Differential Diagnosis of Child Abuse
The differential diagnosis for severe attachment pathology is child abuse by one parent or the other.
1) Either the targeted parent is abusing the child, creating the child’s attachment pathology toward that parent (2-person attribution of causality),
2) Or the allied parent is psychologically abusing the child by creating a shared persecutory delusion and false attachment pathology imposed on the child for the secondary gain of manipulating the court’s decisions regarding child custody, and to meet the parent’s own emotional and psychological needs (3-person attribution of causality).
In all cases of severe attachment pathology, a proper risk assessment for possible child abuse needs to be conducted to the appropriate differential diagnosis for each parent.
Bases for Professional Judgments
Standard 2.04 of the APA ethics code requires the application of the “established scientific and professional knowledge of the discipline” as the bases for scientific and professional judgments.
2.04 Bases for Scientific and Professional Judgments
Psychologists’ work is based upon established scientific and professional knowledge of the discipline.
The established scientific and professional knowledge of the discipline is:
- Attachment – Bowlby and others
- Family systems therapy – Minuchin and others
- Personality disorders – Beck and others
- Complex trauma – van der Kolk and others
- Child development – Tronick and others
- Self psychology – Kohut and others
- ICD-10 and DSM-5 diagnostic systems
The pathology of concern in court-involved child custody conflict is possible child abuse – either by the targeted-rejected parent creating the child’s attachment pathology – or psychological child abuse by the allied parent creating a shared (induced) persecutory delusion in the child.
There are two potential dangerous pathologies involved, possible child abuse by one parent or the other, and possible spousal emotional and psychological abuse of the targeted parent by the allied parent using the child as the weapon (DSM-5 V995.82 Spouse or Partner Abuse Psychologial.
- A proper risk assessment for possible child abuse needs to be conducted to the appropriate differential diagnosis for each parent (DSM-5 V995.51 Child Psychological Abuse)
- A proper risk assessment for possible spousal emotional and psychological abuse of the targeted parent by the allied parent using the child as the weapon needs to be conducted (DSM-5 V995.82Spouse or Partner Abuse, Psychological)
Shared Persecutory Delusion
The diagnostic concern is a possible shared persecutory delusion created by the pathogenic parenting of the allied parent.
From the APA: “Persecutory Type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way” (American Psychiatric Association, 2000)
Google malevolent: Having or showing a wish to do evil to others
The differential diagnosis of a possible shared persecutory delusion should be anticipated surrounding court-involved custody conflict and attachment pathology displayed by the child.
From Walters & Friedlander: “In some RRD families [resist-refuse dynamic], a parent’s underlying encapsulated delusion about the other parent is at the root of the intractability (cf. Johnston & Campbell, 1988, p. 53ff; Childress, 2013). An encapsulated delusion is a fixed, circumscribed belief that persists over time and is not altered by evidence of the inaccuracy of the belief.”
From Walters & Friedlander: “When alienation is the predominant factor in the RRD [resist-refuse dynamic}, the theme of the favored parent’s fixed delusion often is that the rejected parent is sexually, physically, and/or emotionally abusing the child. The child may come to share the parent’s encapsulated delusion and to regard the beliefs as his/her own (cf. Childress, 2013).” (Walters & Friedlander, 2016, p. 426)
Walters, M. G., & Friedlander, S. (2016). When a child rejects a parent: Working with the intractable resist/refuse dynamic. Family Court Review, 54(3), 424–445.
A proper assessment for possible delusional thought disorder pathology in the family needs to be conducted. The assessment for delusional thought disorder pathology is a Mental Status Exam of thought and perception (frontal lobe executive function systems for linear-logical reasoning).
From Chapter 207 of Clinical Methods:
From Martin: “The inability to process information correctly is part of the definition of psychotic thinking. How the patient perceives and responds to stimuli is therefore a critical psychiatric assessment. Does the patient harbor realistic concerns, or are these concerns elevated to the level of irrational fear? Is the patient responding in exaggerated fashion to actual events, or is there no discernible basis in reality for the patient’s beliefs or behavior?”
From Martin: “Of all portions of the mental status examination, the evaluation of a potential thought disorder is one of the most difficult and requires considerable experience. The primary-care physician will frequently desire formal psychiatric consultation in patients exhibiting such disorders.”
Few (if any) court-involved mental health professionals are competent in the assessment and diagnosis of delusional thought disorder pathology. Dr. Childress is available for professional-to-professional consultation with scheduling through his online Scheduling Calendar.
To assist mental health professionals in the assessment of a possible shared persecutory delusion in the family, Dr. Childress has also developed two checklist symptom documentation instruments that can be used to guide the involved mental health professional through the assessment and diagnosis with delusional thought disorder pathology in the family.
This instrument documents the child’s symptoms in three areas, 1) Attachment Bonding Suppression, 2) Narcissistic Personality Traits, and 3) a Persecutory Delusion.
Parenting Practices Rating Scale
This instrument documents the parenting practices of the targeted parent as either abuse-range or normal-range.
Parent-Child Relationship Rating Scale
This instrument is an outcome measure of daily reports to the family therapist by the parent on three areas of functioning, 1) Affection (Aff; attachment networks), Cooperation (Co; emotional regulation), and Social Involvement (SI; arousal and mood). The daily ratings are placed into an Excel file by the therapist, and are discussed in family therapy sessions using applied behavioral analysis and relationship-communication skills.
If excessive texting or email communication is a symptom feature, the the Texting Modification to the Parent-Child Relationship Scale to bring this symptom feature into the treatment.
Treatment: Court-Adapted DBT
I recommend court-adapted Dialectic Behavior Therapy (DBT; Linehan) for the treatment of Child Psychological Abuse surrounding child custody conflict and severe attachment pathology surrounding divorce. I recommend that the DBT family therapy be informed by the attachment literature, especially by Tronick and the breach-and-repair sequence.
Diagnostic Questions from Assessment
These are the diagnostic questions that need to be answered from all assessments of attachment pathology surrounding court-involved custody conflict.
This assessment checklist identifies professional constructs from attachment, family systems therapy, complex trauma, and personality disorder pathology which would indicate pathogenic parenting by the allied parent.
Roberts Apperception Test for Children
If clinically relevant information is needed about the child’s emotional status, then I would recommend using the Roberts Apperception Test for Children for that information.
This information is not necessary for diagnosis and is therefore not part of my standard assessment protocol recommendation. However, if information about the emotional functioning of the child is needed, I would recommend use of the Roberts Apperception Test for Children to obtain this information.
A number of avenues for professional consultation are available,
Dr. Childress has professional expertise and background in six relevant domains, 1) the assessment and diagnosis of delusional thought disorder pathology, 2) attachment pathology in childhood, 3) child abuse and complex trauma, 4) Factitious Disorder Imposed on Another, 5) family systems therapy, 6) court-involved family conflict.
Dr. Childress is available to provide direct tele-health supported second-opinion consultation for diagnosis in ongoing assessments:
Dr. Childress has published a booklet describing a recommended six-session protocol for the assessment of attachment-related pathology surrounding divorce:
From Improving Diagnosis in Healthcare:
From Improving Diagnosis in Healthcare: “Clinicians may refer to or consult with other clinicians (formally or informally) to seek additional expertise about a patient’s health problem. The consult may help to confirm or reject the working diagnosis or may provide information on potential treatment options.” (Improving Diagnosis in Healthcare, 2015)
From Ethical Principles of Psychologists and Code of Conduct of the American Psychological Association:
3.09 Cooperation with Other Professionals
When indicated and professionally appropriate, psychologists cooperate with other professionals in order to serve their clients/patients effectively and appropriately.