Parental Alienation: In the child’s worst interest

Parental alienation (PA) is a form of childhood emotional abuse in which one parent instrumentally uses the child to inflict psychological harm on the other parent for revenge. The consequences of parental alienating behaviours range from mild (e.g., the child shows a certain resistance towards visiting the targeted parent but warm parenting is still possible) to severe, where the positive affective parent–child bond is severed and extremely difficult to reinstate under family therapy. In PA processes, parenting is disrupted with the targeted parent and dysfunctional with the alienating parent. Consequently, the child is at a high risk of developing internalising (e.g., depression, anxiety) and externalising (e.g., use of drugs/alcohol, violence) problems during later developmental stages and through the lifespan. Although the prevalence and severity of PA cases in our societies are largely unknown, in part because the construct is still an ongoing debate among academics, practitioners and family justice professionals, different authors defend that it should be treated as a public health problem. Early prevention should be the primary objective and family justice, child protection and mental health services must coordinate efforts to support the families and promote the best conditions for the development of affected children.


Introduction
"It has been a terrible time […] In some way worse than losing your children by death, because they hurt you over, and over, and over again. Of course, you understand that it's not what they really think, and I remember all the good times we had together […], but it's very hard to handle that sorrow." (Göran 1 , targeted parent of parental alienation).
Göran is a Swedish physician and father of two who was alienated from his children over the course of a high-conflict divorce. At the time of his interview, 10 months had passed since the last time he had been together with his children, although they lived nearby. The children strongly refused to visit Göran, and during the few contacts they had, the older child repeatedly engaged in hostile and rude behaviour against him, tearing apart their previously positive relationship. Göran's story is the same drama of many parents who had been through the ordeal of parental alienation (PA), each a story of pain and suffering and, behind all of them, Parental Alienation: In the child's worst interest DOI: http://dx.doi.org /10.5772/intechopen.101231 rejected parent, (3) the adoption of alienating strategies by the favoured parent, and (4) the demonstration of alienating behaviours by the child [17,18].
Some authors claim PA can only occur in high-conflict divorces [15,19], while others claim that although divorce and post-divorce parental disputes are the most common scenario, PA can also occur within intact and separated families [20,21]. Regardless of the divorce status, it is commonly accepted that PA results from the strain that a family system endures because of the pathological dynamics born from impaired relationships between its members [19,22].
The strategies used by the AP to alienate the child vary in type, number, and severity. In accordance, the harshness of the behaviour displayed by the child against the TP also varies. In fact, PA is considered a dimensional construct rather than a dichotomous diagnostic entity [1], can range from mild to extreme forms, and not all children are affected in the same way. Alienation seems to be less likely among young children since the mechanism of persuasion, indoctrination, and brainwashing require a certain level of cognitive ability to process the cognitive biases and distortions transferred by the AP. The typical age range among children who display alienating behaviours is 8-9 to 15-18 years old [15,23], and this is found in both male and female children, and it can affect either parent [23].
PA can be conceptualised as a type of family violence perpetrated by the AP against the child, in which the parenting processes from both parents are severely disturbed. Besides the dysfunctional bond established between the child and the AP, the bond with the TP is disrupted and may eventually dissipate in extreme cases. The child will not adequately mourn the loss of the TP, who, furthermore, will possibly be substituted by the AP's new partner in an unhealthy way. Since the consequences of PA for the child's physical and mental health are often devastating, it is urgent to develop institutional mechanisms that efficiently identify, treat and support families and the individuals affected. Given the complexity of the problem, the variation in the type of families nowadays far from the traditional two biological parents living together with biological children and the fact that each alienation process differs from family to family, individual-based assessment and intervention are highly recommended.
In this chapter, I present the grounds to defend that PA is a form of family violence and should be considered as such by the family justice system. What are the consequences? How is parenting affected? How should social institutions proceed to prevent major harm and protect the children? These questions are addressed in the following pages. The text aims to contribute to the current discussion about the PA concept among scholars, practitioners, and other professionals, but technicalities were avoided so that it is possible to be understood by a broader audience as well.

Parental alienation is a form of family violence
PA is a poorly understood form of violence [24]. The behavioural strategies used by the AP during alienation constitute emotional abuse of the child and may include tactics such as ignoring (e.g., denying effective response to the child's emotional requests), rejecting (e.g., spurning, constant criticism), isolating (e.g., preventing the child from spending time with family and friends), terrorising (e.g., threatening the child with abandonment or harm), exploiting (e.g., making the child responsible for the care of the parent or other children), and corrupting (e.g., involving the child in immoral or illegal activities) the child [15,[25][26][27][28][29]. Haines, Matthewson, and Turnbull [2] found similarities between PA behaviours and the brainwashing stratagems seen in cults. The AP may inflict abuse directly or indirectly, saying to the child that the TP has done or will do any of these actions.
Consequently, the child develops a sense of worthlessness and of being unloved and endangered [30]. Fostering and encouraging cognitive biases and attitudes in the child that promote denigration and estrangement of the TP is itself a form of emotional abuse [18]. Common PA behaviours by the AP are listed in Table 1.
In PA processes, the child is victimised [31] and should receive the same attention as other children victims of parental maltreatment. Prioritising the wellbeing of the child requires urgent legal and clinical intervention. In this regard, it is necessary to develop competencies within the family justice system, child protection, and mental health services to evaluate and prescribe this indispensable family intervention efficiently.
PA is a process that generally starts with the deterioration of the relationship between both parents, and evolves over time. Emotional or physical abuse between the parents can occur but not necessarily. A common first step of PA, and a form of coercive control often seen in high-conflict divorces, is the threat to prevent the other parent to see and spending time with the child. During his interview, Göran revealed, "When I said 'I'm going to separate' , she told me twice, 'You can forget your kids' , I think she said that to make me stay. Otherwise, why would she act like that if we had such a terrible relationship at the end?" Because of this manipulative strategy from his partner, Göran accepted staying and, in this way, guaranteed access to the children for some time, although the relationship between the couple continue to crumble.
Frequently, a power imbalance between both parents precedes PA, and the AP increasingly overpowers the TP in family relations. Among the personality traits found in APs is a wish to control and dominate others [33,34]. Göran reported, "At the beginning, there were a lot of hassles, and usually she refused to stop the discussions. She would demand me to realise how stupid I was or that I was wrong. But each time she undermined my authority towards the children more." Recent research suggested that we must better understand the abusive power dynamics between the couple if we aim to be more effective in our intervention methods [35]. to the children and eventually to the extended family. Often the AP openly displays verbal aggressive behaviours towards the TP in the presence of the child. APs justify their aggressiveness in their manipulative strategies, arguing that the TP is dangerous and therefore they need to protect the child and themselves [26]. This creates fear in the child that they might be harmed by the TP or are not secure in their presence.
The scientific literature identifies personality features among APs characteristic of the DSM's cluster B personality disorders, including narcissistic, antisocial, and borderline, besides other mental problems and substance abuse [19,[36][37][38]. Among the narcissistic traits, a sense of entitlement produces strong confidence when making decisions regarding the child and makes APs feel they are right and superior to others. As a result, they likely disregard court orders if they are against their wishes [2].
The alienating strategies have dire consequences and long-term effects on the child's mental health and wellbeing [9]. The alliance established between the AP and the child during alienating processes is in many ways similar to the trauma bonding victims of maltreatment create with their abusers [39]. The child feels physically and emotionally distressed when the AP is not present because of the manufactured belief that the AP is the only person they can trust and with whom they are safe. The child, then, defends the AP in every circumstance, even when the AP treats them harshly or rudely. In such cases, the child changes their behaviour to please the AP as much as possible. Subsequently, the AP positively reinforces the child and creates a behavioural pattern by conditioning.
In extreme cases, the AP can manipulate the child's believes to the extent they create false memories and the idea that the TP has physically or sexually abused them. In consequence, the child deploys a range of alienating behaviours against the TP. Common PA behaviours by the child are listed in Table 2.
In sum, PA is a form of family violence in which the AP uses the child instrumentally through a set of emotionally abusive behavioural strategies to harm the TP. Revenge is the primary emotion fuelling the AP's alienating behaviour. The traumatic bond between the AP and the child is reflected in the alienating behaviours displayed by the child against the TP, and parenting is severely disturbed (see Figure 1).
A campaign of denigration against the TP Weak, absurd, or frivolous rationalisations for the deprecation Lack of ambivalence (the child is consistent in their opinion about the TP) The "independent-thinker" phenomenon (the child asserts that the negative thoughts and feelings they express against the TP are their own) Reflexive support of the AP in the parental conflict Absence of guilt over cruelty to and/or exploitation of the TP The presence of borrowed scenarios (words, expressions, and phrases are common to both the AP and the child) Spread of the animosity to the friends and/or extended family of the TP The child resists or refuses visits with the TP The child will singly express the wish to terminate the relationship with the TP Table 2. PA behavioural manifestations by the alienated child [19,40].
Parenting -Challenges of Child Rearing in a Changing Society 6

Parenting by the targeted parent is disrupted
Parent-child interactions determine to a great extent the child's behaviour during childhood and adolescence. As Silva and Sandström [41] noted, "the child's psychological wellbeing and mental health, the behavioral adjustment in different situations, and the capability to establish positive relationships with others are closely related to the level of parental competence during early stages of maturation" (p. 60). In PA processes, the TP-child interaction is seriously compromised, and the positive affective bonds are broken. Under such circumstances, the TP's parenting role is disrupted and eventually completely ceases. If the AP does not succeed in suppressing the input of the TP in the life of the child and the TP is somehow able to maintain contact with the child, the objective of the AP will then turn towards sabotaging the TP's attempts at parenting by forcing negative parenting practices. For example, encouraging the child's defiant behaviour and aggression towards the TP makes a harsh response by the TP to control the child's behaviour more likely. On the other hand, the TP may find it more suitable to withdraw from conflict in an attempt to satisfy the child, which gives the AP an argument to say that they are irresponsible or uncaring.
Responses elicited in the TP by the child's behaviour vary depending on multiple factors, such as the parent's personality characteristics, mental health status, the psychological and economic strain they sustain because of the legal battle, their capability to cope with it, the presence of a supportive social network, and the parent's previous parenting style. Regarding their parenting role, many TPs experience an identity loss [42][43][44]. Göran reported, "My children said they didn't want to have any contact with me, they had never had a good time with me and that I had never been interested in them. So, they showed that they felt awful when they were with me". The loss of the parenting role may be particularly difficult to cope with when the AP chooses a new partner, who will serve as a replacement. The new partner ends up making parenting choices while any attempt by the TP is invalidated. It is only natural for the TP to become extremely distressed due to the alienating process, as it affects every aspect of their life, influencing how they interact with the child. As the alienating process evolves, TP's find themselves in a helpless situation; whatever they do, the child will fight against it. The gap in the relationship grows, and the TP is unsuccessful in their attempts to restore the affective bonds. Any positive attempts at parenting the child (e.g., assertive control, demonstrations of acceptance, and warmth, autonomy support) are futile.
It is difficult for TPs to assert themselves in the face of the alienating strategies [45], especially if the starting point is a partner relationship characterised by a power imbalance favouring the AP who consistently undermines their authority as a parent. TPs have been reported to behave passively in the face of conflict, being less involved with the child and becoming progressively more distant [9,19]. During the legal battle, they are likely to reach a point where they are too overwhelmed and may seem to have withdrawn from the fight over communicating, spending time, or reconstructing the affective relationship with the child. However, their outwardly apathetic posture may well be an extension of the pattern of interpersonal interaction developed during the marriage [2]. Furthermore, the economic burden of paying for legal proceedings, the uncertainty that justice will be delivered if they litigate, and the fear that fighting back with the AP will further compromise their relationship with the child may deter the TP from being more active and seeking closeness [46]. Avoiding upsetting the AP is a possible strategy adopted by TPs to control their behaviour [2].
In a non-quantified number of cases, TPs have faced false accusations of physical or sexual abuse of the child, which almost automatically severs free access to the child and the possibility of spontaneous interactions. If the court determines that contact with the child must be supervised, the parent's behaviour is extremely conditioned, further preventing normal parenting mechanisms. The TP will then avoid any confrontation with the child for fear of worsening their odds of recovering the free access to them. Nevertheless, even in the absence of false accusations, the TP may feel compelled to change their parenting approach to a more permissive style (e.g., lax-control, non-directive, indulgent). The TP is just too afraid of further alienating the child and, consequently, will restrain from disciplining them [2]. To avoid upsetting the child and deepening the deterioration of the relationship, the TP may avoid normal parenting actions they otherwise would take. The child then perceives the TP as not having authority or significant influence in their lives, and the opportunity to parent the child is lost. Further, the AP instrumentally uses this to remark and reinforce the notion that the TP does not care, does not love the child, and is not worthy of the child's love.
In contrast to a passive attitude, in some cases, the TP adopts a rigid approach. Because, in general, the time they spend with the child is limited, the TP sets harsh rules while they are together. For example, the TP may restrict or obstruct the child's socialisation with peers, interaction with the AP or AP's family in special events (e.g., birthday parties, celebration of special dates), or involvement in physical or cultural activities not scheduled by them. While it is easier to enforce rules with younger children despite the child's opposition, this could ignite a war in the case of adolescents. For the TP, the disrespect and defiance displayed by the child add to the continuous conflict with the AP. The child's repeated aggression and rejection possibly elicit anger in the TP and an urge to retaliate, although the TP eventually understands that the child's behaviour emerges as a consequence of the alienation tactics, rather than the child itself. With older children, the TP may blame the child instead of the true source of the problem, which triggers negative parenting practices (e.g., inflexible discipline, derogation, coercion, hostility). This creates more retaliation and rejection by the child and reinforces the image of a bad parent that the AP instilled in them. Under such circumstances, the terrain is fertile to grow coercive exchanges between the child and the TP. The parent's actions reinforce problematic behaviour in the child, which reinforces the parent's coercive behaviour [41]. The TP retaliates by criticising the child, emphasising weaknesses, frailties, and exploiting weak points, thus generating hurt feelings. In the child's mind, the TP becomes the culprit of every difficult dark moment they experience, reinforcing that parent's hideous image imbued by the AP. At this point, the relationship is almost irreversibly damaged, and any parenting attempt by the TP is unsuccessful. The psychological adjustment of both child and TP is seriously compromised and family therapy, if pursued, will only achieve modest results.

Parenting by the alienating parent is dysfunctional
PA processes are pathological in nature. Individuals with features such as those classified by the DSM's cluster B personality disorders do not react to the end of their intimate relationship with sadness or sense of loss. Instead, they are likely to ruminate about past grievances, remain enraged, and seek vengeance [47,48]. If they experience the separation or divorce as shameful or humiliating, they will probably retaliate quite negatively towards the other parent [19].
The AP cannot stand different or oppositional opinions in the TP, and they will manipulate and force the child to acquire their point of view. APs are prone to disrespect and violate court orders that do not align with their perspective or serve their purposes. Their narcissistic sense of entitlement gives them the mentality that they have the right to decide the course of the relationship between the child and the other parent above everyone else, including the justice system.
APs despise everyone who opposes their alienating attitudes, including the TP, the TP's extended family, the child (if the child resists being alienated), and whoever confronts them (e.g., school personnel, child protection services, and court personnel). They talk incessantly about the TP's flaws, shortcomings, and weaknesses to thwart the good image that others, including the child, have and undermine the child's confidence in the TP's love and capacity to keep them safe. At the same time, APs presents themselves as devoted, protective, and stable parent, giving the child a false sense of security. However, despite the image of protector of the child's best interest that the AP likes to sell, in reality, they lack empathy and concern about the child's feelings and needs. They play with the child's affection and may threaten to withdraw their love if the child does not comply with the alienation. They do not hesitate to disavow or show their coldness to the child if it fails to comply with their expectations. In this climate, the child learns that the AP's affection is contingent on their rejection of the TP.
Borderline personality features include affective instability due to a marked reactive mood. Such cases usually swing between intense episodic dysphoria, irritability, or anxiety that confuses their social environment. In an alienating context, the dysphoria and irritability are possibly contingent on the child's alienating behaviours. The AP may show intense anger and have difficulty controlling it if they perceive that the child fails to reject the TP. Therefore, the child learns to please the AP to avoid triggering their intense negative moods.
Certain antisocial personality characteristics such as deceitfulness and conning others, the use of manipulative tactics, and repeatedly lying to serve the purpose of getting the TP out of the child's life have also been found among APs. The APs take advantage of any information to falsely demonstrate that the TP has mental health, substance abuse, or anger management problems. Anything may be used to vilify the TP and make them seem threatening to the child. APs with such personality features feel no remorse in distorting information and biasing the child's cognitive and belief system against the TP. In extreme cases, the AP may risk the child's safety, act recklessly, or abduct the child to antagonise the TP without any regret.
If authoritarian parenting was the AP's dominant parenting style before the PA process, harsh parenting might worsen as the alienation evolves. Authoritarian parents place high expectations on their children, force obedience, and punish non-compliance, sometimes in a psychologically brutal way. Authoritarian APs may use the expression "you are like your father/mother (the TP)" to criticise the child when they do not meet their expectations. This sends a powerful message to the child; they have the same weaknesses, flaws, and negative features as the TP and are not worthy of the AP's love and affection. The frequent derogation, high demands, and low responsiveness characteristic of authoritarian parents create on the child the necessity to demonstrate that they are worthy of their love. Accordingly, an alienated child will fight the TP in every way possible. Paradoxically, the child fights against a parent with whom they once had a warm relationship while trying to earn the attention of a parent who, most likely, was never as effective as the TP and will never be. Less affection is the price of feeling safe since the alienating process makes the child consider the TP a hazard. The door to trauma bonding is then open.
Controlling and coercive behaviour are also characteristic of authoritarian APs, in line with narcissistic personality features. APs with such characteristics will demand that the child report details of their time spent with the TP. It is not unusual for such APs to demand that the child spy on the TP, such as searching for clues about whether the TP has a new partner, is buying expensive new goods, or places the TP visits. The AP will want to have as much information as possible to use in the legal battle against the TP. For this purpose, they do not hesitate in using the child. They may coerce the child by saying that it does not comply with their requests, the consequences will be severe, and the child will be to blame. This behaviour gives the child no choice, and if for any reason it cannot comply, the AP will show anger, coldness, inflexibility, and will criticise and punish the child.
On the opposite extreme, we find APs that present dependent personality features such as separation anxiety and feeling helpless when alone because of an exaggerated fear of being unable to care for themselves. Dependent APs have difficulty making everyday decisions without an excessive amount of advice, need others to assume responsibilities for most major areas of their lives, and go to excessive lengths to obtain nurturance and support from others. In such cases, the alienating process arises from other persons in their environment like the extended family (e.g., the child's grandparents, aunts, uncles). Parenting is further seriously compromised in these situations because parents with dependent personalities are very likely to have permissive parenting styles with lax-control and non-directive discipline. The child ends up being parented by those who actively encourage the alienating practices. In such cases, the child is submitted to different parenting approaches from several people, creating even more confusion. They will not know whom they can trust and will probably feel insecure with everyone. Insecure attachment in future close relationships is then almost guaranteed.
Garber [49] reported that three dynamics in the child-AP relationship can develop in the context of an alienating process. First, the AP may use the child as a confident and disclose information about themselves and their thoughts and feelings, forcing the role of an ally on the child. In this case, the child is provided with information inappropriate for their age, when they still lack the emotional maturity to handle it, in interactions more proper for an adult-adult than a parent-child relationship. Garber called this adultification. A superior level of this dynamic is called parentification. In such cases, the child-parent role is exchanged, and the child is encouraged to care for and look after the parent due to the parent's dependency. When this happens, parenting by the AP is inexistent, which added to the disrupted parenting by the TP, leaves the child without any guidelines during critical developmental stages. Child development may then be more a matter of survival with a considerable cost for the child emotional and potentially physical wellbeing.
On the other hand, Garber also described a dynamic called infantilisation, when the child is treated as much younger than their chronological age. The AP gives the child no space for independence and restricts the child's emotional and social development. Moreover, in their demands during a legal custody battle, these parents appear concerned for safety issues for the child that are not age-appropriate.
Each of these dynamics comes at a cost to the child. Adultification has been related to symptoms of depression, anxiety, and impact on academic achievement [49], while parentification has been associated with suicidal ideation, negative emotionality, psychosomatic symptoms, and isolation from peers [50]. Likewise, infantilised children are at risk of developing different internalising and externalising problems [2].

Consequences of PA for the child
During the alienation process, the child is manipulated into believing the TP does not love them, possibly never did, disregards their safeness, and is a threat. As a result, feelings of abandonment, loss, and fear grow inside the child, who will then interpret any of TP's behaviours through these cognitive biases, and will consistently express unreasonable anger, hatred, and rejection [15]. On the other hand, the child seems not to regret their hateful behaviour against the TP [11], but paradoxically a sense of betrayal and loss is likely to develop, leading to feelings of guilt and shame [51]. In her retrospective study of adults who experienced PA as a child, Baker [51] reported that most individuals in her sample recalled claiming they hated and feared the parent they rejected. However, they did not want that parent to disappear from their lives and hoped someone would realise their words and acts were not truthful.
The child's alignment with the AP has many characteristics of traumatic bonding, like the emotional response described in Stockholm syndrome. The child mimics the AP to survive their harassment and psychological pressure. Having effectively lost one parent, the child is compelled to do all the possible to be worthy of the AP's affection and to avoid the AP's coldness when they fail to show rejection of the TP.
Through their alienating manipulation strategies, the AP succeeds in transforming the emotional climate generated during interactions of the child with the TP into a negative experience. Soon the child will generalise the negative emotionality to anything that relates to the TP. The consequences of this are severe in the medium-to long-term. School-related difficulties, depression, anxiety, alcohol and drug abuse, and low self-esteem have been found in adults victims of PA during childhood [9,25,51], leading to the conclusion that turn a child against a parent is to turn a child against itself [30]. The child's belief that a parent does not love them has a significant impact on their self-esteem [52]. In addition, due to the alienating process, the child loses the capacity to trust itself or anyone else [51]. As a result, the child becomes angry, resentful, and permanently alert and afraid of being emotionally manipulated and controlled.
Without clinical intervention, the effects of PA may last the lifespan [30]. Among other symptoms, insecure attachment, relationship difficulties and breakdowns, lower self-sufficiency, identity loss, alienation from one's own children, major depression symptoms, and poor health in adulthood have been identified in adults who have suffered PA [9,25,51,53,54]. In a review of the scientific literature. Filder and Bala [55] discovered that PA impacts four spheres of the child's life and reverberates at later ages. In the cognitive sphere, alienated children demonstrated simplistic and rigid information processing, difficulty in distinguishing Parental Alienation: In the child's worst interest DOI: http://dx.doi.org/10.5772/intechopen.101231 the internal world of thoughts and feelings from the external world, and illogical manipulation of mental representations. Second, in the interpersonal sphere, alienated children show inaccurate or distorted interpersonal perceptions, and disturbed interpersonal functioning. Third, in the personal sphere, low self-esteem, self-hatred, pseudo-maturity, gender identity problems, and poor differentiation of self-have been identified in alienated children. Finally, in the behavioural sphere, alienated children are at risk of developing antisocial personality features such as disregard for social norms and authority, poor impulse control, aggression and conduct disorders, and lack of remorse or guilt.
In PA processes, the child grows in an emotionally hostile environment, without the guidance of parents with whom they feel understood, valued, loved, respected, and protected. If the child cannot trust that parents are open to listening to them with an accepting attitude they will not disclose (or will lie) about their whereabouts, daily activities, relationship with peers, and problems in school. During adolescent years, a child who feels overly controlled by one parent as is the case when the AP demands to know about time spent with the TP and at the same time suffers limitations imposed by the other parent, for example when the TP controls the time they spend together, will naturally rebel and seek the warmth and connectedness that they cannot find with either parent outside the home. The peer group then assumes the primary function of socialisation without parents having any control. The function that parents have in steering the child away from problematic peers, discouraging drug and alcohol use and dissuading rule-breaking behaviours is nullified.
Of course, not all children who suffer alienating processes will develop internalising or externalising problems. This depends on multiple other factors present in their environment during their upbringing. For example, establishing a warm relationship with a positive role model, such as a relative in the extended family, the parent of a friend, or a teacher, can work, to a certain extent, to prevent psychopathology. However, PA must be treated as an important risk factor that multiplies the probability of mental health and behavioural problems similar to other types of child maltreatment.

Prescriptions for the justice system, child protection, and mental health services
The construct of PA and its damaging effects is largely misunderstood by the public, the judges, and many professionals who work with children [56,57], perhaps because of the controversy surrounding the concept. Years of discussion about whether it should be considered a psychiatric syndrome and catalogued within the DSM or whether it complies with the criteria for a mental disorder has distracted and obstructed the development of effective solutions. Problematic situations do not receive the necessary attention to prevent children submitted to PA processes from suffering the consequences. There are no consistent and systematic measures of the prevalence of PA cases within the family justice system. There are no specialised services and personnel to address PA cases effectively. In addition, poor understanding of the relationship dynamics and psychological mechanisms involved in PA leads to mistakenly identifying PA where it does not exist (i.e., false positives) and dismissing legitimate PA cases (i.e., false negatives) [58]. Besides, PA is neither a yes/no construct nor it is a static process. On the contrary, alienating behaviours by the AP and by the child most likely worsen over time [2]. For example, Göran reported, "It got worse when I met another woman who cared for the kids, and they liked her. But after a while, it got bad, and my daughter told me 'I don't want to live with you' […] somehow, they were getting more and more alienated".
Concurrently to PA, the AP's false allegations of domestic violence and child sexual abuse by the TP causes the immediate interdiction of the TP's visits to the child on many occasions. Allegations of abuse further complicate investigation and intervention. Like PA, false allegations are largely understudied. Some asseverate that is a rare phenomenon [59] but as Silva [46] pointed out, what surfaces might be just the tip of the iceberg. Allegations of abuse take time to investigate, time that the AP has to manipulate and alienate the child further. If the AP further complicates the case by not complying with court orders or by taking actions that purposefully delay court proceedings, any attempt to recover the relationship between the TP and the child will undoubtedly fail.
In addition, the lack of economic and psychological resources to continue lengthy litigation possibly drives the TP to desist from pursuing judicial action. Many TPs feel hopeless after their repeated unsuccessful attempts to manage the problem through the family justice system [2]. Eventually, doubts about the best course of action arise in the mind of the TP. Göran reported, "They [child protective services] claimed they would actually argue that the children should live with me and have minimal or no contact with the mother. But they were afraid of how that would work because the children were so against being with me. They didn't have anything to complain about me as a father, neither had the school in their opinion, when they wrote the report. But, on the other hand, they thought the children didn't have enough bad time with the mother that they would require to enforce drawing them away of her. And I was kind of… reflecting… what is the best for my children?
[…] May be it is better to leave them with the mother and try to manage my life and show them I love them, I want to be with them and that I'm waiting for them to come when they feel like it." In some cases, TPs feel so powerless due to their repeated fail in getting closer to the child, they may threaten to abduct the child or harm the AP in some way. However, as Haines and colleagues [2] indicated, the threats are the result of the distress and frustration produced by the alienation dynamic rather than a wellformulated plan of action.
Due to the severe short-and long-term consequences PA processes produce in the child, prevention and intervention should be prioritised, and PA should be considered a public health issue [57]. Preventive efforts must be a shared responsibility among professionals, schools, organisations, and the public. At-risk children must be identified as soon as possible so that case-based, individualised interventions with the children and their families can take place during an early stage. Since PA is a dimensional construct, principles of proportionality should apply to case management. Severe cases will require a long time to heal and APs might recidivate in alienating practices when institutional support ends. Therefore, interventions ought to include relapse prevention.
It is essential that children are considered a priority and placed at the centre of institutional actions as plotted in Figure 2. To protect the child's wellbeing and mental health is an overriding objective beyond the legal resolution of the conflict between the parents and the parents' rights. The family justice system, child protection, and mental health services must coordinate their efforts to achieve successful results.
The court must monitor whether parents comply with its prescriptions and impose sanctions if they fail, and in coordination with mental health services, must oversee the progress of family therapy and parent-child reconciliation [57]. It is necessary to ensure that mental health support is available for every child who suffers a PA process. Psychiatric care may be essential to treat severe cases. Unfortunately, that is not always the case. As Göran reported, "My daughter hadn't been with me for a few months, and when I told her we should have some contact, DOI: http://dx.doi.org /10.5772/intechopen.101231 she claimed that she didn't want to live. She threatened that she didn't want to live twice. She made scars in her skin although she didn't cut herself. My ex-wife took them [the children] to a child psychologist but with no results. She only tried to give my daughter advice 'When you feel like this it is better to paint. So, yeah… that's how much of psychology she had. I think that's a big shortcoming in the Swedish system that we don't have child psychiatrists or a psychiatrist that could help us parents." In general, the PA process does not end when the interaction between the TP and the child ceases. The AP continues their alienating dynamics until the child completely demonises the TP. The alienation feeds itself in the absence of the TP, because it distortedly confirms their abandonment and neglect, therefore justifying the alienating behaviour. Therefore, support services must be fast and flexible, primarily when highly dysfunctional parenting by the AP, and complete cessation of the relationship with the TP concurs.
To ameliorate the child's alienating behaviours and prevent the psychological consequences of PA, a change in custody or residential arrangements favouring the TP may prove effective [60]. Family therapy ought to target the relationship dynamics of each node (child-TP, child-AP, AP-TP) and the family as a whole. Re-establishing the bond between the child and the TP is essential, but there is also a great need to restructure the dysfunctional relationship between the child and the AP. If there is more than one child in the family, PA may affect each of them differently. Likewise, PA can involve the stepparent and the extended family (e.g., grandparents, uncles, aunts) who should also take part in family therapy sessions. Clinical intervention with the AP and to prevent them from continuing the alienating practices is crucial, but it is challenging when there are underlying personality disorders.
Although PA has been considered in legal and clinical work for more than 40 years, and there are available some reviews of the scientific literature in the field [20,60,61], the phenomenon is still largely unstudied and in need of more research. In this regard: (1) the construct validity explored for example by Baker and colleagues [32,62,63] needs to be replicated, (2) whether PA should be defined as a syndrome and introduced as a new diagnostic entity in the DSM [64] or it is better defined as a form of family violence [65,66] has to be settled, (3) the Author details Teresa C. Silva Mid Sweden University, Sundsvall, Sweden *Address all correspondence to: teresa.silva@miun.se implications of PA for judicial outcomes examined by Harman and colleagues [67] calls for more studies, (4) available assessment tools [68,69] need to be further tested and new ones developed if necessary, (5) more studies that determine the prevalence of PA in different stages of family conflict are also necessary, and (6) more research is required to fully understand how PA affects each of the family members. Only after we completely understand what the PA problem is in all its spheres, we can effectively design, implement, and evaluate programs and interventions to combat it.

Conclusions
PA has severe consequences for the child's psychological wellbeing. Even in mildest levels, alienating strategies can potentially cause the child to develop the feeling they are not loved and a sense of abandonment, and neglect by the TP. The AP teaches the child to disparage, reject, and hate the TP while creating traumatic bonds with the AP. Under these circumstances, parenting is highly dysfunctional. Any parenting effort by the TP is rejected by the child and can eventually come to a halt if the AP successfully interrupts the interaction between the TP and the child. At the same time, the AP's emotionally abusive strategies reflect a significant impairment in the relationship with the child. In addition, the APs' authoritarian or permissive parenting styles leave no space for the healthy development of the child, precipitating the development of psychopathologies, such as anxiety, depression, alcohol and drug abuse, and violent behaviour. It is in the child's best interest for the family justice system, child protection, and mental health services to coordinate their efforts to intervene as early as possible. Likewise, for the benefit of society, there should be an investment in research in this field to produce empirical evidence that supports the development of necessary prevention and intervention programs.

Conflict of interest
The author declares no conflict of interest.
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