Differential Diagnosis of Parent-Child Conflict

In a comment to my Facebook page, a parent asked about the process of diagnosis.  I thought my response might be more broadly of interest, so I responded as a full post on my Facebook page, and I’m also responding here on my blog.

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Patient Identification

The patient is the child.  It is the child’s symptoms that are of concern relative to treatment.  Our goal is to ensure that the child has a normal-range and developmentally healthy childhood.

The second component of the patient is the parent-child relationship, since a healthy and affectionally bonded parent-child relationship is centrally important to the healthy emotional and psychological development of the child.

Children have a right to love both parents, and they have the right to receive the love of both parents in return.  So in addition to alleviating any child symptoms of pathology in order to restore the child to a healthy developmental trajectory, we also want to (if possible) establish a normal-range and healthy affectional bond between the child and both parents.

Differential Diagnosis

Diagnosis involves a process called “differential diagnosis” in which all possibilities for creating the child’s symptoms are initially on the table, and then we begin to narrow down the possible causal factors through a systematic collection of information that begins to rule-in some diagnostic possibilities and rule-out others, until we reach only one possible diagnosis that would explain the child’s symptoms.

Each type of pathology has a characteristic pattern of symptoms.  The goal of differential diagnosis is to systematically collect information on the pattern of symptoms that will lead to an accurate diagnosis of the cause.

Possible Cause 1:  Inherent Child Difficulties

The cause of the child’s symptoms may be some factor inherent to the child, such as ADHD, autism-spectrum issues, or neuro-developmental problems such as emotional regulation difficulties.  So one set of assessment inquiries will be to systematically collect information to rule-in or rule-out possible inherent child issues related to the child’s symptom presentation.

Typically in the family conflict surrounding divorce, a few questions in this area will be sufficient to rule out ADHD and autism-spectrum pathology (although I have seen cases of high post-divorce family conflict and co-occurring autism or ADHD issues with the child – typically diagnosed by another mental health professional long before my assessment of the post-divorce family conflict).

Inherent child emotional regulation problems may be a factor in post-divorce parent-child conflict, but a set of questions about school behavior (consistency of symptom display across settings) and prior history of explosive-angry outbursts can typically rule-out this inherent-child cause of the post-divorce parent-child conflict.

Possible Cause 2:  Problematic Parenting by the Targeted Parent

The next set of differential diagnostic possibilities is that the parent-child conflict is being caused by problematic parenting of the targeted parent, and perhaps a co-contributing factor is the child’s problematic response to the problematic parenting of the targeted parent (called circular causality – the parent’s behavior produces the child’s behavior, which then produces the parent’s behavior, which then produces the child’s behavior, which then… and who knows exactly where it all began – a chicken-egg sort of original causality – but it’s just going around-and-around; circular causality).

This assessment benefits from a specific type of diagnostic inquiry called the “behavior-chain sequence” (Assessing the Behavior Chain in Parent-Child Conflict) in which both parties are asked to describe, step-by-step, the interaction sequence during prior incidents of parent-child conflict.

Behavior-chain interviews are a standard form of inquiry in a particular type of behavioral therapy called Applied Behavioral Analysis.  We start by asking what was going on just prior to the beginning of the conflict, where was everyone, what was each person thinking and doing?  Then we walk through step-by-step (parent-child-exchange by parent-child-exchange) how the conflict began, how it progressed, how it ended, and what happened after it ended.  The entire “behavior-chain” of interactions before, during, and after an incident of conflict.

Behavior chain interviewing is critical for assessing causality in the parent-child conflict surrounding high-conflict divorce – and it is essential for assessing the attachment-related pathology of AB-PA.  All mental health professionals who are assessing attachment-related pathology surrounding divorce need to employ the behavior-chain assessment technique of Applied Behavioral Analysis.

Possible Cause 3:  Problematic Parenting by the Allied and Supposedly “Favored” Parent

This type of problematic parenting is called “triangulating” the child into the spousal conflict (commonly called “putting the child in middle” of the spousal conflict) through the formation of a “cross-generational coalition” of the child with the allied parent against the other parent.

Triangulation and the formation of a cross-generational coalition are abundantly described and defined in the family systems literature – Bowen; Haley; Minuchin.  A Wikipedia search on these preeminent family systems therapists and the construct of triangulation can provide a description of this pattern of family conflict.

The preeminent family systems therapist, Jay Haley, provides a definition of the cross-generational coalition.

“The people responding to each other in the triangle are not peers, but one of them is of a different generation from the other two… In the process of their interaction together, the person of one generation forms a coalition with the person of the other generation against his peer. By ‘coalition’ is meant a process of joint action which is against the third person… The coalition between the two persons is denied. That is, there is certain behavior which indicates a coalition which, when it is queried, will be denied as a coalition… In essence, the perverse triangle is one in which the separation of generations is breached in a covert way. When this occurs as a repetitive pattern, the system will be pathological.” (Haley, 1977, p. 37)

There is also a characteristic pattern of symptoms associated with a cross-generational coalition, particularly the constructs of an “inverted hierarchy” and the absence of “stimulus control” over the child’s behavior by the targeted parent’s behavior. I describe these constructs in my essay:

Stimulus Control and Identifying Inauthentic Parent-Child Conflict

The family pathology of a child’s triangulation into the spousal conflict through the formation of a cross-generational coalition with one parent against the other parent can range from mild to moderate to severe, and can occur in both intact families and divorced families.

The attachment-related pathology of AB-PA represents a subset of triangulation and cross-generational coalition that includes the addition of parental personality pathology to the cross-generational coalition.

The addition of parental narcissistic and/or borderline personalty pathology to the cross-generational coalition with the child transmutes an already pathological cross-generational coalition into a particularly malignant and virulent form in which the child seeks to entirely terminate the child’s relationship with the normal-range and affectionally available targeted parent.

This is because of the “splitting” pathology associated with the narcissistic and borderline personality (extreme polarization of perception) which requires that the ex-spouse must also become an ex-parent; the ex-husband must become an ex-father, the ex-wife must become an ex-mother.  This is a neurologically imposed imperative of the splitting pathology on the narcissistic/(borderline) parent’s perception of family relationships.  This distorted parental perception surrounding family relationships after divorce is then transferred to the child’s perception through the aberrant and distorted (manipulative and exploitative) parenting practices of the allied narcissistic/(borderline) parent in a cross-generational coalition with the child.

The addition of this form of parental personality pathology to the cross-generational coalition creates a set of three distinctive and definitive diagnostic indicators in the child’s symptom display for this specific type of attachment-related family pathology.

No other pathology in all of mental health will display this characteristic set of child symptoms.  Not authentic child abuse trauma; not problematic parenting by the targeted parent.

No other pathology in all of mental health will display this characteristic set of symptom identifiers. 

Try it.  Try to come up with an explanation for ALL THREE diagnostic indicators.  Not just one or two, but all three at the same time.

Authentic Child Abuse Trauma:  How does child abuse trauma produce a haughty and arrogant attitude and sense of entitlement in the child (diagnostic indicator 2)?

Problematic Targeted Parent:  How does problematic parenting by the targeted parent produce an encapsulated persecutory delusion in the child? (diagnostic indicator 3).

Try it.  Try to come up with an explanation for ALL THREE diagnostic indicators. 

No other pathology in all of mental health will display this characteristic set of ALL THREE child symptoms.  Not authentic child abuse trauma; not problematic parenting by the targeted parent.  The only way to arrive at this set of three diagnostic indicators is through a cross-generational coalition of the child with a narcissistic/(borderline) parent (Foundations).

That’s how the child is acquiring the five narcissistic personality traits.  The child doesn’t have a narcissistic personality.  It’s the allied parent who has the narcissistic personality.  The child is acquiring these distorted beliefs through the influence on the child by a narcissistic/(borderline) parent.

I call diagnostic indicator 2 the “psychological fingerprints” in the child’s symptom display that reveals the influence on the child’s beliefs by a narcissistic parent.  We cannot psychologically control a child without leaving “psychological fingerprints” of our control in the child’s symptom display.  Diagnostic indicator 2 represents the “psychological fingerprints” of control of the child by a narcissistic/(borderline) parent, and assessing for the five narcissistic personality traits of diagnostic indicator 2 represents “dusting for fingerprints” of the psychological control of the child by a narcissistic/(borderline) parent.

Diagnostic Checklist for Pathogenic Parenting

If all three of these diagnostic indicators of pathogenic parenting associated with AB-PA are NOT all present in the child’s symptom display, then whatever is going on in the family conflict, it is NOT AB-PA.

If all three of these symptoms are NOT present in the child’s symptom display, then we have ruled out AB-PA as a causal explanation.  Differential diagnosis.

If, on the other hand, all three of these characteristic symptoms ARE evidenced in the child’s symptom display, then the ONLY possible explanation is AB-PA.  No other pathology in all of mental health will produce this characteristic pattern of child symptoms.  Not the trauma of authentic child abuse.  Not problematic parenting by the targeted parent.

For example, a child who has experienced authentic child abuse from the targeted-rejected parent will NOT exhibit a haughty and arrogant attitude toward the abusive parent, nor will the child exhibit a sense of entitlement relative to the abusive parent.  So the child will NOT meet diagnostic indicator 2 for AB-PA.

In addition, the behavior-chain line of questions will have established the abusive-problematic parenting of the targeted-rejected parent, so the child’s belief in the child’s “victimization” is true, so the child will not meet diagnostic indicator 3 of AB-PA.

So an authentically abused child will NOT meet two of the three criteria of AB-PA.  Diagnostically, it’s not even close. 

Plus, the attachment system (diagnostic indicator 1) also looks different in authentic child abuse than from a cross-generational coalition with a narcissistic/(borderline) parent, but this is a technical issue that I won’t get into here (I’ll reserve that discussion for a later time).

In addition, diagnostic indicator 1 has a Secondary Criterion of Normal-Range Parenting by the targeted parent, which would not be met if the parenting practices of the targeted parent are authentically abusive – so actually, an authentically abused child will not meet ANY of the three diagnostic criteria of AB-PA.

Parenting Practices Rating Scale

This means that the three diagnostic criteria of AB-PA can quickly and efficiently rule-out false allegations of “parental alienation.”  So anyone who is worried about potential false allegations of “parental alienation,” it’s really simple, just apply the three diagnostic indicators of AB-PA.  In false allegations of “parental alienation” the child’s symptoms will not evidence all three indicators of AB-PA, so “parental alienation” is ruled-out.

Assessment Leads to Diagnosis

That’s the process of differential diagnosis.  All diagnoses are initially on the table, and then we systematically collect information to rule-in and rule-out various alternatives.

The focus is always on the child’s symptoms since we want to ensure that the child has a normal-range and developmentally healthy childhood free of pathology.  When there is substantial parent-child conflict, we want to make sure that this conflict is effectively resolved and that the parent-child relationship returns to a normal-range of affectional bonding so that the child can benefit from receiving the love of both parents.  If the child is being physically, sexually, or psychologically abused, then we want to take steps to ensure the child’s protection.

To make the conflict go away, we must first establish the cause of the conflict, 1) possible inherent issues with the child, such as ADHD, 2) potential problematic parenting by the targeted parent and possible circular causality, and 3) potential problematic parenting by the allied parent in a cross-generational coalition with the child against the other parent – or possibly some combination of two or all three of these factors.

Every form of pathology has a characteristic pattern of symptoms.

Diagnosis involves a systematic approach to identifying (and documenting) the pattern of child symptoms so that we can determine the cause, which then leads to our treatment plan for addressing the cause.

The Diagnostic Checklist for Pathogenic Parenting and the Parenting Practices Rating Scale are simply means for documenting the symptom features in the family as a process of differential diagnosis.

Assessment leads to diagnosis, and diagnosis guides treatment.

Craig Childress, Psy.D.
Clinical Psychologist, PSY 18857