own attachment system (i.e., personality system) development.

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However, the examples for child psychological abuse that are provided by the DSM-5 diagnostic criteria all concern parental acts directed specifically toward the child, and do not include indirect parental actions emanating from parental psychopathology that could distort the childs healthy emotional and psychological development, such as the distorted parenting practices associated with narcissistic and borderline personality disordered parenting and prominent role-reversal relationships. Based on the examples provided by the DSM-5, the diagnosis of Child Psychological Abuse may be questionable within the conceptualizations of the authors of the DSM-5. So the applicability of the DSM-5 diagnosis for Child Psychological Abuse remains somewhat unclear because of the seemingly mixed applicability of its criteria descriptions. Professional Opinion of Dr. Childress It is the professional view of Dr. Childress that the narcissistic and borderline parenting practices involving a prominent role-reversal relationship, the significant failure of parental empathy, and induced distortions to the normal-range functioning of the childs attachment system development that are associated with the family processes that have classically been referred to as parental alienation, represent a severe form of psychological child abuse that warrant a child protection response. In the professional view of Dr. Childress, when there is a lack of overall clarity in the formal diagnostic description, the text description of the diagnostic criteria should be given primacy over specific illustrative examples, so that the relevant diagnostic criteria for V995.51 Child Psychological Abuse would be, "Child psychological abuse is non-accidental verbal or symbolic acts by a child's parent or caregiver that result, or have a reasonable potential to result, in significant psychological harm to the child" (p. 719) As a result, the additional DSM-5 diagnosis of V995.51 Child Psychological Abuse, Suspected/Confirmed would be warranted when the family processes associated with parental alienation are suspected or confirmed, so that a decisive child protection response involving the protective separation of the child from the psychopathology of the narcissistic/borderline parent during the active phase of the childs treatment and recovery should be strongly considered. As a consequence of this analysis, in the professional view of Dr. Childress, the appropriate DSM-5 diagnosis for the childs psychological symptoms associated with what has classically been referred to as parental alienation would be: DSM-5 Diagnosis 309.4 Adjustment Disorder with mixed disturbance of emotions and conduct V61.20 Parent-Child Relational Problem V61.29 Child Affected by Parental Relationship Distress V995.51 Child Psychological Abuse, Suspected/Confirmed Page 7 of 10

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Agrawal, H.R., Gunderson, J., Holmes, B.M., & Lyons-Ruth, K. (2004). Attachment studies with borderline patients: A review. Harvard Review of Psychiatry, 12, 94-104. Bacciagaluppi, M. (1985). Inversion of parent-child relationships: A contribution to attachment theory. British Journal of Medical Psychology, 58, 369-373. Bartholomew, K., & Horowitz, L.M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61, 226-244. Benoit, D. and Parker, K.C.H. (1994). Stability and transmission of attachment across three generations. Child Development, 65, 1444-1456 Bowlby, J. (1969). Attachment and loss. Vol. 1 Attachment. NY: Basic Books. Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation: Anxiety and anger. NY: Basic Books. Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression. NY: Basic Books. Brennan, K.A. and Shaver, P.R. (1998). Attachment styles and personality disorders: Their connections to each other and to parental divorce, parental death, and perceptions of parental caregiving. Journal of Personality 66, 835-878. Bretherton, I. (1990). Communication patterns, internal working models, and the intergenerational transmission of attachment relationships. Infant Mental Health Journal, 11, 237-252. Cohen, O. (1998). Parental narcissism and the disengagement of the non-custodial father after divorce. Clinical Social Work Journal, 26, 195-215 Dutton, D. G., Denny-Keys, M. K., and Sells, J. R. (2011). Parental personality disorder and its effects on children: A review of current literature. Journal Of Child Custody, 8, 268-283. Fonagy P. and Target M. (2005). Bridging the transmission gap: An end to an important mystery in attachment research? Attachment and Human Development, 7, 333-343. Fonagy, P., Target, M., Gergely, G., Allen, J.G., and Bateman, A. W. (2003). The developmental roots of Borderline Personality Disorder in early attachment relationships: A theory and some evidence. Psychoanalytic Inquiry, 23, 412-459. Smolewska, K. and Dion, K.L. (2005). Narcissism and adult attachment: a multivariate approach. Self and Identity, 4, 59-68. Fruzzetti, A.E., Shenk, C. and Hoffman, P. (2005). Family interaction and the development of borderline personality disorder: A transactional model. Development and Psychopathology, 17, 1007-1030. Haley, J. (1977). Toward a theory of pathological systems. In P. Watzlawick & J. Weakland (Eds.), The interactional view (pp. 31-48). New York: Norton.

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