Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Tuesday, April 19, 2016

Time-Outs, Time-Ins: Good, Bad, and Badly Misunderstood

A brief article published a couple of years ago in Time magazine is still getting a lot of attention. This piece, written by Daniel Siegel and Tina Payne Bryson, was entitled “ ‘Time-Outs’ Are Hurting Your Child” (www.time.org/3404701/discipline-time-out-is-not-good/ ). Siegel and Bryson began with the statement that painful experiences can “change the structure of the brain”  (though they did not follow up by saying what behavioral or mood changes might result, if any). They noted that emotional pain activates the same brain areas as physical pain, commented that isolation can be emotionally painful, and concluded that children who were temporarily isolated in “time-out” may be damaged by the experience. They advised that “time-out” should give way to “time-in” to give increased experience of warm affection.

Members of the Society of Clinical Child and Adolescent Psychology, Division 53 of the American Psychological Association, have been quite concerned about the inaccuracies in these statements. In a press release headed “Outrageous claims regarding the appropriateness of Time Out have no basis in science”, members of the division pointed out the highly selective cherry-picking of neurological evidence that Siegel and Bryson made use of, and noted that there were decades of research supporting the safety and efficacy of “time out”, and little or none supporting “time in”.

The efforts of Siegel and Bryson to argue that “time outs” or harmful were characterized by a common theme among pitchers of woo--  that when the brain is “changed” by events, that the outcome is of necessity a bad one. This ignores the fact that the brain is constantly changing in structure and function because of maturational factors, and is simultaneously being changed as memories of experiences of all kinds are formed. The outcomes of these changes are generally positive, so it is absurd to present “changes in the brain” as evidence of harm. The first problem is to show that an experience (“time out”, for instance) is regularly followed by undesirable behavioral or attitudinal changes; if this had been accomplished, which it has not, the next step would be to trace the brain events that cause the connection between the experience and the bad outcome.

Like all other organisms, children change their behavior in response to reinforcing events that follow behaviors. If something nice happens after you do something, you become more likely to repeat that action. Unfortunately, sometimes behaviors that other people do not want or like get reinforced by accident. For example, most children will cut back on a behavior that gets them scolded and yelled at, but a child who gets very little attention may find that being focused on by an angry adult has reinforcing power. It’s not the yelling itself, but the attention, that reinforces the behavior. Similarly, a preschool child who acts up may find that although the teacher does not reinforce the behavior, all the other kids are excited and interested and attentive--  that reinforces the behavior and makes it more likely to be repeated.  

If children are “being bad” because an undesirable behavior has been reinforced in the past, the unwanted behavior can be reduced by making sure that it does not get reinforced.  The purpose of “time out” is to prevent reinforcement by removing the child temporarily from a potentially reinforcing situation. If done consistently, this is an effective approach--- but ONLY if the unwanted behavior has reached its present frequency because it was reinforced in some way by the social environment.

If a behavior is self-reinforcing, like eating when hungry, scratching an itch, or masturbating, unless it has also been socially reinforced, “time-out” will not affect its frequency. Neither will “time-out” reduce seizures or periods of inattentiveness due to neurological disorders, or fearful behavior stemming from previous traumatic experiences, or attention-getting behavior resulting from the absence of normal adult attention. The reason to choose a method other than “time-out” is that a specific behavior may not have developed as a result of reinforcement, and it will not diminish as a result of non-reinforcement. Under those circumstances, “time-in” and increased interaction with an adult may be helpful to a child who needs social support in order to do his or her best.

“Time-out” is not always the best choice--  but this is not because it “changes the brain” in some mysterious but threatening way.

P.S. Then there’s my two-year-old granddaughter, who when sent to “time-out” trots off looking very pleased with herself as she does just what her older brother is sent to do! Is this experiencing actually reinforcing for her? Maybe, but after all she wasn’t so very naughty to begin with…


Saturday, April 9, 2016

How Kids Enlist in the Culture Wars

Anyone who has been watching American political events this year will be aware of the reasons for the term “culture wars”. We’re not just watching groups of people who happen to agree with each other and not with their opposite numbers; we’re watching groups each bound together by beliefs and practices, and each disapproving strongly of the other’s positions. The beliefs and practices of each group are defined as cultures because they are taught and learned by members whose group shares them. The “war” part is unfortunately pretty obvious these days.

Although the United States is fortunately multicultural, there are two broad groups (each a coalition of smaller groups) that form the cultures now struggling in the political arena. The first of these is a modernist, progressive, liberal group,  consisting of the mainstream religious bodies combined with the secular humanists, whose beliefs and practices are not very different from those of the liberal churches. The second group is traditionalist, fundamentalist, and conservative. As adults, the two groups display strong differences in attitudes and preferred behaviors associated with a variety of issues. For examples of differences in the beliefs of these two groups, we can look at attitudes toward contraception and abortion, toward same-sex marriage, and toward reports of global warming.

Not surprisingly, the modernist and traditionalist groups each do their best to inculcate their beliefs and practices into children growing up in their groups. But how do they do this? When do the children begin to share the adult attitudes? Are modernist 5-year-olds and fundamentalist 5-year-olds already very different in their thinking? Or does it take years of teaching and cognitive development before differences are evident? Gilbert and Sullivan claimed that “Every boy and every gal that’s born into this world alive/ Is either a little liberAL or else a little conservaTIVE”. Were they right?

These are not easy questions to answer, but some help has been provided in a recent article (Jensen, L.E., & McKenzie, J. [2016]. The moral reasoning of U.S. evangelical and mainline Protestant children, adolescents, and adults: A cultural-developmental study. Child Development, 87[2], 446-464; N.B., if you look at this paper—I think the captions to figures 2 and 3 are reversed). Jensen and McKenzie compared moral reasoning in members of two Presbyterian groups, the modernist Presbyterian Church (USA) and the fundamentalist Presbyterian Church in America (PCA). The first is a member of the National Council of Churches, the second a member of the National Association of Evangelicals. (Although I mentioned earlier that secular humanists might share a good deal with the modernist churches, I want to point out that no secular humanists were included here, and the results of this study may not apply to them as well.) Interviews about moral judgments and reasoning were carried out with 60 members of each church, the groups divided evenly into 7-12-year-olds, 13-18-year-olds, and adults ages 36-57. For example, at one point, interviewees were asked whether they could tell about a time when they had an important experience involving a moral issue—this might be a situation where they now think their actions were morally right, or they may now seem morally wrong. 

Of course most people find it difficult to explain all the details of their moral reasoning and judgment, whether they think an action is right or whether they think it’s wrong. Jensen and McKenzie worked out some details of the interviewees’ thinking by analyzing issues and answers on three dimensions. One was the age of the participant, a piece of information that would help establish developmental change in moral reasoning. A second was whether the moral issue being discussed was a private experience (like drug use, behavior toward friends, theft, or volunteering) or had to do with public sphere (like giving money to panhandlers, divorce, or capital punishment). The third dimension had to do with the ethical perspective taken. The authors referred to the three possibilities as follows: The Ethic of Autonomy focuses on harm to the self and the interests of the self and the needs of other individuals (as unique persons, not simply as group members). These moral decisions attempt to protect the self and other individuals, and this type of moral reasoning begins in early childhood and persists into adulthood. The Ethic of Community makes moral decisions on the basis of duties toward group needs, initially the family and later schools and even broader social organizations, whose harmony is seen as important. This type of moral reasoning is minimal in early childhood and may gradually increase through adolescence and into adulthood. Finally, the Ethic of Divinity stresses the role of spiritual or religious entities, with moral decisions involving obedience to a god’s authority, natural law, or spiritual purity. The last ethic has received much less research attention than the others.

Jensen and McKenzie’s interviewees used the Ethic of Autonomy most as children and decreased this perspective somewhat through adolescence and into adulthood. The Community perspective increased for everyone from childhood into adulthood.

The great difference between the groups was in the use of the Ethic of Divinity—rare even among evangelical children, almost nonexistent among modernist children, and increasing with age through adolescence, but by far most common among fundamentalist adults thinking about public moral issues (e.g., same-sex marriage).  Mainline adults, though less likely to use the Ethic of Divinity at all, applied it more often in the private than in the public sphere. A major difference between modernist and fundamentalist adults was in the appeal to scriptural authority, with Bibles being used and on display in fundamentalist households but rarely referenced by modernists.

 Jensen and McKenzie pointed out that the two “armies” in the current culture wars are not committed to the same “moral lingua franca” and therefore find themselves unable to carry out any real discussion of their differences. This is not so much a problem in childhood, when evangelical and mainline children tend to share the Ethic of Autonomy, but looms large after adolescence, when evangelicals emphasize the Ethic of Divinity, a perspective rarely taken by modernists.


That such different moral languages are spoken by the two major  groups may be one of the reasons for the current intense emphasis on angry emotion in politics. Neither understands what the other is saying, and the discussion is regrettably reduced to mime. Can we generalize this view to an explanation of world-wide conflicts? I think that’s possible—but such thinking is only a baby step toward  resolution on any stage.  

Saturday, March 19, 2016

Adopted Children, Lying, Aggression, and Antisocial Behavior

This blog has intermittently been the scene of disagreements between me and certain adoptive parents. Our discussion usually goes something like this:

Parents: Our adopted children are terrible! They lie and steal and are even dangerous to other people. They have Reactive Attachment Disorder, that’s the problem.

Me: That’s not Reactive Attachment Disorder. Reactive Attachment Disorder is [defines RAD as in DSM-5, even in ICD-10 if feeling energetic].

Parents: Yes, they do have RAD!  How dare you say it’s not RAD! You’ve never lived with these kids, how would you know?

Me: I just said, those things you described are not the symptoms of Reactive Attachment Disorder. I didn’t say the kids didn’t do the things.

Parents: You ignorant no-good know-it-all, can’t you see that they need their attachment fixed, etc., etc.

Outside of the Attachment Therapy model, I have not seen anyone writing about RAD including antisocial behavior, or even about antisocial behavior as a problem of adopted children. However, while doing a search of the trauma literature for another purpose, I came across an article that focused on antisocial behavior as a particular problem of later-adopted children. The article proposed certain reasons for such behavior and also outlined a possible treatment, which I will describe. I must point out, though, that the article seems to have been published twice in the same journal in slightly different forms, is poorly proofread, and occasionally cites authors who have approved of holding therapy, so I don’t know exactly how seriously to take it. Nevertheless, some interesting points are made.

The article I’m referring to is: Prather, W., & Golden, J.A. (2009). A behavioral perspective of childhood trauma and attachment issues: Toward alternative treatment approaches for children with a history of abuse. International Journal of Behavioral Consultation & Therapy, 5(1), 56-74.

As you can see from the title of the journal, this paper takes a behaviorist position relative to both the causes and the treatments of undesirable behaviors of adopted children. They do not mention Reactive Attachment Disorder. Instead, they list various disturbing and undesirable antisocial behaviors like lying, sneakiness, and manipulation. Rather than proposing that these were caused by a poor attachment history, Prather and Golden discuss how these behaviors could have been rewarded, first by the child’s experiences with abusive or neglectful caregivers, and second by unintentional behaviors of foster or adoptive parents and of other children. Please note that these authors are not blaming the foster or adoptive parents, but pointing out that their natural actions toward the child may reinforce the very behaviors that they want to eliminate.

Prather and Golden point out that adopted children who behave antisocially may appear to lack “conscience”  or “attachment”, but in fact they have learned very well from their early experiences with abusive or neglectful caregivers. They have never been punished for lying or using unacceptable language—such actions may have been met with indifference or even amused approval. They may have been taught antisocial rules about hitting as a generally acceptable response, and may have been regularly teased into aggressive reactions by adults. They are likely to have learned to avoid adults in some or even most circumstances, as avoidance has led to the negative reinforcement of evading adult mistreatment. Whether or not they were attached emotionally to their caregivers may be seen as a minor problem compared to their history of learning to behave in “unattached” ways.

It is not surprising that abused or neglected children bring their learned behavior patterns with them to adoptive or foster homes. Once there, it may be a while before the new caregivers realize what undesirable behaviors are going on (and I wonder whether the time this takes is what is perceived as the “honeymoon” period of adoption). During that period, adults in the household may inadvertently reinforce the unwanted behaviors, for example, by failing to notice a lie or a theft. People outside the household are even more likely to provide accidental reinforcement, and this is related to an important issue.

The study of learned behavior has yielded some important principles about how reinforcement affects learning and behavior. The frequency of behavior is raised when the behavior is followed by reinforcement, but there is more to it than that. When the reinforcement stops, the length of time it takes for the behavior to stop depends on how and when the reinforcement used to occur. Paradoxically, when the behavior has been reinforced every time, stopping the reinforcement altogether causes the behavior to drop quickly to a low frequency—but if the behavior was reinforced only intermittently, it will persist for a long time after the reinforcement stops.

Most socially-reinforced behavior is reinforced only intermittently. The abusive and neglectful parents of the now-adopted or fostered children are very unlikely to have reinforced a behavior every time; in fact, they may have been just as likely to punish or to appear indifferent as to be amused or admiring of any action. This means that whatever behaviors were learned by the children, it will take a long time for them to be “unlearned”, especially if they are very occasionally reinforced by well-meaning adoptive or foster parents, by strangers, or by other children who are fascinated by the “bad kid”. Also, of course, some of the unwanted behaviors are self-reinforcing—the child is rewarded by getting the thing he stole or by avoiding punishment by lying.

So, what do Prather and Golden suggest as treatment for the concerning antisocial behaviors? I must emphasize that I have not found any published empirical work that they have done, but they made some suggestions that may be fruitful. Much of the focus is on “catching them being good”: encouraging the family to put less stress on “unattached” behavior and more on times when the problems are not apparent, and especially on ways that problems have been solved and parents have managed not to reinforce unwanted actions . Identifying antecedents, or triggering situations followed by unwanted behavior, can help anticipate and control how the child acts. (For example, does the child act up when the mother goes out without telling him she is going?) Acknowledging and paying attention to negative feelings is another important item, especially as the children may have become numb to their own feelings and therefore fail to experience or to anticipate a sense of guilt or fear of punishment. As Prather and Golden point out,” Unlike traditional attachment based family therapies, which often interpret verbal information in terms of underlying emotional dynamics, the rational cognitive emotive view of human behavior focuses solely on the causal sequences of a child’s experiences and perceptions, and the impact that the child’s negative thoughts concerning trauma have on the role of emotion in behavioral causation.”

Again, there does not seem to be any new evidence about how well this approach can be made to work. And those who are committed to an all-attachment, all-the-time perspective may say, “that’s just treating the symptoms!” But, to quote Nicole Hollander’s “Sylvia”, I might respond: Words to live by!

  

Tuesday, March 8, 2016

Flint and Elsewhere: What Aspects of Lead Poisoning Are Irreversible?

Far, far be it from me to imply that lead poisoning in infants and children is a minor problem, but I feel uneasy about the repeated declarations that children exposed to lead in the environment suffer “irreversible” effects. This I find especially worrisome when there is stress on mental retardation as a possible outcome of lead exposure—to say that mental abilities have been irreversibly affected when infants and toddlers are lead-exposed may in some cases be correct, but ignores the many factors that work together to determine an individual’s mental development. How awful it must be for parents of lead-exposed children to encounter these statements and know that people have essentially disposed of their children as beyond help!

 The dramatic statements about lead exposure remind me irresistibly of the “crack baby” concept of the 1990s, when headlines regularly stated that children who had been exposed to crack cocaine prenatally were hopelessly ruined. That did not turn out to be correct, and with proper care given to lead-affected children, the present claims will probably not be true either. Naturally it would have been far better if the children had not been exposed to lead to begin with, but they can be helped to develop at normal levels or close to them. This statement applies not only to the children of Flint, whose water supply was contaminated, but also to the many children in the United States who are exposed to lead in paint, dust, and so on in their own homes.
To support this statement, I am going to refer to a document produced by the Centers for Disease Control, “Managing Elevated Blood Lead Levels Among Young Children” (www.cdc.gov/nceh/lead/casemanagement/managingEBLLs.pdf).

Where children’s blood lead levels are very high, the CDC document recommends chelation therapy, a technique that chemically removes lead from the child’s body. (Please note that while this method is necessary and effective for management of heavy metals poisoning, it is most inappropriate and should never be used for treatment of autism or related problems!) The document points out that chelation should be used with caution and that primary care providers need to seek the help of experts. “A child with a [elevated blood lead level] and signs or symptoms consistent with encephalopathy should be chelated in a center capable of providing appropriate intensive care services!” (! in original; this treatment is nothing to take casually—JM). If the treatment is done with oral chelation agents with the child as an outpatient, the dosage needs to be carefully monitored, and the treatment needs to be done in a lead-free environment.

Children with elevated blood lead levels often have inadequate nutritional intakes of iron, calcium, and vitamins, and nutritional changes have been recommended as ways to prevent absorption of lead or to combat its effects. However, it is not at all clear that nutritional factors affect blood lead levels; it may simply be that children whose families live where lead exposure is likely also have families who do not have access to healthy food or information about child nutrition. Nevertheless, improving children’s early nutrition can be an important step toward good child health and development, both physical and intellectual. Low levels of protein intake and lack of iron are associated with problems of brain and mental growth, especially when they occur in the infant, toddler, and preschool years. Giving children adequate diets is a way to fight mental retardation, even if it does not actually lower blood lead levels. The CDC recommends giving pureed meat to infants as soon as they are developmentally ready, and giving red meat to children once a day. Dairy products and fruits or fruit juices several times a day are also recommended. (Minimizing fatty snack foods is also a good idea, in that it will increase children’s appetites for nutritious foods that may be of less interest when calorie-rich snacks  are available.) In order for many parents to assure good nutrition to their children, they need to have not only enrollment in WIC, but access to grocery stores that offer a variety of foods at reasonable prices.

To ensure that each child reaches the highest intellectual level he or she is capable of, high quality preschool programs are of great importance whether or not children have elevated blood lead levels, and it’s possible that such programs can make the difference between moderate retardation and fairly normal achievement for some children, if they are combined with other ways of treating lead exposure. The CDC document also suggests that developmental monitoring is needed for older children who have had elevated blood lead levels in early life. These need to continue into school age, with times of transition like first grade, fourth grade, and seventh grade getting most attention. Children who are inattentive and distractible will need help in order to have the maximum benefit from school.

To summarize, we have a number of ways to encourage good development in children who have been exposed to lead. The lead exposure may be “irreversible”, but a poor developmental outcome is not inevitable, and the worrisome trajectory present when no interventions take place can be reversed to a greater or lesser extent by help we know how to provide. What is needed, of course, is the political will and the funding to put these interventions in place. In the case of Flint, if the right decisions are made, the interventions could begin almost at once, while replacement of water pipes will take years. Similarly, when lead exposure comes from old paint, interventions can be of help now, while actually removing lead from houses can take many years—the process, indeed, can create even more dust and lead exposure than already exist. 
  
Do I hear any candidates for president talking about this? Not really…



Saturday, February 27, 2016

Apparent "Parental Alienation" and the "Chameleon Child"

 It would be silly to claim that no parent ever caused a child to be alienated from and to reject contact with the other parent. This can be done inadvertently, as when one parent is afraid of the other and an infant sees this through social referencing, or it can be done intentionally with the goal of hurting the other adult. However, it is not silly to consider that the apparent alienation of a child, with refusal to be with one parent, can have a wide variety of causes. That range of causes is not so easy to explore, and a parent who feels rejected may readily assume that any problem is of the other parent’s making.

Benjamin Garber has discussed one possible situation, in which each parent believes that the child fears and wants to avoid the other parent. He calls this pattern the “chameleon child” (Garber, B.D. [2014]. The chameleon child: Children as actors in the high conflict divorce drama. Journal of Child Custody, 11,25-40). The point of Garber’s discussion is not to blame children, but to consider that they are not simply passive recipients of parental pressure. Rather, they actively involve themselves in an uncomfortable situation and attempt to adapt themselves to the situation, and the situation to themselves. In pointing this out, Garber follows (without mentioning it) some important principles of modern developmental psychology. One of these principles is that the effects of family experiences are not just bidirectional but transactional: parents and children affect each other, and the ways in which they do this change over time. The second is that children’s own characteristics can influence the ways in which experiences affect them. This is most often discussed in terms of the ways a child’s genetic make-up and her experiences interact to change developmental outcomes, but it can also be considered with respect to the ways a child’s needs may evoke responses from caregivers, or the ways a child may actively seek to get from caregivers what he or she wants; in either of these cases, the child can also be influenced by the caregivers’ responses.  

The “chameleon child”, according to Garber, is one who tells the father how much the child likes to visit him, and what bad things the mother does. The same child does the reverse with the mother, praising her and criticizing the father. For both parents, the child cries and resists going to the one she is not presently with. Each parent is convinced that the other parent is mistreating the child and that the child hates and rejects the other one.

What is going on here? Is the child simply a wicked little creature who lies and likes to cause trouble? No--  a much simpler and more accurate statement would be that the child wants both parents and wants to have them together. The child wants both parents to love him, so he tells each one what that parent seems to be fascinated by hearing: 1. How much the child likes to be with the present parent, and 2. What bad things the other parent does. This line of conversation gets the deep interest and attention of whichever parent is hearing it at a given time. The child does not imagine that parental conflict is heightened by the stories told to each parent. On the contrary, he may imagine that the conflict is just about him, that one or both parents don’t like him so much and that’s why each is with him for only part of the time, and that if he can get them to like him more, they will reunite and both be with him all the time.

What about the parents? Are they trying to cook up some attack against each other? They may be, but chances are that they, and their attorneys, and their therapists, are all just suffering from the same confirmation bias that all of us have to fight. This means that they (and we) are ready to hear and remember information that supports a way of thinking that we already have, and ready to ignore or forget anything that confuses us by contradicting or only partially supporting our existing assumptions. For each one, the co-parent is a person who is unreliable, or unsympathetic, or sneaky, or cruel in some way--  if it were not so, they would not have separated, and that is the opinion of both the “one who left” and the “one who was left”. That such a person might mistreat a child in some way seems fairly credible, and anything that supports the idea that mistreatment has actually happened fits beautifully into confirmation of this  assumption. In addition, of course, each of the parents sees himself or herself as a protector of children, and to find that someone else treats the child badly and should be stopped is an event that confirms the bias about the self as well as about the other adult. These biases are so powerful that most parents do not investigate further or seek other information to help them decide whether a conclusion is correct—and this may be true of the attorneys and the therapists as well.

Garber recounts an anecdote that shows how confirmation bias can not only lead to the wrong conclusion, but can interfere with seeking stronger evidence about an issue. A four-year-old girl returned from a visit to her father and announced cheerfully to her mother, “Daddy showed me all about sex!”. The mother was flabbergasted, but not altogether surprised--  after all, we all know about pedophiles, don’t we? After a restraining order and much consulting and investigation, it turned out that the father had taken the girl to a museum with an entomology exhibit. He showed her all about, not sex, but insects. The child was obviously safe and happy, but the mother’s confirmation bias prevented her from asking a few questions about this “sex” business, which might have revealed that butterflies and moths were the real topic.


That child’s “chameleon” position came to be when the mother misunderstood or misinterpreted a statement that everyone would agree to be ambiguous at the very least. But a number of children provide fodder for their separated parents’ confirmation biases by adapting their behavior to what a parent seems to want to hear, praising the present parent and criticizing the absent one. Like real chameleons, the children make themselves safe and comfortable by doing what the social environment signals them to do, in ways that are no more antisocial than telling Aunt Lily you like your birthday present when you actually don’t. We want children to have these skills of social adaptation. We also want to know if anything bad does happen to them. For the best outcome, then, we need for co-parents, attorneys, and therapists to examine their own confirmation biases and seek all the factors that may determine a child’s attitudes and statements, rather than leaping to either the parental alienation or  the child abuse conclusions. 

Friday, February 26, 2016

Why Some People Who Should Know Better Still Assume That Reactive Attachment Disorder Involves Violent Behavior

Both professional journals and little independent blogs like this one have been stating for years that Reactive Attachment Disorder may be accompanied by aggressive behavior, but it is not the cause of that behavior, nor is aggressive behavior a symptom of the disorder. The last word about this was thought to have been said by the joint task force on Reactive Attachment Disorder of the American Psychological Association, Division 37, and the American Professional Society on Abuse of Children, headed by the late, much-respected, Mark Chaffin (Chaffin et al, 2006).  

Nevertheless, both parents and mental health professionals continue to assume that “the list” promulgated by attachment therapists, including not only aggression, but “fascination with blood and gore”, cruelty, and unwillingness to make eye contact on the parents’ terms, is an accurate description of Reactive Attachment Disorder. This is even evident in master’s and doctoral theses, which are presumably approved by a committee whose members are regarded (by someone) as knowledgeable.

Why? Why doesn’t this trailing edge pass over us? There are lots of reasons why people believe foolish things, and no doubt they all apply, but there is more to it than that. The problem I want to point to today has to do with the failure of editors and reviewers to properly monitor publications in professional journals, and the resulting publication of inaccurate and misleading claims.

Let’s look at three such publications that I stumbled across while looking for something else.

  1. Taft, R.J., Ramsay, C.M., & Schlein, C. (2015). Home and school experiences of caring for children with Reactive Attachment Disorder. Journal of Ethnographic & Qualitative Research, 9, 237-246. [these authors appear to work in special education and curriculum]
Taft et al state that “Children with RAD demonstrate significant and often dangerous behaviors..” (p.238). They follow this statement with a reference to the DSM-IV diagnosis, but without noting that none of the DSM editions refers to dangerous behavior. In a later paragraph, they reference an attachment therapy practitioner as saying (incorrectly) that children with RAD defy traditional treatment , and then go on to say that the Chaffin et al (2006) APSAC-DIV 37 task force reported that “some RAD children exhibit extreme disturbances”—whereas in fact Chaffin et al acknowledged that extremely disturbed childhood behavior is possible, but did not connect it with RAD. Later, Taft et al describe the children as “very intentional” about threatening or inappropriate behaviors, and state that concerning behaviors are purposeful and directed toward targets rather than the results of temper tantrums or responses to specific triggering circumstances. These statements were based on interviews with parents, most of whom attended a RAD support group (where presumably they told each other these stories and perhaps competed to be the bravest or most martyred parent). The paper’s reference section includes Nancy Thomas, a major promulgator of inaccuracies about Reactive Attachment Disorder, and Michael Trout, a member of APPPAH and believer in prenatal attachment.

  1. Shi, L. (2015). Treatment of Reactive Attachment Disorder in young children: Importance of understanding emotional dynamics. American Journal of Family Therapy, 42, 1-13. [this author is a marriage and family therapist]
Shi describes the case of a four-year-old boy, prenatally drug-exposed, and fostered by a sequence of five families, one of which was said to have chained him to a table. The current foster parents at the time of writing had three bio children and two other foster children in the house as well as this child; the foster mother ran a day care in her house while attending community college part-time. The father wanted to give the child up, but the mother resisted this. In spite of some obvious environmental problems past and present, Shi diagnosed the child as having Reactive Attachment Disorder. Shi stated that the child fit the “classic” RAD picture as described in DSM-IV-Tr, and then immediately proceeded to describe the child’s relevant behaviors, none of which are described in the DSM discussion.

The behaviors in question were, first, “a persistent fear state. He would eat non-stop when food was on the table and would not stop eating until he was forced to. He would steal food and hide it in his bedroom. He would eat garbage… shampoo and charcoal.” [N.B. these statement were exactly as I have given them here, with no evidence of a persistent fear state actually being given—JM].

A second category of behaviors was “dysregulation of affect. He urinated on the carpet when he was upset. …He broke toys on purpose, left holes in walls…ruined furniture, abused family pets, bounced on his two-year-old sister… He would not show emotions when hurt or injured but would cry dramatically over small, insignificant things.” The connection between urinating on the carpet and dysregulation of affect was not made, but as was the case for the fear state, neither the categories nor the specific behaviors are discussed in DSM.

A third category was “avoidance of intimacy…any attempt at physical contact would result in his screaming at the top of his lungs. He had no tolerance for anything soft or comforting. He… slept on a bare mattress. He would fake emotions from time to time yet any genuine feelings and emotions were scarcely observed.” Shi did not comment on how it could be detected that the child was faking an emotion, or how reluctance to lie on bedding was equated with avoidance of intimacy.

Treatment involved play therapy sessions, plus the prescription of ten minutes one-on-one with the foster mother every day. (The foster father also left the home, a factor that was not further discussed.) In an outcome described as “magical” and a “miracle”, after 16 sessions the child got a lot better and maintained his gains over several years, during which the foster mother worked to adopt him. Certainly the therapist and foster mother deserve full credit for their commitment and their work with this child, but the assumption that they were “treating RAD” was never justified.

  1. Stinehart, M.A., Scott, B.A., & Barfield,H.G. (2012).  Reactive Attachment Disorder in adopted and foster care children: Implications for mental health professionals. The Family Journal, 20(4), 355-360. [the corresponding author is in a department of counselor education]
From the abstract onward, this paper shows serious confusion about the nature of Reactive Attachment Disorder  and about the development of attachment. The title refers to RAD, but the abstract speaks of disordered or disorganized attachment. In reality, disorganized attachment behavior is a category used when assessing toddler attachment by means of the Strange Situation. Young children with disorganized attachment behave in unusual ways when reunited with the mother after a brief separation, freezing in place, falling to the ground, or backing toward the mother. The mothers may look frightened of the children and are often suffering from traumatic experiences. This kind of behavior is by no means a positive sign or a predictor of excellent development, but neither is it a symptom of a clear-cut pathology or of Reactive Attachment Disorder. Disorganized attachment reveals a situation in which both mother and child are in need of help to recover from trauma, but it need not be associated with separations or with abusive or neglectful treatment of the child; Reactive Attachment Disorder is by definition found after situations of neglect (sometimes including abuse) or multiple separations associated with neglect.

Having gotten off to a bad start on this paper, Stinehart et al then compound the problem by stating their inaccurate position on the development of attachment. Here’s what they say: “even before birth, a fetus begins to form an attachment to the woman carrying it. After birth, an infant will display an almost biological need [?—JM] to attach to a primary caregiver, typically a mother… [this relationship] is consistently strengthened as a child is comforted when scared, fed when hungry, and in general is made to feel safe and secure. An infant will seem to seek an unbroken gaze into the caregiver’s eyes and may attempt to mirror the caregiver’s facial expressions…”. The authors next repeat their problem from the abstract, by referring in one paragraph to disorganized attachment and proceeding in the next to discuss RAD, implying without either argument or evidence that the first is to be identified with the second. Finally (for the present purposes), Stinehart et al list a series of symptoms that they declare to be part of Reactive Attachment Disorder: early feeding problems, colic, failure to thrive, food hoarding, gorging, and pica, lack of impulse control and of empathy, tantrums, depression, inattentiveness, antisocial actions, cruelty, etc., all as seen in various on-line lists but not in DSM.

To comment briefly on these claims: 1. Attachment does not begin before birth; 2. Attachment is thought to develop as a result of the enjoyable social interactions that usually accompany the caregiving routines mentioned by Stinehart et al. 3. Infants do not make a great deal of eye contact until at least 4 or 5 months of age. 4. When they do make eye contact, the unbroken gaze is only a few seconds in length, as the child looks away to other parts of the face or to other objects, then returns to mutual gaze briefly. 5. Mirroring caregiver facial expressions occurs within a day after birth in the right conditions, and is probably far more important in attracting the caregiver to the baby than in establishing the baby’s attachment. 6. Need I say again that although disorganized attachment indicates a relationship that needs support, it is not the same thing as Reactive Attachment Disorder? No one has demonstrated a connection between these two behavior patterns. 7. Once again, although children may display all the problems on the list, and need help if they do, these problems are not symptoms of Reactive Attachment Disorder.

How did these three papers get published? One reason is that professionals trained in fields that do not involve child mental health have convinced themselves that it is easy to pick up a developmental psychology background that has been missing from their studies. But, more directly and importantly,  journal editors in those fields, who cannot be expected to  know all the material relevant to every submitted paper, err by choosing reviewers who are also untrained in child development. Thus, there is approval of publication of claims that contradict established information and favor pseudoscientific views of children’s mental health. Once publication has taken place, there is no recalling the material, even when an editor revokes a published paper; it stays somewhere on the Internet as a “peer-reviewed” publication. (Unfortunately, this is all too often right, as the reviewer is apparently an equal of the author with respect to understanding the issues.)


Editors and reviewers for guilty journals  need to do a better job. Allowing misinformation to be published is harmful to children and families in ways that are difficult to undo once they have occurred.
 

Thursday, February 25, 2016

What Happened to the Caged Vasquez Children? A Little Bit of News

It may be that most readers do not remember the 2007 trial of Sylvia Jovanna Vasquez, an adoptive mother in Santa Barbara, California, on charges of mistreating her children. According to testimony, Vasquez had kept three of the children (then 13, 9, and 6) in cages with buckets for sanitation and had limited the quantity and variety of their food. A fourth girl was treated very well--  except that arrangements were made for her to receive injections of Lupron, a drug used to treat precocious puberty and delay development. (Because she was already 12 years old, whatever signs of puberty she showed were certainly not precocious. In addition, nude photographs of her were found.) In spite of evidence of mental disturbance (see www.independent.com/news/2007/jun/07/fighting-hand-bleeds-you/ ), Vasquez had been permitted to adopt these children--  and she ran a day care center as well. It was an altercation with a worker at the day care center, and Vasquez’ threat to have her deported, that led the worker to report the mistreatment of the children to authorities.

Santa Barbara judge Frank Ochoa heard Vasquez’ claims that she had simply been following the directions of a book by Nancy Thomas that was recommended to her by a caseworker and a psychologist, and he told her that if she would explain exactly what had happened, he would give her the minimum sentence. But by the time the trial was done--  and especially after the cages were brought into the parking garage under the courthouse and Judge Ochoa actually crawled inside one—he expressed regret that he had made that commitment. Incidentally, although Vasquez was forbidden to communicate with the children, who were in foster care, during the trial, she did so through notes in books.

Vasquez was finally sentenced to one year in prison plus years of probation, over the objections of the prosecutor, but in line with the promise Judge Ochoa had made. Because she had already been incarcerated for 6 months during the investigation and trial, she actually served only 6 more months after the conviction. The children remained in foster care and information about them was very properly not available to the public.  

Nine years later, the children are about 22, 21, 19, and 15 years old, respectively. Nothing appears to be known about the older two, but there has recently been news about one of the caged girls. Nineteen-year-old Cynthia Vasquez is working at the shelter where she was taken by authorities when the children’s situation was first revealed (http://www.keyt.com/news/caged-child-abuse-survivor-speaks-out/38138980 ). Cynthia commented that as a child she just assumed that what was done to her was supposed to happen, that it was part of the experience of an adopted child and would eventually be over. However bizarre it seems to us to have a child live in a cage and eat raw eggs, it was probably no more bizarre or improbable than anything else that had occurred in Cynthia’s life until that time--  a point we should keep in mind when we think how abused children try to make sense of their mistreatment and why they may be emotionally attached to their abusers.

Vasquez claimed that she needed to cage and starve the children because they had “attachment disorders”. It is hard to know what she was thinking, but she seems to have accepted uncritically the claims of Nancy Thomas and others that any child who has been abused and/or separated from the birth mother must perforce have “attachment disorders”, that these children may appear to behave perfectly normally by means of their cunning and skill at exploiting other people, that they must be treated in order to prevent them from becoming dangerous, and that the treatment involves the total assertion of adult authority.  Like Thomas, Vasquez placed this “treatment” as the top priority for the children’s care, so she did not send them to school--  education being, as Thomas has put it, “a privilege and not a right”, and of course this action prevents the treatment from becoming known to nosy teachers and unsympathetic social workers or neighbors.

I am not bringing up this case in order to intrude further into Cynthia’s life or the lives of her brother and sisters. I simply want to point out that, contrary to the beliefs of Thomas & Co., Cynthia obviously understands cause and effect relationships and has a strong empathic response to children in the shelter. These capacities she developed in spite of her exposure to the Vasquez version of Nancy Thomas methods, not because of them.

In all candor, of course, I would like very much to know what has become of all of the children (if I recall correctly, the boy had been sent to a Utah boarding school), how they are doing now, and not least, what has Vasquez been doing during her period of probation? If she has managed to get involved with children, that is something that should be made public.