The Place of Parental Alienation in ICD-11
William Bernet — May 29, 2019
The International Classification of Diseases, 11th Edition (ICD-11) has been in development for several years. At an early stage, several colleagues and I contacted personnel at the World Health Organization (WHO) who were involved in the process of revising ICD-10. We asked WHO staff about including parental alienation as a diagnosis in ICD-11, and they encouraged us to submit a written proposal.
Initially, we submitted a written proposal regarding parental alienation to the individuals who were working on the mental health component of ICD-11. At some point, ICD-11 launched their beta draft online, and they encouraged all interested parties to register in order to participate in that process. Several members of Parental Alienation Study Group (PASG) registered. By that point it was clear that parental alienation would not become a separate diagnosis in ICD-11, but it seemed possible that it could be in the text of ICD-11 in some other way.
In August 2016, I submitted proposals on the ICD-11 beta draft that “parental alienation” and “parental estrangement” be considered “narrower terms” of an established ICD-11 diagnosis, caregiver-child relationship disorder. I also submitted definitions for caregiver-child relationship disorder, alienation, and estrangement. There were a few comments—pro and con—regarding my proposals. After several months, ICD-11 staff partly implemented my proposals. That is, they officially included parental alienation and parental estrangement as narrower terms of caregiver-child relationship problem. That meant that alienation and estrangement became “index terms.” In other words, when a person searched the index of ICD-11 for alienation or estrangement, they would find those terms and would be transferred automatically to the page for caregiver-child relationship problem. However, ICD-11 staff did not adopt any of the definitions that I had proposed.
On June 18, 2018, the final version of ICD-11 was adopted and posted on the ICD-11 website. At that point, it seemed correct to say, “Parental alienation is in the index of ICD-11.” Also, “PA is considered another name for caregiver-child relationship problem,” and so on. Between June 2018 and May 2019, it was possible for any interested party to register on the ICD-11 website and post comments and suggestions regarding the text of the final version of ICD-11. Apparently, WHO personnel continued to consider revisions in the final version, based on comments from clinicians, researchers, and the general public. Over the next few months, the ICD-11 website was flooded with comments for and against the inclusion of parental alienation in the index of ICD-11. There was also a way for readers to “vote” for or against comments that had been posted. In general, there were many more “votes” in favor of parental alienation than against parental alienation.
Perhaps the most provocative comment against the inclusion of parental alienation in ICD-11 was called “Collective Memo of Concern to: World Health Organization.” This document, which was prepared by a number of long-time detractors of parental alienation, has many misstatements regarding this topic.
A few writers complained that some individuals who favor the concept of parental alienation had been saying that ICD-11 had officially endorsed parental alienation theory. The WHO staff cautioned: “Index entries serve to be able to code, in case such term is reported. Index entries can in no way be interpreted and must not interpreted as an endorsement or consideration of endorsement of the underlying concepts” (Team WHO, April 16, 2019).
On May 25, 2019, the World Health Assembly adopted the final version of ICD-11, so Member States can plan how to use the new version, prepare translations, and train health professionals. ICD-11 will go into effect on January 1, 2022.
The announcement on May 25, 2019 is found at:
There are two versions of ICD-11 available on the Internet. First, the “browser” version of ICD-11 is what medical professionals, individuals who code diagnoses, and the general public would go to if they are looking for a term. The URL for the browser version is: https://icd.who.int/browse11/l-m/en. If you go to that home page of the browser, you can search for “alienation” and you will be taken to the diagnosis, caregiver-child relationship problem. Note that at the top of the browser page it says Version April 2019, so it is current. The browser version is also called the blue ICD-11.
The general public can also go to the version of ICD-11 (the orange version), which has additional details. The URL for caregiver-child relationship problem in the orange version is: https://icd.who.int/dev11/l-m/en#/http://id.who.int/icd/entity/547677013. If you go there, you’ll see that alienation and estrangement are listed as “index terms” for caregiver-child relationship problem. That simply means that those terms are recognized when a user searchers for them in ICD-11, and those terms automatically take the reader to caregiver-child relationship problem.
Although the final version of ICD-11 was approved by the World Health Assembly, it seems likely that changes may still be made in future years. If additional diseases are identified or additional knowledge is gained about medical conditions, presumably there is a mechanism to gradually update ICD-11. Thus, it is possible that both advocates and detractors of parental alienation will continue to submit their opinions to ICD-11 staff for their consideration.
Professor William Bernet
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ONE COHESIVE VOICE
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