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Inicio Spanish Journal of Legal Medicine The so-called parental alienation syndrome and its derivations
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Vol. 48. Issue 1.
Pages 22-29 (January - March 2022)
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Vol. 48. Issue 1.
Pages 22-29 (January - March 2022)
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The so-called parental alienation syndrome and its derivations
El llamado síndrome de alienación parental y sus derivaciones
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3309
Juan Gabriel de la Cruza,
Corresponding author
, Julio Antonio Guijab, María del Mar Pastor Bravoc
a Servicio de Clínica Forense, Instituto de Medicina Legal y Ciencias Forenses de Cáceres, Cáceres, Spain
b Servicio de Psiquiatría Forense, Instituto de Medicina Legal y Ciencias Forenses de Sevilla, Sevilla, Spain
c Sección Unidad de Valoración Forense Integral, Instituto de Medicina Legal y Ciencias Forenses de Alicante, Alicante, Spain
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Tables (3)
Table 1. Parental alienation syndrome.
Table 2. Definition of parental alienation according to Darnall21.
Table 3. Clinical complaints and problems included in DSM-5 which may help to define a situation of parental alienation.
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Abstract

The denigration of one parent by the other would be one of the most damaging effects for the child in situations of family breakdown, although the so-called parental alienation syndrome (Gardner) as a supposed childhood mental disorder, has not obtained acceptance in psychiatric classifications nor the necessary validity and scientific support, so its use by mental health professionals, experts and lawyers should be avoided. Instead, one can use the diagnostic criteria contemplated by the international diagnostic psychiatric classifications that we describe. It is essential to establish the differential diagnosis based on the symptom of rejection of a parent, an issue that involves difficulty and may require the assistance of a multidisciplinary team to adequately evaluate all the evaluable aspects. Professionals must act with knowledge of the limits of their science, providing those data and conclusions that are legitimate and valid according to this premise.

Keywords:
Parental alienation syndrome
Conflictive divorce
Child abuse
Forensic medicine
Forensic psychiatry
DSM-5
Multidisciplinary assessment
Resumen

La denigración de un progenitor por el otro sería uno de los efectos más dañinos para el menor en situaciones de ruptura familiar, si bien el llamado Síndrome de Alienación Parental (Gardner) como supuesto trastorno mental infantil, no ha obtenido la aceptación en las clasificaciones psiquiátricas internacionales, ni la necesaria validez y soporte científico, por lo que debería evitarse su empleo por profesionales de la salud mental, peritos y juristas. En su lugar, cabe valerse de los criterios diagnósticos contemplados por las clasificaciones psiquiátricas diagnósticas internacionales que describimos. Es esencial establecer el diagnóstico diferencial a partir del síntoma del rechazo hacia un progenitor, cuestión que entraña dificultad y puede requerir el concurso de un equipo multidisciplinar para valorar adecuadamente todos los aspectos evaluables. Los profesionales han de obrar con conocimiento de los límites de su ciencia, aportando aquellos datos y conclusiones que sean legítimos y válidos según tal premisa.

Palabras clave:
Síndrome de alienación parental
Divorcio conflictivo
Maltrato infantil
Medicina forense
Psiquiatría forense
DSM-5
Valoración multidisciplinaria
Full Text
Introduction

In our region, including our country, family break-up has become an everyday reality, the growth in which is shown by the available statistics. According to data offered by the Consejo General del Poder Judicial1, since legalisation in Spain in 1981 separations and divorces increased constantly until 2006, after which they fell before becoming approximately stable from 2009 onwards, at around 120,000 annulments per year.

There is no doubt, as Arch2 states, that the fundamental concern of the different agents who play professional roles in these situations must be to help children adapt to the new situation, preventing as far as possible the appearance of difficulties or psychopathological disorders which hinder their correct development and evolution. It has been known for some time that continued contact with both parents, in spite of their divorce, is a guarantee that works in the best interests of their children. If one of the parents denigrates the other, this may become one of the effects of the divorce that most harms their children.

This criterion now has great legal repercussion: the tendency is now to go beyond the decision to award custody to one parent in favour of “co-parenting”, in which both parents are involved in the life of their child to ensure better adaptation.

The so-called “parental alienation syndrome”

When children’s relationship with their parents is maintained, this has its opposite pole, to continue with Arch2. This is known generically as “parental interferences”, in which behaviours or attitudes are detected that harm the relationship of a child with one of their parents. The most damaging form of this for children are systematic interferences, a problem which Gardner termed the “parental alienation syndrome” (PAS)2.

PAS was described for the first time by the North American psychiatric doctor Richard Gardner in 19853, who explained the phenomenon of parental alienation in the forensic context. This author warned that this phenomenon, which he termed “PAS”, is important and may occur when there is conflict between parents. He defined it as a childhood disorder which exclusively arises in the context of a dispute for the custody of children.

In his first paper on this subject he described the syndrome as a “defamatory campaign against one of the parents, expressed by the child himself, without any basis”. He also stated that it is the result of a combination of instructions by one of the parents, who programs, indoctrinates and performs what he called “brainwashing” of the child. Once it has been effectively implanted, the alienated child makes their own contribution to defaming the target parent.

The said syndrome is therefore characterised by the presence in children and adolescents of emotions, attitudes and behaviours which express rejection of one of their parents or broader family. This originates in a process of influence by the other parent or their broader family.

PAS is used in some Spanish courts with the justification that it may be a medical syndrome4,5. Gardner alludes to PAS as a medical syndrome until the end of this work, defining it as a medical syndrome and childhood disorder which arises from the concurrence of 8 symptoms that are present in a child (Table 1).

Table 1.

Parental alienation syndrome.

1. A campaign by a child to discredit one of their parents 
2. Rationalisations which are weak or frivolous as the basis of this discrediting 
3. Absence of the ambivalence which should be present, according to Gardner, in all human relationships, and rather than this displaying a dichotomous form of thought in which the hated parent is seen as “completely evil” while the loved parent is “completely good” 
4. The “independent-thinker” phenomenon 
5. Reflexive support for the alienating parent in the parental conflict 
6. Absence of guilt about the cruelty or exploitation of the alienated parent 
7. The presence of borrowed scenarios 
8. Extension of the animosity to include the friends or extended family of the alienated parent 

According to Gardner, PAS arises from the concurrence of these 8 symptoms in a child.

According to Gardner, to define this as a “childhood disorder” both contributions by the parent and child are necessary and of core importance for the concept.

Arch2 states that, although at first Gardner located the appearance of the disorder within the context of divorce proceedings with a high degree of judicialisation, it is true that, as other authors have pointed out6,7, this phenomenon may arise in separations that are not subject to legal proceedings or even in intact families. However, it is when it occurs within the context of extremely conflictive divorce that the risks associated with an inappropriate approach to the problem emerge, and this is also when the need for interdisciplinary collaboration is the most evident, to improve the said approach.

Context and controversy

PAS soon became a controversial subject and it was also under suspicion8, as it is often used in conflictive cases of divorce when arguing about custody of the children: it has been praised by those who defend its use in the clinical and forensic context9 as much as it has been criticised by those who consider it to be unscientific10.

Due to this, in the Anglo-Saxon world it has given rise to a great many studies and research projects, and these generally tend to support its findings11.

The origin of the controversy4 is not so much theoretical or academic as it is to the form is takes in practice, as a means of coercion against a parent who is considered to be manipulative and the child (or children) who argue against them and reject custody by them:

“(…) before the main treatment can begin, the children have to be taken from their mother’s home and taken to their father, when the father is supposedly hated. This may be hard to achieve, and the court may have to use the threat of penalties (such as fines or the permanent loss of custody) and even prison, if the mother does not accept. After this move, there has to be an easing-off period and debriefing in which the mother has no contact with the children”12.

The fact is that in one way or another the repercussions of judicial decisions may be devastating for those involved in litigation.

In the “Guide to the criteria for judicial action against gender violence (2013 update)”13, the Consejo General del Poder Judicial assimilated the use to PAS to, among other things, the reactions to minimise “the specificity of the phenomenon of violence against women in the field governed by the Ley Integral…”.

The PAS theory failed as a scientific project, and this was due, according to its critics, to the inability of Dr. Gardner to classify the disease or psychiatric disorder of the “syndrome” he had described. Based on similar arguments, the Spanish Association of Neuropsychiatry concluded that “PAS, as it was invented by Gardner, has no scientific basis and would give rise to severe risks if applied in the judicial context”4.

Parental alienation within the context of parental interference

Those who defend including PAS in the DSM and CIE argue that parental alienation (PA) is a clear example of a relational disorder, accepted nearly worldwide by mental health professionals, and that adopting its diagnostic criteria would promote systematic research, prevent the poor usage of the concept and improve the treatment of children with this mental disorder14. Here it should be pointed out, as González Sarrió does, that there are differences between the concepts of PAS and PA: PA is usually defined as the persistent rejection by a child of contact with one of their two parents, towards whom they express great unjustified hostility, while establishing a strong alliance with their other parent, without always presenting a specific set of necessary symptoms; this is not the case for PAS, which does require a minimum presence of symptoms in the child, in such a way that some authors consider PAS to be a specific subtype of PA. The chief difference is that in PAS diagnosis is always based on the child, who has necessarily to have a certain number of symptoms before being diagnosed as such.

Therefore, and as an alternative to directly critical approaches, many professionals also consider this problem to be a “relational pathology” and critically analyse the concept of PAS from a viewpoint that does not necessarily involve radical denial.

An example of the latter is the work of the “Technical Assessment Team of Catalonia Attached to the Family Courts of Barcelona and the Judicial Administrative Areas of Barcelona and Tarragona”15. This states that the category of PAS defined by Gardner is hardly operational and is undefined, as the construct is found to be poorly delimited; the diagnostic criteria described by the author are not clear enough to define the severity of this problem. This hinders the detection of the problem by professionals and their treatment of it, and this also favours the often inappropriate use of the PAS category. At the same time, an outstanding finding among the data obtained in this study is that the solutions proposed by Gardner (1998)16 are extremist in some cases, given that they may cause negative repercussions in the child.

On the other hand, the courts have recognised the phenomenon of the negative manipulation of children for years, as a concept similar to the definition of conflict in a relationship or the concept of the superior interest of the minor17,18.

The concept has been accepted and developed in several studies, and PA is said to be a complex concept19. Firstly, the alienation of the parents means that any rejection by a child of the target parent is unfounded, although it must be said that it is necessary to differentiate between real problems in the parents’ relationship with their children and the alienation of the parents.

Kelly and Johnston20 state that distancing is a real reason why a child rejects a parent. These reasons may include negligence, physical or sexual abuse, abandonment or domestic violence. Understanding distancing may help to differentiate between parent’s problematical behaviour and their alienation. This means that the assessor must be able to identify whether the rejection by a child of a parent is based on real reasons or whether it is caused by PA. If real reasons are ruled out, then the hypothesis of PA is considered21.

Darnall21 describes PA using 3 variables (Table 2). This definition is extremely important to understand the phenomenon. The parents have to be separated and in a dispute over custody for the court to reach a decision on the custody of the children. In this case, the phenomenon occurs exclusively in a situation in which the parents are disputing the custody of their children, so that this refers to a forensic assessment.

Table 2.

Definition of parental alienation according to Darnall21.

1) An intentional campaign by one parent to discredit the other 
2) Systematically interfering in the relationship of the child with the other parent 
3) Displaying constant resistance of disobedience to legal determinations 

Vilalta Suárez22, in a sample of families in the process of separation, used the criteria of the syndrome to compare the groups in which visits had been interrupted with those in which they had not. The results showed a strong correlation between the criteria which define PAS. These criteria were far more present in the group with interrupted visits than they were in the group where visits had not been interrupted. This confirms that the presence of PAS criteria in families in the process of separation with interruptions or conflicts in visits. This indicates how important it is for forensic professionals to detect the appearance of PAS reliably and swiftly, given that time is a contextual factor that is extremely important for its development.

Behavioural patterns of alienating parents

Oropesa23 remembers that, according to Gardner, certain forms of behaviour are characteristic of alienating parents in a way that is equally applicable to fathers and mothers. They may commence at a low level and gradually increase and intensify, as well as being combined with other characteristics that may have been absent beforehand. The larger the number of characteristics which emerge, the more probable it will be for the parent to progress from a moderate level to a severe one.

Baker6 identified 66 strategies which are used by parents to alienate. Lass24 found cases of paranoid and antisocial personality disorder, as well as narcissism among alienating individuals. Taking into account the fact that subjects with personality disorders do not change in response to a judicial decision, advice or mediation, this information adds another difficulty to the already complex decision which judges must reach in these cases25.

When the obstruction is put in place by the man, according to De la Cruz26 citing Cárdenas and Albarracín (2001), in general they usually accuse the woman of a supposed mental disorder which puts her children at risk, basing this on treatments she had taken, either psychological or pharmacological.

Consequences of parental alienation

Short- and long-term effects of PA have been identified. Ben-Ami and Baker27 report on the long-term effects, which include alcohol abuse, depression, insecure attachments and low self-esteem. Faccini and Röhnelt Ramires28 confirmed the presence of insecure attachment in children who experienced parental alienation.

Current status

The main critics of including PA, the PA disorder or PAS in the DSM-5 or in the CIE-11 list a series of reasons to justify their opinions4,5,29,30. Although some of them agree that PA arises in custody situations, they do not agree that it should be considered a mental disease. Basically, they argue that the data are insufficient to support this proposal: the relevant studies had a small number of participants, many of Gardner’s papers were published in journals without peer review, and the concept does not elucidate the difference between victims who actually suffer abuse and the victims of parent alienation.

In 2010, Bernet et al.9 presented a proposal to the American Association of Psychiatry to include parental alienation disorder in DSM-5 and CIE 11, basically using Gardner’s 8 criteria to support their proposals. The criteria listed referred to children’s behaviour during the custody process, and they did not include or consider the broader concept of PA, which includes the father–mother–child triad9,31,32.

Nevertheless, in 2013 Bernet stated that31, in response to the proposal to include PA in DSM-5, the “DSM-5 Task Force” answered that “they did not consider PA to be an independent diagnosis with its own code number”. They consider PA to be a clear example of a pre-existing diagnosis: this is the “relational problem between parents and children”. Bernet remarks that “with the recent publication of the DSM-5 we are pleased to see that PA may be identified and codified in several different ways, using the terminology of the new diagnoses. Although the phrase “parental alienation” does not appear, the spirit of PA is strong and it is well-represented in DSM-5”33.

In the said work, Bernet states that “of a clinical or forensic doctor determines that a boy, girl or adolescent is affected by PA, they must consider the following diagnoses”… (Table 3)31,33.

Table 3.

Clinical complaints and problems included in DSM-5 which may help to define a situation of parental alienation.

1. The “problem of the relationship between parents and children” is now discussed in the text of DSM- 5 V61.20 (Z62.820) (p. 715): 
The analysis explains that cognitive problems are a relationship problem between parents and children: “they are negative attributions to the intentions of others, hostility or making the other a scapegoat, and the feeling of distancing without any reason for this”. The foregoing is a very good description of the experience of a child in PA, as the child attributes persistent negative intentions to the feelings and behaviours of the rejected parent. The child is also persistently hostile to the same parent, blaming them for everything negative that occurs 
2. Child affected by a conflictive parental relationship: this is an important new category in DSM- 5. V61.29 (Z62.898) (p. 716): 
This must be used “when the object of clinical care consists of the negative effects of disagreements in the relationship between the parents (for example, high levels of conflict, tension or disdain) over a child in the family, including the effects on a disorder of the child, whether it be mental or medical of any type”. According to Bernet, this is a very good description of what causes parental alienation. That is, PA, in general, appears during the course of a highly conflictive separation or divorce, and it almost always involves persistent discrediting of the alienated parent, who is rejected by the alienating parent 
3. “Psychological child abuse” is another DSM- 5 category. 995.51 (T74.32XA) (T74.32XD); V61.21 (Z69.010) (Z69.020); V15.42 (Z62.811); V61.22 (Z69.011); (V62.83) (Z69.021) (p.719)
It is defined as “acts that are not accidental, verbal or symbolic, performed by a parent or carer of a child and which cause or generate a reasonable probability of causing psychological damage in the child”. In cases of PA, the behaviour of the alienating parent would clearly amount to psychological child abuse 
4. Delirious symptoms in the partner of an individual with a delirious disorder is the DSM- 5 terminology for shared psychotic disorder or folie à deux (“another specified schizophrenia spectrum disorder and another psychotic disorder”. 298.8 (F28) (p. 122)
“Within the context of a couple’s relationship, the dominant member may transfer their delirium to the other, without this meaning that the other must exactly fulfil the criteria for the delirious disorder”. In severe cases of PA, the obsessions of the alienating parent become delirious ideas about the alienated parent which are shared with the son or daughter31 
5. “Factitious disorder by proxy” is the DSM- 5 term for factitious disorder by proxy or Münchausen’s disorder by proxy. 300.19 (F68.10) (p. 325): 
This is defined as “falsification by physical or psychological signs and/or symptoms, or induction of a lesion or disease in another, associated with an identified deception”. In some cases of PA, this describes the behaviour of the alienating parent 

Bernet31 concludes by stating that “the concept of PA is clearly expressed in DSM-5, above all in the section “relationship problems between parents and children” and in the “child affected by a conflictive parental relationship”, even though the expression PA does not appear. This is a major advance over DSM-IV-TR, especially with the addition of the new diagnosis “child psychological abuse”. “Child and adolescent psychiatrists should make use of these diagnoses to assess and treat boys, girls and adolescents who suffer AP”31.

Notwithstanding what Bernet states, we understand that we have to differentiate between the first 3 diagnoses mentioned by him respecting DSM-5, where there may or may not be psychopathology, and the last 2 mentioned, which necessarily involve a mental disease and are distant from the most widely accepted definition of PA (Table 3).

Miller, in 2018, stated again34 that PA fulfils the standard and generally accepted criteria for child abuse, and that there is no controversy about this among child abuse specialists. He argued that, due to several reasons, it is not possible to state that PA is not a form of child abuse. On the one hand he states that PA fulfils the standard definitions of psychological abuse defined in the DSM-533, the American Professional Society on the Abuse of Children (APSAC)35 and the Centres for the Control and Prevention of Diseases (CDC) of the Department of Health and Human Services of the United States36. As an illustration, the DSM-5 definition of child psychological abuse is expressed as: “non-accidental verbal or symbolic acts performed by a parent or carer of a child which provoke or generate a reasonable probability of causing psychological harm in the child”33.

On the other hand, it has now been firmly established that, as risk factors for important physical and mental problems in adult life, including premature death, psychological and emotional abuse is at least as harmful for children as physical abuse and even sexual abuse37,38. Studies have shown that adverse experiences during childhood may cause structural damage in the brain and even a shortening of chromosome telomeres, proving that they may cause cellular and molecular damage in the brain. However, cases of PA are often managed, in clinical practice as well as in the courts, as if PA were not really an abuse, or as if it were not a major problem.

As PA is a form of child abuse, the number one priority in such cases is, according to Miller, to protect the child against new abuses.

It is therefore of key importance to centre the interest of the scientific community on the need to properly explore the problem of rejection, to offer suitable treatment for its correct resolution2,38,39.

There have been significant advances in the understanding and practice of problems involving contact between parents and children, with increasing agreement on certain subjects, although others remain controversial. It is now widely recognised that cases of contact problems between parents and children are understood more fruitfully from a multifactorial viewpoint. Thus although some cases may be the sole responsibility of one of the parents (a parent who perpetuates violence or abuse, or a parent who displays alienating behaviour), in many situations both parents bear some responsibility: it is rarely useful to centre on a single cause40–42.

Legal perspective

The European Court of Human Rights has included the phenomenon of parental alienation or manipulation of children during divorce in more than 50 sentences14. It does so as an element to be evaluated when condemning a country for violating the rights of parents who are separated from their children due to this type of negative parental interference.

The Spanish Supreme Court also mentioned the phenomenon of parental manipulation of children in divorce cases in its sentence 519/2017, of 22 September. This involved a dispute about the type of custody, and shared custody was awarded in a case in which the child rejected the father due to clear psychological manipulation by the mother14,17. In this sentence the Supreme Court stated that “the parents have to ensure that they have no negative influence on the opinions of their daughter, allowing her personality to develop harmoniously, preventing unhealthy emotional dependencies and injurious verbal expressions against the other parent or their family”43.

With this phrase the Supreme Court accepted the legal definition of parental alienation established in 1980 by the Supreme Court of New York17, including it in our law as a doctrine.

According to Arellano Ferrer and Sariego Morillo17, the said sentence of the Supreme Court of 22 September 2017 would create a precedent, in such a way that from then on, when a child rejected one of his parents, family courts and tribunals had to assess whether this rejection is caused by parental manipulation, or if there is a real and accredited reason for its existence.

The doctrine of the Supreme Court is therefore that although it is necessary to listen to children, this does not mean that judges have to decide in favour of what the children want, quite the contrary, as their opinion must be taken into account according to their age, free of pressure and manipulation by their parents or other close individuals.

Conclusions

  • 1.

    The so-called PAS described by Gardner as a supposed childhood mental disorder has not, in spite of his efforts, been accepted by any international psychiatric classification of mental disorders.

  • 2.

    The PAS category as defined by Gardner is hardly operative and is poorly defined, from which it can be deduced to be poor in terms of construct delimitation. The diagnostic criteria described by the author are insufficiently clarifying to delimit the severity of this problem. This hinders professionals from detecting this reality and working with it, thereby favouring the often inappropriate use of the PAS category.

  • 3.

    Thus definitively, the use of the PAS category as defined by Gardner currently lacks the necessary validity and scientific support, so that mental health professionals, assessors and legal experts should avoid using it.

  • 4.

    Nevertheless, the majority of the scientific and legal communities admit that a dysfunctional family dynamic may sometimes arise due to an intentional campaign by one of the parents to discredit the other. This interferes systematically in the child’s relationship with their other parent, and this situation has often been subjected to scientific study and tackled in hearings.

  • 5.

    Studies indicate that these dysfunctional family dynamics, when they reach a certain level of importance, may cause serious psychopathological alterations and even long-term sequelae in the children who suffer them. They are considered to be a form of child abuse which contributes to their possible maladaptation.

  • 6.

    Mental health professionals or assessors who detect such psychopathological alterations may use the diagnostic criteria included in international psychiatric diagnostic classifications to define them. Within the DSM-5 it would be possible to use the following items: “problem of the relationship between parents and children”, “child affected by a conflictive parental relationship”, or “psychological child abuse”.

  • 7.

    The core manifestation of these situations would be the unjustified rejection of a parent, regardless of their gender, within the context of a conflictive separation or divorce.

  • 8.

    Nevertheless, rejection may also be the manifestation of an important situation as the expression of justified feelings of distancing that may be explained by an underlying cause, such as a history of physical or psychological abuse, sexual abuse or negligence or abandonment by the rejected parent.

  • 9.

    In such cases, the essential thing is therefore to establish the differential diagnosis based on the symptom of rejection of one parent. This is of critical importance, due to the special severity of the effects that either problem may cause for children, as well as for the evident difficulty it involves for professionals in deciding on a suitable diagnosis and treatment.

  • 10.

    This differential ad hoc case-based diagnosis may require the combined work of several professionals (a multidisciplinary team working together on the correct assessment of all of the aspects evaluated, such as psychologists, doctors and social workers) and the inclusion of data supplied by the child as well as both parents and the social and family context.

  • 11.

    Error in the differential diagnosis of these cases often causes serious prejudice for the child, their family and the social system; it is therefore fundamental for professionals to be aware of their relevant level of skill, avoiding any active participation in an assessment of this type if they lack the necessary training and experience.

  • 12.

    In the said task, the different professionals involved also have to work in the awareness of the limits of their science, supplying legitimate and valid data and conclusions for this purpose, while leaving the courts to decide on the matters which require the integration of partial data and other data which are solely available to them.

Appendix A
Supplementary data

The following is Supplementary data to this article:

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Please cite this article as: de la Cruz JG, Guija JA, Pastor MM. El llamado síndrome de alienación parental y sus derivaciones. Rev Esp Med Legal. 2022;48:22–29.

Copyright © 2021. Asociación Nacional de Médicos Forenses
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