Book to be released August 1!

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

Sunday, August 31, 2014

Does Reactive Attachment Disorder Have Anything to Do With Cause and Effect Thinking?

A reader’s recent comment referred to the tendency shown by believers in the “Attachment Therapy” system to attribute children’s behavioral difficulties to a lack of  cause-and-effect thinking. At www.fromsurvivaltoserenity.com/2014/08/educating-about-rad.html, a graphic is presented showing dozens of “symptoms” of Reactive Attachment Disorder, few or none of them to be seen in the DSM-5 list of criteria for the disorder. Among them, problems with cause and effect thinking are noted. A document for teachers at www.attachmentnewengland.com/documents/educators/pdf also refers to such problems, and claims that children with Reactive Attachment Disorder cannot learn from behavior modification methods that use reinforcement for desirable behavior. (The latter document warns parents against using sarcasm, while providing a list of obviously sarcastic responses to children--  a point that raises questions about the sincerity of the writer—and states that attachment begins prenatally, raising further questions about the writer’s knowledge of the field.)

Strangely, however, these documents also stress the belief that children with behavioral difficulties can manipulate, exploit, and fool intelligent, well-trained, and experienced adults. How do they manage this, one must ask, if they cannot associate cause (their own behavior or speech) with effect (the beliefs and behavior produced in the apparently hapless adult)? For that matter, without some mastery of cause and effect associations, how can they do anything at all in the way of self-care, schoolwork, household chores, or play?

It does seem that just as these documents are not really talking about Reactive Attachment Disorder when they use that term, neither are they really talking about understanding cause and effect. Let’s have a look at the development of cause and effect thinking first, then maybe I can hazard some guesses about the real issues referred to by that name.

Learning about cause and effect is a gradual process, but one which begins quite early and is slowed only by cognitive impairment. Jean Piaget, the famous theorist of cognitive development, first described some steps in understanding cause and effect almost a hundred years ago. He suggested that between about 4 and 8 months of age babies begin to notice the effect of things they do, like kicking their feet or making sounds. They discover that sometimes their activities seem to make interesting events (like an adult smiling at them) continue--  but this little insight into cause and effect is only a beginning, because if the interesting event stops, the baby gives up and does not try to make it start again. From about 8 to 12 months, babies begin to put together single activities so that they can look, reach, and grab, and use that combination to keep interesting things going on. But, in Piaget’s theory (and many observations), a much more important step waits until about 12 to 18 months, when babies catch on to the fact that they can actually start interesting events by themselves--  and they do this over and over, by dropping and throwing objects and watching carefully to see what happens (cereal splashes, cheese doesn’t, and they all get eaten by the dog). This understanding of cause and effect is needed for a wide range of learned skills, from pulling a stool to the table in order to reach something, to drinking through a straw, to all forms of communication with other people and all planning of actions.

It’s common for people to assume that Piaget was taking a behaviorist position--  that infants develop cognitively only because they are repeatedly gratified by what happens when they exercise a new skill. That assumption is reflected in the idea of the “bonding cycle” of alternate needs and gratifications, as claimed by Attachment Therapy advocates. However, that is not at all what Piaget said.  His theory (and recent work on cognitive growth)  is based on the idea that cognitive development is driven from within and requires only ordinary experiences that the baby himself produces. When the attachmentnewengland document says “this [bonding] cycle promotes the development of cause and effect thinking which is the basis of all problem solving”,  it reveals a misunderstanding of how cognitive development proceeds. Naturally, reasonable physical care is needed for survival and healthy brain development, and social interaction is needed for attachment and language learning, but experiences of care are not privileged factors in the development of cause and effect thinking. To assume that they are is simply a rationale for the use of non-evidence-based methods.    

Of course, the understanding of cause and effect is not complete at age 18 months. The more steps intervene Rube-Goldberg-like between cause and effect, the harder the connection is to make. When someone doesn’t understand how something works, their comprehension of specific causes and effects will be limited. In the natural world, it is common for more than one cause to produce an effect, for one cause to produce more than one effect, and so on, and these situations make real understanding more difficult. In addition, even adults are prone to fallacious reasoning about causes. They may accept superstitious beliefs about spilling salt or having a black cat walk in front of them--  a matter of confusing cause and effect relationships. They may be swayed by fallacies about the order of events and how that reveals cause and effect, so that they assume that when B followed A, it must have been caused by A. They readily jump to the conclusion that if two things are correlated, one must have caused the other. In the Attachment Therapy- Nancy Thomas-Foster Cline belief system, they assume that when adopted children have mood and behavior problems, the events surrounding adoption must have caused the later problems.

Unless children have severe cognitive impairments, we can expect them at school age to be somewhere between toddlers and adults in their understanding of cause and effect. They know that they can make things happen, but they are still likely to display fallacious reasoning about complicated causes or those that are separated in time from their effects. Certainly they are able to know when their actions bring about immediate approval or disapproval from adults. As for responsiveness to behavior modification techniques, there is no reason why they should not respond as well to a properly-designed and implemented program as do all other living creatures right down to flatworms.

What’s the problem, then, if there’s no actual difficulty with understanding cause and effect? Might it not be that advocates of Attachment Therapy beliefs are convinced that when they use poor behavior management methods, those methods fail to be effective only because the children are so bad?  Using behavior modification or similar management methods requires careful planning and depends strongly on timely intervention. Research in this area showed many years ago that rewards work best when they come very quickly after an desired behavior, and reprimands or “consequences” for undesired behaviors work best if they occur in the middle of the act, or even better, just as the child prepares to do it. There is no reason to think that these rules would apply differently to children said to have Reactive Attachment Disorder than to other beings.

It’s my guess that much of the issue of unwanted behavior in “these children” (those considered to have attachment disorders by Attachment Therapists) actually has to do with the idea that the children must never “win” or “be in control”. The attachmentnewengland document recommends, per Nancy Thomas, that an adult “establish eye contact with the child and ensure that the child always looks up at the adult. The child with Reactive Attachment Disorder dislikes eye contact and will try to avoid it except when he/she is lying or trying to manipulate others. Avoid bending down to establish eye gaze with the student…”. In other words, mutual gaze is required because the child does not like it, and he or she must be made to submit, ideally through an uncomfortable posture that reminds the child of the adult’s size and power.

The document also insists that no explanations may be given to a child who is “consequenced”. “When giving a consequence, educators must stop themselves from telling the child why a consequence is given. When a child doesn’t have cause and effect thinking, he/she will never connect their inappropriate action with the consequence no matter how many times the connection is explained. … The child really doesn’t want to know why and just wants to argue… After the consequence has been given, it is important for educators to let go of caring about whether or not the consequence changes the child’s behavior, or has any impact upon the child, or his/her actions…”. 

It appears, then, that teachers are to abandon any hope of establishing cause and effect thinking in their pupils; if a child cannot make the connection with an explanation, surely he or she will not make it without one.  In addition, teachers are apparently being advised to abandon their own capacity for cause and effect thinking, and to ignore the outcome of their methods rather than to pay attention to what works for them with a given child. Rather than modeling the thinking behavior they should want, they are to adhere rigidly to what they are told, and to fall into their places in this authoritarian system just as the children are to do.

This is not about cause and effect thinking, any more than it’s about attachment or even Reactive Attachment Disorder as the evidence shows it to be. It’s all about obedience and punishment. Cotton Mather would recognize it easily.

   








Friday, August 29, 2014

Why Mental Illness Isn't Exactly a Brain Disorder

It’s a common thing nowadays to hear mental illnesses referred to as “brain diseases” or “brain disorders”. The National Alliance on Mental Illness (NAMI) has made a particular point of this.
In a policy statement in 2014 (www.nami.org/TextTemplate.cfm?Section=NAMI_Policy_Platform&Template=/ContentManagement/ContentDisplay.cfm&ContentID=124562 ), NAMI made the following statements:

 “NAMI advocates for research and services in response to major illnesses that affect the brain, including schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, panic and other severe anxiety disorders, borderline personality disorder, post traumatic stress disorder (PTSD), autism and pervasive developmental disorders, and attention deficit/hyperactivity disorder.”

“NAMI … believes that mental illness is essentially biological in nature. Mental illness affects behavior and behavior can affect mental illness—but mental illnesses are not behavioral.  The term ‘behavioral health’ obscures and hinders effective treatment of co-occurring disorders. Also, because behavior is perceived as a matter of choice (‘good’ or ‘bad’ behavior), the very term ‘behavioral health’ can add to the stigma and discrimination endured by people living with a mental illness.”

“Therefore, throughout this document, we are discussing the term ‘brain disorder(s)’ interchangeably with mental illness and serious mental illness.”

The NAMI statement is not easy to unpack, but its goal is clearly to emphasize a medical-biological view of all mental illnesses whether they have strong genetic components (autism, for example) or derive from factors in the environment (PTSD). It is true that the term “behavioral health” is confusing, because surely a behavior cannot be healthy or unhealthy independent of some other aspect of the individual, but this does not seem to be the reason for NAMI’s rejection; instead, there is an assumption that behavior is generally seen as voluntary, and that calling it “good” or “bad” indicates this and leads to stigmatization of mentally ill persons. These various choices of terminology are confusing, as they conflate mental illness both with sin and with problems like seizure disorders, Parkinsonism, and dementia, which are clearly brain disorders but have little in common with the mental illnesses listed earlier.

Is mental illness properly seen as a type of brain disorder, or has this view been determined by public relations concerns like those of NAMI and by a history dating back 30 years or more? Before discussing possible answers to this question, let me point out that whether or not moods and behavior that distress mentally ill persons and others are brain disorders, it is probably not appropriate to think of them as intentional, or to blame adult patients or the parents of mentally ill children for disturbing characteristics. Considering non-brain factors as contributing causes of mental illness does not condemn us to hating the mentally ill, or using confinement, starvation, and cold as “treatments” for their challenges.

Gregory Fritz, writing his editorial column in the Brown University Child and Adolescent Behavior Letter, recently addressed some of these issues with respect to brain disorders as a cause of depression (“The chemical imbalance explanations for depression: Setting the record straight”, CABL, 30(9), 8). Fritz noted that he still hears “the idea of a chemical imbalance discussed in relation to depression, though fortunately not among psychiatrists. Given that there is no empirical evidence for this explanation of the cause or treatment of depression [my italics—JM], why is it so tenaciously a part of the lay understanding of the disorder?” (as indeed brain disorders are a part of popular assumptions about all mental illnesses).

Fritz went on to say that the chemical imbalance theory of depression was not invented by the public, but “was presented to them by psychiatrists, the popular press, and pharmaceutical advertisements starting with vigor in the 1980s… The hypothesis was that altered levels of neurotransmitters lead to disturbances of mood. It was an attractive hypothesis, one that was behind the development of the SSRI family of antidepressants—for which there is solid evidence of benefit in treating depression.” But, Fritz commented, “There were two major problems with the popularization of the chemical imbalance idea: (1) an appealing hypothesis was treated as fact [my ital—JM], and (2) evidence that SSRIs had a significant clinical impact… was treated as proof of the mechanism of depression.”

Why have ideas about brain problems as causes of mental illness become so entrenched? The NAMI material suggests that one real reason is the belief that blame and stigmatization are diminished when brain disorders are pointed to as the basis of mental problems. Fritz’s editorial also emphasized the human “distaste for ambiguity” as responsible for the assumption that depression is caused by chemical imbalances in the brain. He pointed out the difficulties we have with dealing with the “complex truth about depression—that many genetic, environmental, biological, social, physiological, and psychological factors interact with development and other, still unknown factors in complicated ways to produce depression, and that we’re still not sure how antidepressants work”; this statement could be applied equally to other forms of mental illness.  

Evidence about differential effects of early maltreatment on different parts of the brain suggests that attributing mental illness to “brain disorder” in general is painting with too broad a brush. Simultaneously, though, the concept appears to be too narrow when we consider the list of known and unknown factors that appear to help determine mental illness. In either case, overemphasizing the role of brain structures and functions as causes of mental illness is treating a hypothesis as a fact, which is not likely to lead us to any real understanding.  We can surely treat mentally ill children and adults benevolently without oversimplifying the causes of their problems.   



No,Your Baby Can't Read-- She's Working on Baby Jobs

{My thanks to Barbara Reynolds for bringing this to my attention!}

The video series Your baby can read, by Robert Titzer, appeared some years ago and is still being sold on Amazon (where, to my incredulous amusement, it’s sold in the form of CDs, “as seen on TV”, presumably by non-reading adults). Titzer has claimed remarkable effects on early learning achieved by putting infants as young as three months in front of a screen. By nine months, these children were supposed to be able to read words--  a promise that led to many purchases by parents who thought they were doing the right thing, but a claim that had no evidence basis and indeed was contradicted by reliable information.

Fortunately, the Campaign for a Commercial-Free Childhood (www.commercialfreechildhood.org)  (the same group  that fought “Baby Einstein”) went to work against the sale of Your baby can read, and now can celebrate success in getting rid of this material (and we’ll see how soon Amazon drops it--  I notice that they’re having a sale right now, a bit like the paint manufacturers selling off the lead-based paint years ago).
It’s difficult to fight fraudulent commercial claims in the United States, where commercial speech receives more legal protection than it does in many parts of the world. However, in 2011, the Campaign for a Commercial-Free Childhood (CCFC) and its attorneys filed a complaint with the Federal Trade Commission on the ground that Your baby can read was falsely marketed as educational for infants. In particular, CCFC stated that there was no evidence that the program teaches babies to read, or that there is a “window of opportunity” for learning to read that closes at age 5 years or earlier, or that babies exposed to the Titzer program do better than other children later in life. In 2012, a FTC decision and settlement prohibited advertising that claimed any educational benefits for the program, with a judgment of $185 million against the company. A final order for the settlement was entered in the U.S District Court for the Southern District of California last week.

What evidence would Titzer and his company have needed to present in order to argue that their claims were not fraudulent? Testimonials, of course, would not be sufficient, however enthusiastic they were. Organizations like the American Psychological Association define evidence-based treatments as those shown to be successful by specific types of research; an adequate number of infants would have to be assigned randomly to a group receiving the Your baby can read package, or to a comparison group that did not receive it, and the Your baby group would have to show statistically significant superiority over the other group on some measure. What’s more, an independent researcher would need to replicate the study and find similar results. Weaker types of research could be used to argue that the claims were not fraudulent, under some circumstances, but Titzer appears to have established neither strong nor weak evidence to support the claims he made.

One of Titzer’s most questionable claims was about a “window of opportunity” to learn to read quickly, which was said to close by about age 5--  at about the same time that most children begin the process of learning to read. It’s true that there are “windows of opportunity” in the form of critical or sensitive periods, during which certain aspects of development (e.g., binocular vision, learning of the sounds characteristic of a language, or attachment to a familiar caregiver) occur more readily than they would earlier or later in the individual’s life. But reading obviously does not have a window of opportunity in early life, or young children would learn to read very quickly simply as a result of being read to or hearing adults read signs or other material out loud. For some children, learning to read is not a genuine developmental possibility until about age 8, and adults who have not been schooled learn to read when given instruction, as we see from accounts of slavery in the U.S. and the motivation of adult slaves to learn this forbidden skill.  

 Why can’t babies read? There are a number of developmental steps that must be in place before reading can be learned. In languages like English where speech sounds (phonemes) are represented by letter shapes (graphemes), a new reader must understand that connection and then learn the associations between specific phonemes and graphemes. (And pity the poor reader of English, where several different phonemes may be represented by a grapheme, or various graphemes may work together or separately to represent a phoneme!) This connection cannot possibly happen before the baby has learned, in the second half of the first year, to realize that only the phonemes of its family’s language are part of speech, and that all other “mouth noises” that humans can make should be ignored while trying to understand speech--  that when people say “uh, mmm” or cough, those sounds don’t carry the meanings that speech has. A baby who has not yet learned about phonemes can’t connect speech sounds with graphemes.

Although babies can learn to recognize shapes, there are some shape features of graphemes like those in our Roman alphabet that will elude them for years to come. Even at kindergarten age, many children cannot yet recognize that the orientation of a shape makes the difference between “b” and “d”, or “p” and “b”, or between “g” and “q” in some type faces. They do not “see letters backward” but have not reached the developmental milestone of paying attention to right-left or up-down differences.

So, babies can’t learn to read, no matter what methods we might try. And they already are busy with their own baby tasks which must come before speaking and certainly before reading. Those tasks are ones that babies do not learn from a screen, but do master as a result of looking at and listening to smiling, playful, talking, singing caregivers, adults who delight in the babies’ joyful responses to social fun. You can’t package the experiences that help babies develop skills that will help them learn to read with pleasure, when the time for reading comes.  





Saturday, August 16, 2014

Child Trafficking By Any Other Name Smells Equally Bad

Over a year ago, I posted several pieces (e.g. http://childmyths.blogspot.com/2013/01/kafka-again-more-on-capture-of-child.html ) describing the situation of a woman I called Eve Innocenti. (She has told me it’s all right to use her real name, but I am not going to because I’m concerned about unforeseen consequences of disclosing.) Eve has two sons who are in the custody of a Colorado county following more or less accidental proceedings years ago, coupled with the involvement of the biological father of one (yes, one ) of the boys and the father’s wife. It does not really matter how this all came about, except for the fact that there was never any abuse or neglect of the children on Eve’s part, and retrospective attempts to claim that there was some have been completely unsuccessful. (For example, there was a claim that one child showed signs of fetal alcohol effects, therefore Eve must have drunk alcohol while pregnant, therefore she was by definition abusive; however, when after examination the child was clearly stated NOT to show any such signs,  that whole structure fell to the ground.)

Well, it’s all still going on. One child (B.) is with his father and stepmother and is not allowed contact with Eve. The other boy (K., as in Kafka)  is in a placement managed by the Institute for Attachment and Child Development ( the quondam Attachment Center at Evergreen, Colorado), whose director, Forrest Lien, is well-known as a proponent of the alternative psychological theories and treatments associated with Attachment Therapy. K. has unsurprisingly been diagnosed with Reactive Attachment Disorder among other things and is on heavy medications as well as receiving unspecified psychotherapy, and being denied contact with his mother. Eve’s efforts to work through her lawyer and the children’s law guardian have been fruitless. She wrote recently, “I’m at a serious loss here. I have done everything I can and nothing has worked. Laws don’t mean anything, rules and regulations don’t matter, the county can get away with everything and no one will stop any of it. I am now convinced that I will never see [K.] again. [B., the older boy] will make his way home, something I am sure of, but poor [K.] has never stood a chance.”

Why is Eve so particularly discouraged at this juncture? There is in fact something new happening. Although her parental rights with respect to K. have not been terminated, and although she is still required to pay the county for his support, she is told that a search is on for adoptive homes for him. This is happening in spite of the fact that adoption cannot occur unless parental rights are first terminated, but of all the possible reasons for termination, as described at https://www.childwelfare.gov/systemwide/laws_policies/statutes/groundtermin.cfm, Eve’s case presents only one, and that one has occurred against her wishes--  her involuntary failure to see the children for many months.  

As the statutes about termination of parental rights show, it’s assumed that it is in the interests of as state and its citizens not to terminate rights unless it is clearly necessary for the protection of a child. Maintaining family relationships, and reuniting separated parents and children, are goals secondary only to keeping a child safe.  The stress on family reunification is so strong that there has been more than one incident in which children who have been placed in foster care because of abuse or neglect (remember, this was not what occurred in Eve’s case) were mistakenly reunited with parents who are not safe, and there were tragic consequences. Why, then, do we see a case where a mother who has never been neglectful or abusive, who is not indigent, and who wants the children--- is nevertheless apparently en route to termination of her parental rights with respect to at least one child?

I don’t know why, of course. But I do have some suspicious thoughts about this situation, and they have to do with the hurry to make adoption arrangements. Children are a commodity in the eyes of some people nowadays, and we pay for our commodities when we must. Commodities brokers are also paid by those who want the items they supply. Who is going to benefit financially from the adoption of K.? Is money or other benefits going to change hands--  indeed, have they already done so?

If this is the case, and caseworkers or other county employees are already arranging a transfer of “ownership” for which they will be paid, I would say that there is a name for what they are doing. It is child trafficking. Most commonly, this term is used to describe purchase of children for sexual use, but it does not necessarily mean this (although that definition cannot be ruled out, I am very distressed to say). People can traffic children as slave workers, or as adoptees for those desperate for parenthood for any of a number of reasons. Once a judge follows the recommendation of a caseworker to give legal custody to a purchaser (and someone who gives a kickback to a caseworker is a purchaser), a child may have no way to call society’s attention to his plight until he reaches adulthood.

I don’t say that this is what is happening to K. I don’t know. But I think readers will agree that the scenario I have presented is not an impossible explanation of events without any other obvious rationale.


Friday, August 15, 2014

Are Hugs Necessary?


Reader Sandee—who had asked me to comment on Tina Traster in the previous post--  was also questioning the idea that all children must be physically affectionate with their parents, or something is not right. She referred to an adoptive family in which the mother wanted the child to huge the dad, and had another child tell her that it was a good thing to do.

A hug from the right person at the right time can be a very pleasant and gratifying thing, of course. Because we know this and are concerned for others, as adults we may hug people we don’t really want to hug, or at least hug them under circumstances that don’t appeal to us. But does hugging mean we really care about someone, and does failure to hug mean we don’t?

Seems pretty unlikely--  yet some purveyors of parenting advice have made almost exactly that statement with respect to adopted children. According to them, a symptom of Reactive Attachment Disorder, the notional scourge of adopted children, is a failure to show affection on the parent’s terms. That means how, when, and where the parent elects to have an affectionate exchange. Nancy Thomas, the “foster parent educator”, has stressed that the parent need not and even should not hug a child who asks for a hug, but should insist that the child hug the parent at some future time when the parent chooses it. The child who does not comply to the parent’s satisfaction must be a little RADish (as they used to say—I haven’t seen this for a while) and is certainly not attached (i.e., obedient and grateful) to the parent; serious unconventional treatment is needed.   

Why do people like or not like to hug other people? Part of this certainly has to do with ever-changing cultural standards. Older readers will remember when hugging was pretty limited to occasional bouts with family members who had been absent for a while, or to actual or potential romantic partners. Young children got a goodnight kiss, or a kiss-to-make-it-well when needed , and had their hands held when crossing the street, but that was about it. Everybody else got handshakes, or in the case of older ladies and theatrical people, an air kiss. Graduations were formal events where principals or presidents presented diplomas and shook hands; they did not kiss all and sundry. A hug for the wrong person at the wrong time or place could give considerable offense.

Fast-forward to approximately the 1970s, where peace, love, and freewheeling pre-HIV sexuality created an atmosphere where only uptight old fuddy-duddies would fail to hug at all opportunities. It was refraining from hugging that was offensive, not doing it.

So, at which time did parents and children actually love each other? Was their affection indicated accurately by the amount of hugging? I would presume not, and I would strongly question the idea that children who do not hug when ordered don’t love their parents, or that those who do hug as ordered, do love them. I would also note the likelihood that children who come from “hugging cultures” are no different in their filial affection than those who come from “non-hugging cultures”. No, what has happened with all of them is that they have learned to comply with social rituals just as all human beings do.

It’s common for people to assume that a hug is motivated by a need to give and receive affection. Therefore, they figure, if there is no hug, there must have been no need for an affectionate exchange… and, stretching logic considerably, if you make a hug happen, you will also cause the antecedent need for affection to appear! Unfortunately, this line of thought is not only illogical but omits the possibility that a person who wants to give and receive affection may have learned ways to show love that are not hugs and perhaps not even physical acts. An enthusiastic handshake or a bow and namaste may express what a hug says for other people.

If it’s hard to think whether this is correct, just consider--  has your experience been that parents and children kiss on the lips, or not? If you are used to one in a nonsexual relationship, you probably find the other quite unnerving, yes?    

There are also some normal individual differences between people that can affect their hugging tendencies, quite independent of whether they care for someone or not. It can be perfectly normal to prefer less or more touch, just as a preference for bland or spicy food is a normal individual difference. The preference for mutual touch is to some extent different from or independent from the kind of tactile sensitivity that demands that all clothing tags be cut out upon purchase. Individual experiences based on other characteristics can also help determine touch practices; one of my sons, who as a skinny child was a great lap-sitter, got at the age of 10 one of those awful orthodontic appliances they called “headgear” and could only be kissed by his ear when he had it on--  to this day, that’s the way I kiss him and the way that feels comfortable to us. His brother, who was a lot heavier so I could not cope with him on my lap after about age 6, never had that appliance, and I kiss him much more in the middle of the cheek, as he does to me.   

Bottom line: hugging someone is not necessarily an indication of real affection for that person, nor is failing to hug a symptom of “non-attachment”. Also, making a child hug or be hugged doesn’t make the child love the huggee. If people care about each other and enjoy some of their time  together, who can ask for more? After all, the ritual is not the relationship.



Traster and That Primal Wound: Quick, Call a Celebrity!


A reader, Sandee, suggested the other day that I write about a disinformative blog, http://www.adoption.net/adoptive-parents/blog/rescuing-julia-twice-conversation-with-the-author-adoption-groups-can-t-stop-talking-about?vnc=wuavX09V9a14E.  The blog post in question poses Tina Traster as an expert on the development of adoptive children and pursues her beliefs with admiration. She seems to have become the Jenny McCarthy of the adoption world and is having her 15 minutes of fame in a similarly dangerous way (dangerous to other people, that is). This is evident in one of the interviewer’s first questions: “What is RAD, in your own words and as a parent?” (my italics).

Who cares how Tina Traster defines Reactive Attachment Disorder “in her own words”? Are diagnostic criteria now a matter of personal opinion? Do worried hospital ethics committees now tell each other, “this is serious. We’d better consult a celebrity”? There is no question that over the years the DSM criteria for Reactive Attachment Disorder have changed somewhat (it was originally defined as an early feeding disorder), but the term has never been up for grabs in Humpty Dumpty fashion.

Someone I knew a long time ago insisted on calling apple jelly marmalade, and was always annoyed when he was handed marmalade after asking for it, rather than getting the apple jelly he meant. If we are going to communicate about anything--  and especially about important issues rather than condiments—we need to be in agreement about the meanings of terms, and for maximum communication we do well to accept the definitions of people who have studied a topic systematically and empirically. Traster and many others of her type want to define Reactive Attachment Disorder as “apple jelly” when knowledgeable people have already defined it as “marmalade”. This does nothing but darken counsel, and it leads unsophisticated readers to think that Traster is talking about the same disorder that is described in DSM ; but, she isn’t.  

That Traster is not really talking about Reactive Attachment Disorder is evident in the list of symptoms she describes as characteristic--  none of which are diagnostic criteria given in any of the editions of DSM. Traster states that the children who should receive the Reactive Attachment Disorder diagnosis are superficially charming and manipulatively engaging with strangers, but aloof and disengaged with familiar caregivers. She says they don’t make eye contact, chatter incessantly, and want to control everything. They also fail to connect cause and effect, according to her.

Anyone who has studied the alternative or vernacular psychological theory that is the basis of Attachment Therapy will recognize these characteristics as part of the diagnostic checklist used by people like Walter Buenning and Elizabeth Randolph,  and more recently by “Kali” Miller, who has had her psychology license suspended in Oregon. Children who show some of these symptoms in a severe and persistent way may indeed have mental illnesses or other conditions which if unresolved will produce a concerning developmental trajectory; it’s also possible that their parents or caregivers are the ones with the emotional or behavioral problems, or that the adults may have fallen for a much mistaken belief system.  Superficial charm and exploitation of others (if intense) can be aspects of psychopathy. Failure to make eye contact can be a part of autistic spectrum disorders, or, of course, it can be culturally determined, as many groups regard a child’s direct gaze at an adult as highly disrespectful. Constant talking can be part of some genetic disorders, and as for wanting to control everyone and everything, who doesn’t?! The cause and effect thing is something that Attachment Therapists seem to have picked up from Piaget’s work on cognitive development, but they don’t appear to have thought through what a person would be like if he or she actually did not understand cause and effect (could they catch a thrown ball, for example?). I think what they actually mean by this is that the children keep performing unwanted acts even though they are severely punished for them; however, the parents’ failure to understand behavior management is not the same thing as the child’s inability to comprehend cause and effect relationships.

But let’s go on with this interview. Where does Traster think Reactive Attachment Disorder comes from? She names a number of potentially harmful experiences such that no one in their right mind would predict good outcomes as their results. But then she goes on to the crunch: that the real causal problem is “the traumatic break of the maternal bond, or the primal wound,as some call it…”. Now, talk about failure to understand cause and effect relationships! Traster is assuming that early separation from the birth mother is traumatic, because she believes that there is a “maternal bond” or emotional connection of child to mother, that has occurred before birth. She ignores the well-known development of child attachment to caregivers (father too) over the later months of the first year after birth, and therefore misses the developmental period during which abrupt, long-term separation does cause obvious emotional trouble. Why does she do this, other than simple ignorance about child development? She is following the claims of various “alternative” thinkers, such as Nancy Verrier, David Chamberlain, Lloyd DeMause, the Association for Pre-and Perinatal Psychology and Health, Nandor Fodor, Frank Lake, old uncle Georg Groddeck, and all. These people have all claimed that on the basis of their own mystic knowledge, sometimes assisted by LSD or partial asphyxiation, that empirical evidence about early development should be rejected and their own assumptions accepted instead.

Now Traster states that she is no longer worried about her adopted daughter because the child is both “bonded and attached”. She seems to miss the point that the real meaning for “bonding” has to do with the adult’s emotional commitment to the child, not vice-versa. And this interview shows enough of her ongoing concerns about how people have treated her (no baby shower!) that one does wonder to what extent her own needs have gotten in the way of the relationship with the child. Her warning that parents should avoid therapists who seem to be “charmed by the child” also suggests an ongoing uncertainty about which person is the child, and which person a therapist has to find charming. Again, this is good old Attachment Therapy stuff--  that the adult caregivers deserve special attention and care and are having a really hard time, while the unfortunate child is simply causing trouble and should be ignored by other people (e.g., Nancy Thomas’s advice that the children should wear dark glasses when in public so they can’t give people sad looks).


Really, it’s all very depressing. Traster knows how to work the celebrity thing, and her followers love that. The fact that she’s wrong again and again, and that there are many other people who know better than she does, just doesn’t seem to make much difference. Unfortunately, celebrities aren’t held accountable for bad outcomes, as professionals sometimes are.    

Thursday, July 31, 2014

You Can't Tell a Book by Its Cover, But Sometimes You Can Tell by Author, Editor, or Publisher


Nowadays, we tell each other all the time to be cautious about accepting information offered on the Internet. People may not actually follow that advice (especially if they find statements that they want to believe), but they think it’s accurate enough to pass on to others. And there is a general understanding that some kinds of websites, like .gov and .org, are often more accurate in their statements than .com sites may be.

But what about actual printed books? Traditionally, non-fiction book publishers have been rather careful about the manuscripts they accept. Part of their concern has been whether a book would sell, that’s true, but they were also concerned that if a book turned out to contain misinformation, this would reflect badly on the publishers, good authors would not want to work with them, and both reputation and business would go downhill quickly. Traditional publishers have usually sought outside reviews of manuscripts before they were accepted, and have asked authors to correct any inaccuracies or other problems found by reviewer.

Times have changed, though. Enter first vanity publishing (sometimes daintily called “boutique publishing”) and then self-publishing. These publishing methods are ideal for non-fiction authors and editors who want publication without review or criticism, a quick turn-around and ads swiftly  up on Amazon, in exchange for a fee. They are also excellent for lightweight publishers who “troll” for equally lightweight authors in order to put together a publication that will sell and provide the authors with bragging rights. The result? A book that is fine on the outside, but that does not necessarily contain reliable information. Unlike the Yankee farmer’s blind horse that “pulls good, just don’t LOOK so good”, these books appear to be the reliable things we learned to respect in grade school, but they may be quite otherwise.

I have these issues on my mind today for two reasons. One is a message I received from Marianne Milton, alerting me to some potential authors who are looking for material to put a book together.  The would-be authors are Gregory Keck and Lynda Gianforte, and here’s what they have to say:

"Dr. Keck and Lynda Gianforte are writing a book whose working title is Keeping Families Strong after Adoption. They want to include success stories written by parents and children. The stories will be edited and returned to people for their approval. People can respond to the questions below. Contributors may send the stories to Gregory Keck, PhD at goyo113a@aol.com

FOR PARENTS:
• Did you do anything special to make your adoption successful?
• Are there any parenting strategies that were particularly effective for you?
• Is there anything you did that didn't work?
• Did you get therapy for your child? If so, what kind?
• Did you get therapy or any specialized training to help you parent your adopted child more effectively?
• Do you have any suggestions for new adoptive parents that you'd like to share?
FOR KIDS:
• What did your parents do that made you feel good about being adopted?
• If you could talk to new adoptive parents, what advice would you give them about raising their kids?
• When you're a grown-up, do you think you'll ever adopt a child?"


The potential publisher of this book is not named, so I don’t know whether this is to be self-published or simply go to a printer-ready press that will handle distribution. However, some information about the authors is available. Gianforte, writing under the name Lynda Gianforte Mansfield, is an adoptive mother who has since at least 1994 been collaborating on books with attachment therapists. One such book was published by Pinon Press, a small publisher in Evergreen, Colorado; Evergreen was home of a version of holding therapy, and Pinon Press specialized in related work, at least prior to the 2000 death of Candace Newmaker at the hands of two holding therapists. Gianforte was also strongly associated with “Love & Logic”, the commercial parenting program run by Foster Cline, one of the most influential proponents of holding therapy.

Gregory Keck is a licensed clinical psychologist in Ohio, but his educational background is ambiguous. He received a doctoral degree from the intermittently-accredited Union Institute, an institution that allows students to name the discipline that they believe their dissertation topic belongs to. Keck chose criminology for his discipline. Keck’s book Parenting the Hurt Child, co-authored by the social worker Regina Kupecky, recommends holding therapy. Of a group of psychologists writing for a special issue of the journal Attachment & Human Development in 2003, Keck  (along with Helen Minnis) was the only one whose article failed to reject the use of holding therapy (curiously, it was also the only article that appeared in the form of a dialogue rather than a normal scholarly paper format, so I assume it was accepted only because Minnis has some influence).

What, then, can we expect from a book produced by Gianforte and Keck? Is it likely to agree with expert views on holding therapy and on attachment disorders like those stated by the American Professional Society on Abuse of Children in 2006? Somehow… I doubt it. But will na├»ve readers be aware of that? Somehow I doubt this too.

All right, one more example of the untrustworthy book issue. I recently received from Nova Publishers an e-mail inviting me as follows:   

“Dear Dr. Mercer,

We have learned of your published research on theory of mind and would like to invite you to participate in our publishing program. A number of possibilities are available for our cooperation.

In particular, we welcome two possible avenues of collaboration (you can select one or both and let us know by return email):

1. Your authorship or editorship of a monograph or edited collection on a topic of your choice.

The format (monograph or edited collection), approach and the manuscript submission date would be at your discretion. Our Publication Idea Form might be of use to you in this regard and is attached to this email. If you are interested, please fill it in and return it to my attention at n.columbus@novapublishers.com. If your book proposal is accepted for publication, we will send our agreement for your evaluation and signature. Your book will be published in printed and electronic formats simultaneously.


2. Your submission of one or more original research or review chapter(s) for our upcoming hardcover edited collection (by selected invitation only) tentatively entitled:
Theory of Mind: Development in Children, Brain Mechanisms and Social Implications

Related Nova publication:
Autism Spectrum Disorders: New Research
https://www.novapublishers.com/catalog/product_info.php?products_id=30926


The deadline for the abstract is August 25, 2014 and for the completed chapter November 25, 2014. Please send the abstract and the chapter to
nova.main@novapublishers.com.
We also welcome proposals to serve as the editor of this volume. If you are interested, please send your latest CV to [\"mailto:n.columbus@novapublishers.com\"]n.columbus@novapublishers.com. Proposals to serve as the editor are welcome up to the abstract deadline.

The contributions for this edited book are intended to range from 4,000 to 35,000 words (chapters over 10,000 words can be updated by the author for the e-version of their chapter for a period of 2 years at intervals of 6 months, 12 months and 24 months after publication). If you are interested in participating, please consult the Notes for Contributors at the bottom of this letter. Should your schedule not allow a full contribution at this time, we would welcome either a Commentary or Short Communication of 1,000-4,000 words.

The book will be published in about 6-9 months after the close of the volume. As soon as a book is listed on our Website ([\"http://www.novapublishers.com\"]www.novapublishers.com), the codes in the status field will indicate the production stages through publication cycle.

Select one:

Peer review to be arranged by author ...................................

Review at Nova ................................... “



Let me state, to begin with, that I have never done any empirical research whatsoever on Theory of Mind, and although I could “mug it up” and write something about other people’s work, it would be quite deceptive to present me to readers as a researcher in that area. Let me point out, too, that the last couple of lines tell us a lot: I, the author (if I were going to do this), could decide whether a review of the work should be done by someone at Nova, who is not likely to know much about the topic, or by a reviewer I asked to do it--  potentially, my friend or even my student.

This contact on the part of Nova explains to me part of the story behind the only Nova book I ever bought—New Developments in Child Abuse Research, edited by one Stanley Sturt, apparently a graduate student at the time. This volume contains a publication by Arthur Becker-Weidman in which he claims to have demonstrated the efficacy of Dyadic Developmental Psychotherapy, but includes much information suggesting that the treatment actually involved holding therapy. Now I understand what I suspected before--- that Becker-Weidman’s paper was never reviewed by anyone who knew the field, and that was why it was published, to its author’s presumable benefit. (I had queried Nova on these points years ago, but got no answer.)

Not to belabor this issue any longer, but skeptical caution obviously needs to be brought to information in print as well as on the Internet. As Pogo once suggested, it may not be the truth even though it’s more interesting.



Tuesday, July 29, 2014

Robert F. Kennedy Jr. Is Badly Mistaken About Vaccines and Autism

A recent article by Keith Kloor in the Washington Post Magazine discussed the position taken by Robert F. Kennedy Jr., who has edited a new book claiming that the preservative thimerosal, used in some vaccines, is responsible for a large proportion of neurodevelopmental disorders, including autism (www.washingtonpost.com/lifestyle/magazine/robert-kennedy-jrs-belief-in-autism-vaccine-connection-and-its-political-peril/2014/07/16/f21c01ee-f70b-11e3). Kennedy is untrained in any of the scientific disciplines that would enable him to critique the evidence for such a claim. One of his co-authors, the physician Mark Hyman, is a purveyor of diets and alternative medicine as preventative of common disorders and as guides to “UltraWellness”.

According to the Kloor article, the book, Thimerosal--  Let the Science Speak, was published without some of the draft chapters, as even Kennedy’s co-authors felt they were too “combustible” (for which I read, “impossible to support with empirical evidence”). Nevertheless, the book makes strong claims about  the dangers of the mercury-containing preservative, and attacks the Centers for Disease Control and other federal agencies for their unwillingness to remove thimerosal from all vaccines. Kennedy and his co-authors interpret the fact that thimerosal was removed from vaccines for childhood diseases years ago as an admission of evidence of toxicity, rather than as what it was: a policy decision taken to counteract the mistaken thinking of some parents, who wanted to avoid vaccination because they thought the procedure could cause autism. They reason (?) from this assumption that CDC and other agencies know they are in the wrong about thimerosal, but for unknown motives continue to maintain their mistaken position.

There are three basic ideas in all of the anti-vax, anti-thimerosal arguments, and all three are problematic. One  idea is that because mercury in some forms and quantities is known to cause brain damage, all forms and quantities must have the same effect. Because people who ate fish contaminated by high levels of methylmercury effluents developed Minamata disease, with sensory disturbances, movement problems, and tremor caused by the mercury neurotoxicity, it is argued that occasional exposure to small quantities of other forms of mercury can have devastating effects.  This is similar to arguing that because a person can drown in the ocean, salt-water nasal sprays are also dangerous. In fact, in spite of homeopaths’ claims to the contrary, minimal exposures can be harmless even though greater exposures to a toxic substance can be fatal. 

The second idea depended on by Kennedy, Hyman, and others is that autism and other neurodevelopmental disorders are caused entirely by environmental factors.  However, there is strong evidence that genetic factors are largely responsible for autism and most other such disorders. This can be difficult for concerned parents to accept, because they imagine that all genetic problems follow a simple dominant-recessive pattern as some eye colors do; when their child is diagnosed as autistic, the parents say “it can’t be genetic, because no one in our families ever had such a thing”. However, genetic problems may involve a number of genes and be evident only when all the required genes are present together. They may also emerge from mutations or other changes which occurred in previous generations but were not apparent until the present one. Of course, the importance of genetic factors does not mean that there must have been no environmental factor at work, but it might well mean that only persons with certain genetic make-ups are vulnerable to the effects of certain environmental events (as discussed by Beaudet in a Science article in 2012).  

The third problematic idea is that there is an epidemic of autism. It is certainly true that many more children in the United States are diagnosed as autistic than was true in the past, but this is far from the same thing as an epidemic. What I am going to say about the frequency of autism diagnoses in the U.S. today has been said many times, but apparently it needs saying again: the number of cases of any disorder diagnosed depends on two different things--  the number there actually are, and the method of diagnosis. Before Leo Kanner proposed the diagnosis of autism, no children were diagnosed as autistic, but this is not likely to have been because there were no autistic children before the 1940s. Kanner did not “invent” autism or autistic individuals, but just called attention to an existing condition that had been confused with other speech problems and  with mental retardation. Definitions, symptom lists, and ways of diagnosing autism have altered over the years, and the present approach to autism includes both serious disorders and many mild problems that received other labels in years gone by. Unless some dramatic changes occur, combining mild and serious disorders will obviously result in having a larger number of people assigned the combined diagnosis than would have been the case for each previous diagnosis separately.  (Incidentally, this problem of categorizing and counting also applies to statistics about Sudden Infant Death Syndrome; while deaths attributed to SIDS have been reduced in number in recent years, there has been an increase in infant deaths whose causes are unidentified—the same number of deaths, but placed into different categories.)  Categorization is one source of the “epidemic”; another is increased awareness (not to say frantic anxiety) among parents, and haste in seeking diagnosis of peculiarities which in the past were often dismissed as trivial individual differences. This haste can lead to early diagnoses of autism in children who are later identified as typical in development.

Kennedy and his co-authors are thus wrong about the existence of an epidemic of autism, about environmental causes of the disorder, and about the actual effects of exposure to small doses of the form of mercury in thimerosal. By continuing to press these mistaken points, they discourage parents from immunization in general (even though thimerosal has long been removed from vaccines for common childhood diseases), and from flu vaccines in particular, as these continue to contain the preservative.  Kennedy’s celebrity status enables him to publish and push as scientifically based a position contrary to what scientific investigation actually shows, and to use this position to argue against all common sense that the Centers for Disease Control are deliberately working against public health needs.



  

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.