Book to be released August 1!

Book to be released August 1!
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Sunday, July 13, 2014

The Randolph Attachment Disorder Questionnaire: When a Psychological Test Is Not a Test

On several occasions over the last couple of years, I’ve referred on this blog to the case of a mother whose children’s fates seem to be under the control of one Forrest Lien, LCSW, of the Institute for Attachment and  Child Development in Colorado (for instance, http://childmyths.blogspot.com/2013/01/kafka-again-more-on-capture-of-child.html).

As recently pointed out by my colleague Linda Rosa, it turns out that Lien was working under a “stipulation” by his licensing board for some years, beginning in 2009, following an unstated problem in his work. This stipulation, as noted at
https://doraimage.state.co.us/LibertyIMS::/sidddju9VRUN5UYhtZ5/Cmd%3D%24%24AD95qbmpzCUTnb%3Bq3UWd0%3D%23eqD4%3BOBP%3DLDg%3B0tz5%3DA%3Bgk9D-%3DpTn9xhf3x1FN2uFU7R377fT89%3BJPvIx%3Djf%25
 ,
required him to be supervised  and mentored by another social worker for two years--  a requirement that must have been rather galling for someone who had years of experience and who was accustomed to supervising others. In addition to the supervision, Lien was required to take 30 hours per year of approved continuing education courses dealing with assessment and diagnosis, ethics, dual relationships, clinical supervision, and recordkeeping.
                                             
All of these continuing education requirements give us some idea about the problems that got Lien into trouble in the first place, but the one that needs the most discussion is the requirement for study of assessment and diagnosis techniques. This topic is of interest because of Lien’s past advocacy of tests and diagnoses without acceptable evidence bases. His IACD website, www.instituteforattachment.org (under previous guises), had been engaged with inventive but unsubstantiated diagnostic approaches in the past, then had stopped mentioning them.

But the IACD site is once again making claims that are unsupported and selling a test that has never been demonstrated to be valid or reliable: the Randolph Attachment Disorder Questionnaire (RADQ, not to be confused with another test with the same acronym developed some years ago by Helen Minnis). The RADQ was developed and marketed by Elizabeth Randolph, a practitioner who had lost her license in California and moved to Colorado.

What do I mean when I say that a test has not been shown to be either reliable or valid? Some readers will know this, and others may remember it vaguely from Intro to Psych, so I think I’d better clarify.

Psychological tests have two jobs to do. One is to identify problems quickly and easily, without having to wait years to see how development goes, or having to commit months of time to tedious observations. The other is to help decide whether a treatment has had the effect it was intended to have, and thus whether it should be used again.

In order to do these jobs, a test must be reliable and give the same results each time it is given to a person, unless something like a treatment has acted to change the underlying condition. In addition, the test must be valid--  it must test what it is supposed to test.

 To find out whether a test is reliable, several methods can be used. Sometimes there are two or more test administrations to a group of people, and the results are examined mathematically to see whether they are sufficiently similar. Sometimes the test results for a group are “split” so that the results from one half of the test questions are compared with the results from the other half, and the comparison is examined as before. Reliability is very important when a test is used to determine whether a treatment is effective; if the test does not ordinarily give the same results each time, it can hardly be used to detect whether the treatment changed patients’ characteristics.

However, validity is even more basic to the usefulness of a test. If a test does not give information about the issues it purports to examine, it adds confusion instead of clarity to assessment. But how do we know whether the test is valid? We have to find out whether the test results give us information about people that are similar to the information we could get in some other, more difficult, more time-consuming way. For example, we might give a test to a group of children, then wait until they grew up and see whether the test had done a good job of predicting their adult characteristics. Or, we could give the test and compare it with the results from some other well-validated but expensive or cumbersome test we wanted to replace. Or, if there was agreement among clinicians about how to diagnose a problem, we could give the test, and compare its results to the diagnoses given by clinicians who did not know anything about the test or its results and who were not involved in the test administration.

Let’s look at the RADQ in terms of validity. First, Elizabeth Randolph herself says in her test manual that this is not a test of Reactive Attachment Disorder, but of some other “unofficial” disorder she calls Attachment Disorder. Confusingly, although many people shorten Reactive Attachment Disorder to RAD, the R in RADQ is for Randolph, not Reactive. What is Attachment Disorder, then? According to the IACD website, it is a term that covers a number of dissimilar problems, each with different symptoms as described in DSM or ICD: Reactive Attachment Disorder, Oppositional and Defiant Disorder, Post-Traumatic Stress Disorder, childhood trauma effects, and Pervasive Developmental Disorders (now usually called Autistic Spectrum Disorder). Whatever AD is, it can begin before birth when baby and mother do not bond prenatally (whatever this means) or can occur later. Its symptoms, or perhaps I should say the symptoms of all the diagnoses mentioned earlier in this paragraph, are said to include the usual list used by attachment therapists, including cruelty, provocative behavior, lying, and superficial charm, none of which are actual symptoms of most of the diagnoses named as making up AD.

Evidently, there are problems here. The RADQ is presented as a way to diagnose a number of dissimilar difficulties of behavior and mood. Yet it consists of a fairly small number of questions. Are the answers used to detect a pattern of behavior that is characteristic of each of the diagnoses? No, the total number of answers is supposed to measure the notional Attachment Disorder that somehow shares the sometimes-contradictory characteristics of a whole set of different diagnoses. There is no clear definition of the problem to be assessed, so it is impossible to work out whether the RADQ is a valid assessment of … something.

There’s more to deal with here. Randolph says she can diagnose AD; one of her methods is to see whether the child is able to crawl backward on command. [I’m just reporting the news, you understand.] So, she can identify AD, and she will validate her test by seeing whether she and the test come to the same decision about each child. In order to do this, of course, what she needed to do was to have someone else administer the test, and to look at the mathematical relationship between the test results and her assessments of a group of children. But, no. That was not what happened. Not only did Randolph administer the test herself, she did so by discussion with each child’s familiar female caregiver. The RADQ is not a test of what children think or do, it is a test of what their mothers or guardians say they think or do. Randolph, who had already worked with and knew the children, administered the test by talking over each question with the caregivers until she and the caregiver came to a conclusion about the correct answer to the question. In other words, Randolph, who had already come to a conclusion about the child, guided the caregiver to a set of answers on the RADQ--  perhaps unwittingly, but it is impossible to think that there was no influence brought to bear.

 Not astonishingly, there was a high correlation between Randolph’s diagnosis and what the RADQ responses said, so Randolph reported that the test was a valid one. But, of course, it was not, and would not have been even if AD existed as a disorder in any meaningful sense. To validate a psychological test, the test administration and the validating criterion (in this case, Randolph’s diagnosis, whatever it meant) must be independent of each other to begin with. If they influence each other, one will predict the other without actually being a valid way to assess a problem.

What does all this mean about Forrest Lien and the IACD? If they are selling the RADQ, as they advertise on the website, they are committing what appears to be a fraudulent act. If they have paid the slightest attention to the professional literature over the last ten years, they must be aware of the criticisms that have been leveled against the RADQ, and are selling it anyway. If they have not paid any such attention, they have failed to keep up with professional development and are not meeting the  practice standards required for continuing licensure.

The stipulation under which Lien practiced for some years did not clearly state the reasons for the disciplinary action, but it did require him to do further study about assessment and diagnosis. Could it have been the use of the RADQ that was the original problem, and that was why the test disappeared from the website for a while? If so, what will happen now that the RADQ is back? What ought to happen is pretty clear to me.  
    



Monday, July 7, 2014

You Wouldn't Treat a Dog the Way This Woman Tells Social Workers They Should Treat Foster Children

I was surprised to find out some years ago that some people were disciplining their children with methods like limiting or forcing food and drink consumption.

I was even more surprised when I discovered that Nancy Thomas, a former dog trainer and present foster care educator, has a large Internet following for her advice about confining children to their rooms and demanding that they sit immobile for lengthy periods of time.  Thomas recommends what she calls “basic German Shepherd training”, in which children learn to come, stay, or stop what they are doing instantly on voice command, or receive “consequences” for noncompliance. The kind and amount of food they get may be part of the consequences.

I was astonished when I discovered that a presentation by this same Nancy Thomas had been approved for the award of continuing professional education units by the American Psychological Association, the National Association of Social Workers, and other groups. I received an ad for the presentation by accident, and as a member of APA I immediately contacted the office that deals with sponsorship of continuing education credits, which most clinical psychologists must earn in order to keep their professional licenses. Knowing that APA works with a system of “approved providers” rather than approving each continuing education workshop individually, I did not really think that anyone at the top of the organization had made this decision—but someone close to the top had to refuse to give the credits that licensed psychologists need to maintain their professional standing.

I was delighted and relieved when I learned that APA was cancelling the credits that had been planned for Thomas’s presentation—but less than pleased when I saw on the workshop website that social workers and other mental health professionals who attended would still receive credit toward continuing licensure from their national organizations.

What is the story here? Who is Nancy Thomas and what is the “Nancy Thomas parenting” that she teaches?  Yes, Thomas was a dog trainer, and as such she learned about the functions of reward and punishment and the goal of obedience to authority. When she became a foster parent, she put the same ideas to work and did “treat children like dogs”.  Under many circumstances, Thomas would have received little approval and probably would have moved on to a different nonprofessional job—perhaps back to dog training.

By chance, however, Thomas was in touch with a Colorado psychiatrist (later admonished by his medical licensing board following harm to a child) who shared her views about authority and parenting. This man, Foster Cline, had learned how to do “holding therapy” from a mentor who had surrendered his psychology license after hurting an adult patient. Cline believed, and still believes, that “all bonding is trauma bonding”. He likened the emotional attachment of a toddler develops for a parent, to the Stockholm syndrome phenomenon in which a captive “falls in love” with her captor.  Attachment, he claimed, was shown by obedience and gratitude; if a child was disobedient, he was “unattached” and needed to have parental authority demonstrated until he changed. Otherwise, according to both Cline and Thomas, first we see a bad kid, and later we see--  Ted Bundy!

Cline’s impressive though incorrect argument, and his use of the painful and frightening “holding therapy”, jibed perfectly with Thomas’s methods. In the 1990s, she developed a technique of “therapeutic foster care” in which children received a diet limited in quantity and variety, were required to ask adults for everything they needed including use of the toilet, and spent their days in tedious, pointless labor like moving all the rocks from one side of the yard to the other, and then moving them back again, or like cutting the lawn with nail scissors. Children received “holding therapy” several times a week, and spent the rest of their time being “therapeutically parented” according to Thomas’s rules, one of which was (is) that they receive no answer to their questions about going home or seeing their parents.  Schooling was considered a privilege, not a right.

This idyllic arrangement (from the viewpoints of Cline, Thomas, and their colleagues) halted abruptly in 2000, when a ten-year-old girl, Candace Newmaker, died in the course of a therapy session. Those who had supported “holding therapy” and its theory backed off, and some later returned advocating a “gentle, nurturing” treatment that involved physical holding said to involve no pain or fear. Cline began to put all his energies into a commercialized program for parents and schoolteachers (Thomas, too, has made a minor specialty of instructing teachers). But Nancy Thomas continued to recommend the same practices for children as she had learned for use with German Shepherds—practices that are disturbing to many people concerned with child welfare, and that are in no way supported by research evidence.  In fact, she built something of an empire, with “attachment camps” to which mothers and children may go, and invitations to speak in Russia on issues of adoption and fostering.

How can a person like Thomas become a success as she touts cruel and pointless child-rearing practices? The first reason is probably her extraordinary charm. Youtube pieces and training videos show her as cute, warm, responsive, and infinitely supportive of the parents who consult her. She mothers the parents in a style diametrically opposed to her recommendations for treating children. She praises the parents, and blames the children and the culture for any problems that occur, including the children’s failure to be affectionate enough when the parents want them to be. Her audiences love this stuff.

In addition, Thomas tells some quite exciting stories. In one of her books, she recounts how a badly disturbed preschooler would take a younger child around and around a grassy field on their tricycles while the adults sat out in their lawn chairs. Each time the children would pass behind a clump of grass, the older child would take the opportunity to sodomize the other, then they would emerge again into adult view. This was how Thomas told it, and it’s difficult to know how to interpret it. Was the preschooler the fastest sodomist in the West? Or does Thomas not know what sodomy is?

Stories like this one underline Thomas’s position that foster or adopted children are evil. Their wickedness is not exactly their fault, because it results from their early traumatic experiences, but nevertheless it is demonic in the literal sense. She has counseled against allowing foster or adopted children to say grace before meals, because “you don’t know who they might be praying to.” This level of evil presumably cannot be dealt with by standard child or family psychotherapies, but Thomas states that her methods have been successful with the children she works with, of whom “80% have killed” (the question “killed what?” is not answered). For over ten years, the dramatic made-for-TV movie “Child of Rage”, purporting to show how Thomas’s own adopted daughter was transformed from a potential murderer into a respectable citizen, has served as unpaid advertising for Thomas’s methods, and has convinced many a na├»ve viewer.

One factor in Thomas’s success is her current care to avoid direct responsibility for what may happen when families take her advice. She simply states her opinion, as the First Amendment allows her to do. If a child is hurt or undernourished or even killed, Thomas wasn’t there; it’s the parents who are the responsible parties and may lose custody of all their children or even go to prison. Thomas cannot be prosecuted for this, and because she is not a licensed mental health professional, she cannot be disciplined by a state professional board. Even when there are tragic outcomes for families, they cannot easily be traced back to Thomas’s influence. In an Oregon case presently under investigation, a 12-year-old attempted suicide after a period of “Nancy Thomas parenting” advised by a local mental health professional; the outcome of this case may be important to the whole issue of responsibility of “coaches” and “educators”.

Finally, the systems that allowed Thomas’s presentation to be approved for continuing professional education units also helped her build her empire. “Approved providers” for the American Psychological Association and the National Association of Social Workers have benefited financially from making decisions that draw large and enthusiastic paying audiences like Thomas’s, and they do not suffer in any way if wrong information has been presented. The professional organizations, too, make money from the fees charged for certification of continuing professional education. Some clinical psychologists and social workers may have been pleased to find an easy and exciting continuing education workshop whose content would appeal to their clientele. So what’s not to like? Only the impact on children and their families, and the adverse events that are someone else’s fault, not the workshop instructor’s.

It’s time for professional organizations to take a stand against “treating children like dogs”. To begin, NASW can follow APA’s lead in cancelling continuing professional education credits for Thomas and her ilk.





Tuesday, July 1, 2014

Infant Eye Contact and Visual Development-- How They're Related

Of all the posts I’ve posted on this site over the years, the one that gets read over and over again is about eye contact between infants and caregivers (http://childmyths.blogspot.com/2011/07/eye-contact-with-babies-when-why.html). People seem to be looking for information on this subject because they’ve read that there is an “epidemic” of autism, that autism can be detected through certain “red flags” like the absence of eye contact, and because they quite reasonably believe that early detection allows early intervention and early intervention supports typical development. In fact, there is actually no epidemic, but statistics about autism have been inflated by changing the criteria for diagnosis; whether “red flags” are diagnostic of autism depends on the baby’s age, because younger children typically show some behaviors that are also found in older autistic children; and whether early intervention is effective for autism is still open to question.

Still, worrying is a feature of the natural history of parenthood, and we’re all likely to worry about whatever problem we see or hear most about. Seventy years ago, parents worried about polio, and before that, about tuberculosis. When autism is understood and cured one day, there will be different worries!

I don’t propose to be able to make people stop worrying about autism. However, I think it’s possible that if some aspects of development were better understood, there might be less concern about eye contact with very young babies. I have been thinking about this because I’ve had several similar comments recently on the post linked above. These were queries from mothers who were concerned that their babies seemed to look at people across the room from them, to make eye contact and smile and generally be sociable, but not to do this in response to someone who was holding them. It seemed all too easy to interpret the behavior as not “liking” or “being attached to” the holding person, and by extension to say that there was something wrong with social relationships, and therefore there might be autism developing.

Neither I nor anyone else can guarantee that a certain baby will NOT later be diagnosed as autistic, on the basis of that baby’s behavior at a few months of age. However, I think that if we look at some details about development, we’ll see that there are reasons why a baby might look at and be interested in a more distant person and not a nearer one. (Warning: This is complicated, and you might not want to plough through the whole thing--  but it’s one of those things where you either have the details, or you have only a vague and useless statement.)

The important issue here is about how vision changes with development. If a baby is going to make eye contact or smile in response to someone else’s smile, he or she has to be able to see the eyes or the smile, and this ability develops gradually during infancy. (It does not become really adult-like until about age 6 years.) All babies, autistic or typically developing, go through these changes in vision, which are more complex than you might think.

A lot of parents today know that newborns have very little clear vision other than at a fixed focal distance of about 8-12 inches from the eye. Where most people get confused, though, is in thinking that at a distance of 8-12 inches a young baby can see the same image an adult would see. This is not correct. A newborn sees in daylight the same amount of detail an adult would see in moonlight. In addition, babies have poor acuity (the ability to see small details). At age one month, the acuity is about 20/250, meaning that the baby can see at 20 feet away the same size details that an adult with good vision can see at 250 feet. At age 3 months, acuity is still no better than 20/150. And, keep in mind that a baby cannot do any of the things adults can do to improve their view of an object--  they can’t get closer, turn on a brighter light, or hold the object at a better angle.

But what I’ve just said suggests that young babies ought to be able to see near things better than far things, when they can see them at all. So what explains the queries about babies looking at a distant person and not a near one? Here’s where a couple of complicated things come into the  picture. The first is a matter called a contrast sensitivity function. This basically means that if you make a graph showing how bright a light needs to be in order for a baby to see something, that graph will show that not everything is equally easy to see. In order for babies to be able to see narrow lines, they need the lines to have high contrast--  to be black and white rather than grey and white or pink and powder blue. (Interestingly, one of the people who has done a lot of work about newborns imitating facial expressions, Andrew Meltzoff, had really black eyebrows and a contrasting pale face; I’ve often wondered whether a blond could have had the same success!)  

If the lines are medium-sized, babies can see them even when they are of lower contrast and the light is dimmer. Human eyes seem to be specialized for a certain size of detail and level of contrast; this is true for adults too. But here’s the really counterintuitive piece: when the lines are broad, they are harder to see, and the baby needs more contrast and more illumination to see them. This is exactly the opposite of what we would assume--  we expect big things to be easy to see, small things to be harder, but it’s not so. How does this apply to babies looking at faces? Well, when a face is farther away, its image on the eye is smaller, making it more like the easy-to-see  medium “stripes”. When it’s close, its image is larger, making it more like the hard-to-see broad stripes. This means that the baby needs brighter light to see that a face is a face, but if we are bending over the baby, chances are that our faces are in shadow.

[I know this seems like a strange phenomenon, but I should point out that it occurs at the other end of life too. Elderly people lose sensitivity to broad stripes. When we get right in their faces, they may not be able to recognize us, or even to be sure that what they see is a face. Backing off a bit may enable them to see who is there.]

There’s more to be discussed here, if anyone is still with me. How about the baby’s ability to recognize a shape? This too changes in the first months. Newborns tend to move their eyes to look at the edges of any shape, including a face. After about 6 weeks they still do this, but at the same time will spend some time looking at details within the outline. (And guess what, this is about the time that many babies begin to smile back at a smiling face occasionally.) Details about the eyes are often very attention-getting for young babies--  they are shiny, they move, and there is often high contrast between the iris and the “white” and between eyelashes and pale skin or between dark skin and the “white”. (Does this mean young mothers should be encouraged to wear a lot of eye make-up? It couldn’t hurt, certainly!)

One more thing to consider here: part of a baby’s vision depends on the ability to use the eyes together, and to move them so they are looking at the same object at the same time. This ability, convergence, is much more important for near objects than for distant objects. (You can show this to yourself by looking at a near object and then covering first one eye and then the other. You’ll see that you actually have different “pictures” of the object seen by each eye, with extra information coming from the differences between the pictures. Try it again with a distant object--  the two eyes get pretty much the same picture.) Convergence on a near object is quite inconsistent until the baby is about 2 months old, and still takes a lot of time until about 3 months. This means that an adult can quickly look from a near to a far object or vice-versa, but a young baby cannot. When convergence is good, babies can use a lot of information from it to help figure out how far away something is and therefore what it might be. Is it something that is actually an interesting human being, or is it a doll or a picture? What’s obvious to adults may be a puzzle to a young baby.

I hope this shows the parallels in development of visual ability and in expression of interest in other people. When a baby does not make eye contact, the reason may well be that his or her visual development is not sufficient to identify a face under certain conditions of light or distance. Let’s not wave any “red flags” until that possibility is ruled out!

N.B. To save space, I have not given sources for this information, but I have them available if anyone wants them.





Thursday, June 19, 2014

What Is Childhood Trauma About, and What Can Be Done to Lessen Its Effects?

A reader kindly commented on yet another Tina Traster claim—that adopted children in general have suffered from the trauma of a “broken maternal bond” or “primal wound”. Traster is apparently under the much mistaken impression that a child’s emotional attachment to the mother occurs before birth, and that therefore all adopted children have experienced a distressing separation from an attachment figure. These ideas are authority-based, not evidence-based; someone told Traster these things, and now she is taking her chance as a temporarily famous person to pass them on to others. She is unconcerned with the fact that easily observable evidence shows us her claims are incorrect.

Is it possible that an adopted child can have experienced trauma? Yes, most certainly! Some adopted children did experience trauma as a result of separation from the birthmother or other familiar caregivers, if that separation occurred between about 8 months and about three years of age, if the separation was abrupt and permanent, and if new caregivers treated the child insensitively and unresponsively. Please note that I say “or other familiar caregivers”, because there are many cases where a child who is to be adopted is separated very young from the birthmother, placed with foster parents for many months, and then abruptly separated from the foster parents. Children with these latter experiences are not traumatized by the separation from the birthmother, but may have experienced the separation from the foster family as traumatic.

Other adopted children may have experienced separations at younger or older ages and not found these traumatic as might have been the case for separation during the most vulnerable period. It’s possible that a baby can go from hospital to adoptive parents without experiencing any traumatic events. However, many cases of adoption occur in the wake of trauma of all kinds. Debilitating illness and death of a parent may leave the child parentless, or one parent may kill the other in front of the child and go to prison as a result. Vicarious traumas like these may occur singly, or may be combined with  direct traumatic experiences like car wrecks, physical attacks and injuries, sexual penetration, or uncontrolled and threatening adult rage. When children are adopted later than the first few weeks of life, the chances are that neglect, abuse, or exposure to others’ trauma have been experienced by the child; if nothing had happened, the child would not have been placed for adoption, unless he or she has handicapping conditions that the first caregivers found they could not manage.

In addition to these problems, it is possible that both adopted and nonadopted children may also react negatively to the later experience of coming to understand past events. Perhaps a child did not really know that his father killed his mother; now he finds out and grows mature enough to try to make sense of this. Perhaps a child adopted from China learns that her birthparents may have abandoned her because they wanted to have a son. Perhaps a nonadopted child comes to understand that his parents “had to get married” and may resent his existence because of this. One father of my acquaintance jocularly described to his teenage son all the efforts to abort that the parents had made without successfully ending the pregnancy. All of these later experiences can compound early traumas if such occurred, or can have powerful distressing effects on their own.  

One of the major effects of  traumatic experiences is the tendency for the individual to become emotionally dysregulated in the presence of “triggers”--  events that are not in themselves harmful but are reminiscent of or associated with the original experience. (“Triggers” are much in the news lately, as instructors are being asked to give warnings about reading or classroom material to students who may have experienced related trauma in the past.) Although children in general become dysregulated more often than adults do, they can usually be helped to calm and regulate themselves by familiar people—but when a child’s dysregulation is set off by the effects of past trauma, even familiar caregivers may not be able to help control a tantrum, rage, “meltdown”, or panic. The effect on the family, on the child’s relationships with siblings and friends, and on the child’s education may be devastating.

What can be done to help these difficult family situations? There are presently no treatments that are strongly supported by research evidence. However, there have been some attempts to create  multimodal treatments for these problems. One of these, Trauma Systems Therapy (TST) was described by Richard M. Smith in the Brown University Child and Adolescent Behavior Letter for June, 2014 (p. 1, pp. 6-7). Smith described TST as “the disciplined use of the whole range of tools targeting all levels of the system”. Careful assessment of problems includes understanding of child symptoms, family stressors like unemployment or caring for many or special needs children, school history, and financial pressure. Eventually, Smith says, “the work centers on analyzing what triggers and follows from the child’s dysregulated behavior, and then on how to prevent the triggers… It’s like looking at a football game in super slo-mo, only maybe the players don’t even know what game they’re playing or how. Families often start out reporting that there are no triggers whatsoever—‘he just blows up, it’s random’, they may say. Only after a lot of work can they be coaxed to see that it’s much more complicated, and also less, because the triggers are knowable, predictable, and often preventable. Getting people to accept their own role in the triggering can be harder still.”

There has been some work on the outcome of TST, but high levels of evidence are not yet in place. But even in the absence of such support, it’s clear that TST is a highly plausible approach. Unlike the assumptions made by Tina Traster, it is congruent with other things we know about children and families. It does not commit the fundamental attribution error by claiming that any problem is caused by a characteristic of the child, but instead works with a range of child and parent characteristics, temporary and permanent stressors, and long-term strengths and weaknesses of family and community. Whether TST will turn out to be the primary evidence-based treatment for traumatized children is unpredictable,  but it is clear that its approach to problems following trauma is free from the neurobabble and the superstition about early development that dominate Traster’s remarks.    



Wednesday, June 18, 2014

Trauma, Attachment, and "Adoption Today"

A glance at the magazine Adoption Today for June 2014 is enough to raise many questions about this publication’s purposes and accuracy. From page 48 to page 73, we have nothing but advertisements for therapists who purport to handle issues of “attachment and trauma”.

And what names are here! It’s like a history of potentially harmful treatments. I see a number who use checklists to diagnose “attachment disorders”. I see at least one who advocates holding therapies for babies. I see one who is under investigation in her home state after a suicide attempt by a 12-year-old whose parents followed her instructions. I see at least one whose advice was associated with the death of a young child. And I see a lot who think attachment occurs telepathically before birth.

In the midst of these listings is nestled a cameo photo of Ronald Federici (no oil painting as shown here) having a chat with Heather Forbes. The text notes that these two are “top experts”, although they have never published in a peer-reviewed journal; however, they say they are top, and I suppose they should know, shouldn’t they?  (Presumably money changed hands to achieve this conspicuous position for the picture.) In any case, the “as told to” text contains an interesting remark, quite relevant to the matters I want to discuss in this post: “Trauma goes much deeper than attachment. We must work with our children from a developmental spectrum and not focus solely on attachment, otherwise we miss a huge window for healing.”

I am not at all sure what working “from a developmental spectrum” might mean. The reference is possibly to the importance of developmentally appropriate practice, so rarely considered in Attachment Therapy or its various cousins. If that is what’s meant here, that would be a step in the right direction, as most of the therapists in the Adoption Today listings have long persisted in the view that they can “regress” a child to any developmental period and then move him back to his original stage, so consideration of his actual developmental status is not necessary.

But what about the rest of the statement? Here’s how I translate it: “Trauma is the flavor of the month! It’s all about trauma-informed stuff nowadays. Attachment issues are old-fashioned and too many people are getting to know that what we’ve been saying about attachment is wrong. Our business plans had better include moving to the trauma thing, or we’re sunk. But attachment is still a good buzzword, so what to do? How about we say ‘attachment and trauma’ for a while, just like we used to say ‘attachment and bonding’? That should work, because the public will start finding ‘trauma” just as familiar as ‘attachment’. Then we can pull in the families that obviously don’t have attachment problems (like the ones where the kid was in the NICU) and we can tell them the problem is trauma--  or even more likely, they’ll come and tell us that there must be trauma.”

Am I saying that trauma is not a problem? No, of course not. A trauma is by definition an event that causes long-term adverse outcomes of physical or psychological development and functioning. An event that looks horrible to bystanders may not act as a trauma and may cause no adverse outcomes. Another event that seems innocent to bystanders may be experienced by the victim in such a way that it acts as a trauma and causes adverse outcomes over the long term. For example, in Susan Clancy’s work on  adults who had been sexually abused as children, some of the experiences did not act as traumas, even though we might have expected them to, but for some people their later thinking about the childhood events was somewhat traumatic in light of their learned expectations and  beliefs. Traumatic events are often re-assessed as the individual’s development progresses, and they may be remembered vaguely, vividly, or anywhere in between, but it does not seem likely that they are “repressed” or show up later as “recovered memories.”

There are both good and bad messages about trauma in circulation today. The accurate messages remind adults that a child’s resistance to certain actions or reluctance to come close to certain people may be caused by earlier trauma and are not evidence of defiance or opposition. When adults understand this, they can learn to manage the child’s experiences more appropriately and will be less tempted to threaten or punish a traumatized child into compliance. The right messages about trauma are helpful in this way.

Inaccurate messages, on the other hand, suggest that if children show unwanted moods or behaviors, they must have experienced trauma, even if no other evidence supports this idea. These messages encourage adults to forget the roles played by the situation and by non-traumatic learning in bringing about problem behavior. Bad trauma messages also tend to “horribilize” the child’s position by stating that his entire body is a repository of unconscious memories of trauma, and that the memories can only be released by non-cognitive methods. These messages also imply that trauma is monolithic--  that every bad experience, at every point in the child’s development, causes equal difficulty. As a result, adults who receive inaccurate messages about trauma are persuaded to ignore some useful approaches to helping the child, and to accept treatments that may be ineffective and even potentially harmful.  

What’s the connection between attachment and trauma? It’s certainly true that there can be one. When children between about 8 months and three years of age are abruptly separated from familiar caregivers for many months, and when they do not receive sympathetic support from a small number of new caregivers, they respond with serious distress and grief. They sleep poorly, are reluctant to eat, and do not play or seem interested in engaging with other people. Their physical health may suffer and language and cognitive development is slowed. Not only do they seem to experience distress over the loss, but they miss out on a variety of experiences like speech interactions that contribute to normal development. If they have the opportunity to form new attachments to good caregivers, the children recover from this experience (although they may assess it as traumatic when they learn about it in later life). If they do not have that opportunity, they will show problems of development--  but it’s hard to say whether this is because of trauma or because the situation involves a cascade of other unusual experiences unsupportive of good development.

Children who are under perhaps 6 months of age, or over three years, at the time of separation from familiar caregivers do not respond with the intense distress we see during the period described above. The older they are, the better their cognitive and language abilities enable them to withstand the potential effects of their experiences. If they are young enough, and if they now are in the care of sensitive and responsive adults, little or no distress will occur, and no trauma is experienced. (This statement, of course, is at odds with the beliefs of a number of the therapists listed by Adoption Today, who are convinced that attachment occurs prenatally and that all adopted children have experienced traumatic separation, no matter when the adoption occurred.)

What take-home messages do we have here? One is that whether a specific event is experienced as traumatic depends on a number of factors, among which a primary one is developmental age. Attachment-related events, especially, can be traumatic during a particular age range, and if supportive caregivers are absent--  but they are less traumatic when a child receives sensitive, responsive adult care, and still less traumatic when the child is younger or older than the most vulnerable age period. A second is that worrisome child moods or behaviors are not in themselves evidence of earlier trauma, and that assuming this connection robs caregivers of tools to use in helping the child. Third, there are a number of much mistaken assumptions about the nature of therapy for either trauma or attachment-related problems.

Good therapy for children with mood or behavior problems works in the same ways whether the difficulties are caused by trauma, attachment history, genetic factors, social learning, or situational variables. Each of these factors needs to be considered as it affects the individual child. Among the social learning and situational variables, the influences of adult caregivers are especially powerful, and that means that understanding and managing adult behavior must be given high priorities.

How do parents find therapists who will do this? They need to look for practitioners whose licensure and training show them to have the needed skills, acquired in respected academic programs. Such people are not to be found by looking in the listings of Adoption Today or Psychology Today, nor do they call themselves Registered Attachment Therapists or overemphasize the importance of trauma, and I doubt that many are members of the American Psychotherapy Association. The website of a state psychological association can be helpful for concerned parents, and licensure verification can be done through state websites. But these methods are not enough, if parents have the wrong expectations about how treatment works, and if they reject the possibility that they are part of a problematic situation. Parents who genuinely want to help children need to understand that they themselves may need to change in order to achieve the outcomes they want.



Tuesday, June 17, 2014

Can Post-Partum and Post-Adoption Worry Amount to Maternal Depression?

Over the last couple of days, the New York Times has been featuring articles on maternal mental illness in the year following childbirth. A striking account of one tragic case is at www.nytimes.com/2014/06/17/health/maternal-mental-illness-can-arrive-months-after-baby.html?hpw&rref=health. In this case, a mother developed terrible fears that she had caused, or permitted by her carelessness, serious brain damage to her perfectly healthy child. She sought extensive diagnostic work for the baby, but the assurances that there was no brain damage, and that brain damage could not have occurred under the circumstances she described did nothing to change her distress or her delusions. When the baby was ten months old, she put him in a carrier and jumped with him from a height that killed her, but the child was cushioned by her body and survived.

It is only in the last ten years that real understanding of perinatal mental illness has begun to develop. (I use the term perinatal because such disorders can show up or be predictable before the baby is born, not only post-partum.) One important step has been the demonstration that screening of all new mothers can help identify those who may need treatment while their babies are young. I am happy to say that my own state, New Jersey, has screening for all new mothers, thanks to the impressive leadership of Mary Jo Codey, wife of former governor Richard Codey and herself a survivor of perinatal mental illness. Such screening is based in part on the understanding that perinatal mental illness is not a single entity, but involves a continuum of trouble that ranges from the sadness and slowing of responses we usually think of as depression, to the hallucinations and delusions that have led to suicide and murder in cases like that of the tragic Andrea Yates. Concerns about perinatal mental illness have been led to some extent by the understanding that for every child’s or mother’s death due to perinatal mental illness, there are probably hundreds in which a child’s language and cognitive development are impacted by her mother’s depression.

It has been enormously important for people to understand that poor care for babies, or even attacks on them, are not necessarily because the mothers are “bad people”, or even because poor environmental circumstances push the mothers past a breaking point. These events may be part of a mental illness that will respond to medication and psychotherapy. Blaming the mothers will not help them or their children.

The Times articles bring up two other important points. One is that it is now clear that maternal mental illness does not necessarily appear right after childbirth. An older view that tried to attribute perinatal mood disorders to hormonal changes tended to insist on an onset fairly soon after the birth. But it is now clear that there is much more to these disorders than a response to changing hormones, as is shown by emergence of the mental disturbance months after a new hormonal balance has been achieved, in some cases.

The second point is that although we think of mood disorders and depression as characterized by sadness and hopelessness, anxiety may be an important feature for some people, and in perinatal mental illness it is likely to be focused on the baby. Although every parent worries about their baby, a constant concern, with an inability to be reassured, and a sense of having harmed or being about to harm the baby, can be an indication of maternal mental illness and should be treated as such. (I am saying nothing here about fathers’ mood disorders because they have received very little study, but presumably they can exist.)

Reading about the Times case, in which the mother could not escape the delusion that she had damaged her child’s brain, made me think of some questions I receive from readers of this blog. Not all, but a few people who comment, seem to be excessively worried about the possibility that their child is autistic, and that they, the parents, may be at fault either because they caused the condition or because they are not getting treatment soon enough.

One post I wrote several years ago (http://childmyths/blogspot.com/2011/07/eye-contact-with-babies-what-when-why.html) has had thousands of reads and is almost always the post that gets most reads in any given day. Many readers have responded with questions about eye contact and autism, often in reference to babies of a few weeks old, who are far too young for anyone to diagnose autism even if they had it (which they probably don’t). Now, it is not surprising that people worry about this. First, there is a great deal of misunderstanding about what baby eye contact actually consists of, and many young parents think their baby will look steadily into their eyes for minutes at a time; young babies don’t do this, so the parents are disappointed and frightened. Second, sensational journalism has spread the idea that there is an “epidemic” of autism, rather than the actual shift in diagnostic criteria, so young parents are sure that this “epidemic” is threatening their babies, especially the boys. Third, young parents have heard about early intervention and the logical position that early treatment can prevent the development of some problems, so they naturally do not want to fail to get early treatment for any disorder. Add these to the natural tendency to worry about early development, and it’s hardly surprising that there’s so much concern.

However, I am asking myself whether severe concerns about autism, concerns that are taken from specialist to specialist without any reassurance ever being successful, can be evidence of maternal mental illness. Obviously a line has to be drawn between the typical worried state of young parents, which will resolve with ordinary support, time, and experience, and a mood disorder that becomes more and more frantic, at best creates developmental problems, and at worst culminates in tragedy. But when there seems to be no reason to be concerned about a baby, but a young mother is constantly deeply distressed, whether about brain injury or autism, would it not be a good idea for someone to ascertain whether this is really about treatable mental illness? The mother’s own primary care physician will probably not be aware of the problem; her OB/Gyn may pick it up at some point; but her pediatrician is most likely to know whether she is repeatedly asking for referrals. (The health insurer may also know this, but probably will not figure it out for many months.)  Her partner, friends, and relatives may also catch on to the fact that there is more at stake than is typical of this stage of life. And clearly the handling of this situation by anyone who is aware of it must be most delicate, because the stigma of mental illness is still such that the affected person may essentially flee in panic anyone who suggests that she needs help.

I want to make one more point about this issue, and that is to remind people that maternal mental illness may emerge not only post-partum, but post-adoption. It is perfectly reasonable for adoptive parents to think about their adopted child’s background. Were alcohol or drugs a factor in relinquishment by the biological parents? What might have been the outcomes of neglect or abuse in earlier life? The answers to these questions might sometimes help adoptive parents to know what they may expect and what they need to do, but there may be no answers. It is perhaps in response to this set of concerns that adoptive parents can become terribly worried about disorders caused by fetal exposure to alcohol, and about Reactive Attachment Disorder. Certainly they are bombarded by descriptions and explanations of these problems even when they do not ask. Unfortunately, some of these descriptions and explanations are quite inaccurate, and they convey the message that such disorders can have signs that are so subtle that only a very few diagnosticians can detect them--  or even that the children can slyly conceal their problems in order to cause trouble.

As is the case for nonadoptive parents, adoptive parents can have their natural worries ratcheted up painfully by misinformation. In addition to that problem, however, when maternal mental illness emerges following adoption, its symptoms may include the inability to believe that a child does not have an attachment disorder or suffer from drug or alcohol effects. Mothers with these mood-disorder-fueled terrors can be easy prey for charlatans, who may be unable or unwilling to consider that a mother seeking them out might be mentally ill. In addition, medical professionals, partners, friends, and relatives may be bogged down in the old belief that perinatal mood disorders are caused by hormonal change, and therefore may dismiss the possibility that an adoptive mother could have a mental disturbance related to the adoption.

Could injuries to adopted children--  including starvation, caging, and so on—be caused in part by unrecognized maternal mental illness? I emphasize the words in part, but I believe this possibility deserves serious consideration by those of us who  are concerned with the welfare of all children.
  


Friday, June 13, 2014

Having a Look at Love and Logic

A reader suggested that having written a post about the plausibility of alternative psychotherapies, I might examine the available facts about the program Love and Logic ®. The website www.loveandlogic.com is informative when looked at carefully, although other sources add much to an understanding of this program.

A quick look at materials describing Love and Logic gives the impression that the program is intended to improve parenting practices and therefore to lead to better developmental and educational outcomes for children. However, this does not seem to be exactly the case, according to the website. This describes Love and Logic as “a philosophy of raising and teaching children which allows adults to be happier, empowered, and more skilled in the interactions with children. Love allows children to grow through their mistakes. Logic allows children to live with the consequences of their choices. Love and Logic is a way of working with children that puts parents and teachers back in control, teaches children to be responsible, and prepares young people to live in the real world, with its many choices and consequences.”

I see in this paragraph two types of outcomes predicted for Love and Logic users. The first is that parents and teachers are happier and have more success in controlling children. The second is that children become responsible (without further definition of how this responsibility is displayed behaviorally) and will eventually be prepared to live in the “real world” (where have they been living up to that point, I wonder, and how does their preparation play out behaviorally now or later?). The statements about Love and about Logic are difficult to relate to specific outcomes. I am not sure how children can be prevented from growing (i.e., learning) from their mistakes, nor whether an absence of love would be considered a cause of such a notional outcome. Neither do I see how Logic lets children live with consequences or whether illogic would prevent them from doing so. Semantically, these two statements would seem to have the same meaning, or lack thereof, if we were to reverse the tasks of Love and of Logic. But let’s drop these side issues and focus on the clearly predicted outcomes: happier parents and teachers who successfully make children do what the adults want. A later paragraph on the website says that Love and Logic “products help parents and teachers enjoy working with children”, and this predicted effect on adults is described more clearly than any statements about the effects on children.

I’m trying to figure out the outcome wanted by users of Love and Logic , because I see that various other websites (e.g., www.colorado.edu/content/fsap-workshops-parenting-love-and-logic(R)-course-starts-july-18 )  refer to this approach as “research based”. (I haven’t found this on www.loveandlogic.com yet.) Research, as the term is usually used, would involve an assessment of whether the predicted outcomes resulted from use of Love and Logic. However, the expression “research based” is a vague one without a common or clear definition, and it may not be intended to communicate the same evaluation of effectiveness as “evidence-based” does.  I note that the California Clearinghouse for Evidence Based Programs (www.cebc4cw.org/program/love-and-logic/detailed) does not give a ranking for scientific evidence to Love and Logic because of the absence of research information. A critique of parent education programs done by Christina Collins (www.joe.org/joe/2012august/a8.php) ranked Love and Logic as an “additional” program, rather than as “top” or “promising”. Love and Logic is described as “innovative” but without an evidentiary foundation in a document developed by Prevent Child Abuse Iowa in 2011; the Iowa document points out that Love and Logic is not listed in SAMHSA’s National Registry of Evidence-Based Practices and Programs (NREPP).

At www.loveandlogic.com/t-research.aspx, a graph representing how parenting stress went down after parents attended a Love and Logic program also shows a reduction in child misbehavior, suggesting that this outcome is also a goal of Love and Logic and may be an operational definition of “responsibility” and “preparation for the real world”.  The same page provides a link to an unpublished article by Charles Fay, a member of the Love and Logic group along with his father Jim Fay and the holding therapy proponent Foster Cline. Fay’s 2012 paper is entitled “Effects of the Becoming a Love and Logic Parent  training program on parents’ perceptions of their children’s behavior and their own parental stress”. As the title suggests, Fay asked for responses from parents who were about to begin the training program and compared those to post-training responses for 2431 of them. There was no comparison group receiving treatment as usual or no treatment, and Fay did not report how many parents failed to complete the program, were lost to follow-up, or showed negative changes following the program. As Fay himself seemed to be aware in the discussion of this study, this evidence is at a very weak level, and there are obvious alternative explanations for the results.

In addition to these research weaknesses, an examination of the evidentiary foundation for Love and Logic requires attention to the fact that Love and Logic® is a highly commercialized, for-profit program, with the ® indicating a registered name. This situation makes it very difficult to have the valuable replication of a study by an independent researcher. That Fay, Fay, and Cline have not been eager to have independent examination of relevant evidence is shown by a copyright infringement suit  (www.plainsite.org/dockets/ic5dk1os/colorado-district-court/love-and-logic-institute-inc-et-al-v-slattengren-et-al).

Is Love and Logic a plausible program? Is it congruent with established information about child development and learning? Its basic ideas about the role of reward in learning have long been supported by clear evidence, although I am not sure why a citation of the work of Edward Thorndike in the 1920s is needed, and I am sure that a citation of John B. Watson is not relevant. There are also elements of William Glasser’s “reality therapy” as used in some schools in the ‘60s and ‘70s, and a plausible approach on the face of it but without much research support. Certainly the advice given to parents and teachers about relaxation and avoidance of anger and punishment is congruent with most established thinking about early relationships, although the suggestion that one simply repeat over and over “I love you too much to argue with you” seems questionable in terms of the transactional view of development.   Love and Logic is said to be easy to learn and to have “immediate results”; these statements appear to be at odds with the experiences of most evidence-based parenting programs that are successful in bringing about changes in parent-child interactions (Parent-Child Interaction Therapy, for instance). It is notable, of course, that specific methods of Love and Logic are available only upon purchase of proprietary books and CDs, so a complete analysis of plausibility is difficult.

It is not usually desirable to pursue an examination of this kind ad hominem, because even the most unpleasant characteristics of individuals (if they existed) would not be relevant to the plausibility or effectiveness of a treatment they advocated. However, as Love and Logic provides little to discuss ad rem, it seems appropriate to look at aspects of the website and of its founders. Once again, a high degree of commercialism is shown by the website. Testimonials and anecdotes abound, and there is no indication that Love and Logic may be inappropriate or even potentially harmful in some cases. “Parenting products” are for sale, and one may join an “Insider’s Club” (the position of the apostrophe suggests that there is only one insider).

Much of the Love and Logic website is devoted to selling training and to attracting trainers, who when they have completed their studies, can take advantage of a “facilitator map” and national referral list. Purchasing a book “gives you the ability to offer an unlimited number of parenting classes… No additional training is required.”   This statement seems to confirm what I was told several years ago by a Love and Logic trainer--  that there was no quality control after a course was taken.

What about the three founders of Love and Logic? Little is available about Jim Fay, except from his short bio on the website. He appears to have been a high school teacher. Charles Fay has a Ph.D. in psychology (possibly with a specialty in school psychology, although it is hard to tell). His dissertation had the title “Factors affecting teachers’ impressions and judgments of students: Individual differences, social-contextual factors, and underlying cognitive processes” (University of South Carolina, 1997). This title does not suggest any formal study of developmental principles or of parenting processes, although Fay may certainly have studied these topics post-doctorate.

A source of concern about Love and Logic comes from the involvement of Foster Cline. Cline’s associations with holding therapy, a physically-intrusive, potentially harmful treatment without an acceptable evidence basis, are undeniable. Cline surrendered his Colorado medical license following a 1995 letter of admonition in connection with the accidental or suicidal death of a child.  His books in the early 1990s stressed his belief that “all bonding is trauma bonding”, suggesting that the relationship between a parent and an infant is parallel to the relationship between a kidnapper and his victim who develops Stockholm syndrome. His long-term mentoring relationship with Connell Watkins, one of the therapists under whose treatment Candace Newmaker died, is well-known, as are his involvements with the defense of parents who killed their children.

Cline’s books have supported the idea that powerful adult authority is essential for the rearing of psychologically-healthy children. Like his colleague and mentor, Robert Zaslow, Cline has stressed the ideas that obedience is evidence of attachment and that adult attachment figures must be seen as powerful by children. Although Cline’s version of holding therapy had strong physical components, there seems to be no reason to think that physical coercion is a part of Love and Logic, which concentrates instead on psychological control. Whether children who “fail” in Love and Logic are then recommended for holding therapy is an unanswered question, but this suggestion was made to me by an individual who had received Love and Logic training.

In the past, Cline was willing to state that holding therapy was not abusive. He was one of several holding therapy-oriented expert witnesses in an investigation of an Arizona man who taught a mother to use unsupervised holding with her daughter (www.azbbhe.us/pdfs/BoardOrder/1994-0002.pdf). Cline’s position has been countered by a multitude of arguments, including the report of a task force of the American Professional Society on Abuse of Children and of Division 37 of the American Psychological Association. Given this history, it is perhaps not surprising that he presses Love and Logic without any evidence that it is an effective treatment, either for parent education or for working with mild childhood behavior problems.

If there are all these problems related to the effectiveness of Love and Logic, why do school systems purchase its training for their teachers? There are some simple answers, I think. One is that K-12 educators are rarely skilled at assessing the evidence for a treatment. Instead, as a group, they tend to be “faddy” and to clutch at attractive proposals, especially if they do not involve much cognitive effort. (Does anyone remember “Paddlin’ Madeline home” T-shirts for teachers?) In addition, Love and Logic is beautifully marketed, with repeated claims of “easy to learn” and “instant results”. The Love and Logic website even suggests ways to create enthusiasm for its trainings--  administrators are not to offer training to all teachers, but to make the opportunity a reward for some.

Conclusion: Love and Logic is a business like any other. Caveat emptor.