Concerned About Unconventional Mental Health Interventions?

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

Monday, September 19, 2016

When Threats Substitute for Therapy

Changing oneself through legitimate psychotherapies can be hard work – work of the kind that adults can decide to do, but work that most children and even adolescents are not mature enough to manage. Child psychotherapies usually offer gentle though concentrated guidance in the direction of changes that adults think will be good for the child. The child does not necessarily think the changes are needed and may not really understand change processes, so treatments must be pleasant to experience, and any hard work must be encouraged and thoroughly supported by the therapist.

Of course, people can be made to change their behavior in ways other than their own hard work or gentle guidance. They can be threatened with punishment or unpleasant experiences unless they straighten out. If a person is capable of changing voluntarily, threats can be an effective change agent, and they work that way in most of our everyday lives. I’m looking for a parking place--  there’s a good one--  but there’s a sign that threatens me with having my car towed away if I park there. The threat makes me change my planned parking behavior.  Or, I don’t want to take time to go to the doctor and get a flu shot—I’d rather go for coffee and gossip. But I had flu once, and the threat I perceive of catching it again is enough to change my behavior. Even preschool children can respond to clearly-stated threats of unpleasant experiences in the near future: “If you hit your sister, you will get a time-out”.

Do threats make up any part of normal therapies? No, they don’t, and therapists generally are uneasy about situations where there is an implicit threat to a client--  for example, a court order to seek treatment. But there are unorthodox treatments for children where threats are used, and those threats may bring about behavior change if the child is able to make such a change voluntarily.

The classic case of threats as part of an unconventional treatment is “holding therapy”. Children receiving this treatment were (and perhaps still are) threatened that if they do not “work hard”, their parents will abandon them and simply leave them at the treatment facility. The children do not know that such an action would be child abuse and would create serious legal repercussions for the parents; even voluntary legal termination of parental rights is quite difficult and subject to continuing financial responsibility for the child. Children in holding therapy may also be assured that if they do not change in some way, they will end up by killing someone and will spend their lives in prison. Adults may know that these are not realistic threats, but children do not know that and are terrified of the outcome, especially if they do not know how to change or even what needs to be changed.

I recently received a long email from a young woman I’ll call Polly. She is 17 years old, has finished high school, and recently went to court to become legally emancipated. But her emancipation petition was not Polly’s first experience with the courts. Her parents, who are divorced, have become locked into an accusation of “parental alienation”—the idea that Polly and her sister, who preferred to live with their father and avoid their mother’s household and her boyfriend, must have this preference because their father had “brainwashed” them into believing bad things about the mother. (Proof of this claim was that the girls insisted that it was their own decision!)

Polly’s mother contacted a California therapist whose psychology license had been revoked but who said he could practice a “psychoeducational” method called Family Bridges. As is the case for many proprietary treatments, it is not easy to find a description of Family Bridges. However, Polly has described what happened to her and to her younger sister when a judge ordered the girls to travel from their home state to California and to participate in Family Bridges.  

According to Polly’s report, when the girls tried to refuse, they were taken away from the courthouse by employees of a “youth transport service”. (These “services” and the little regulation they undergo were discussed by Ira Robbins at www.americancriminallawreview.com/files/7714/0539/9315/Robbins.pdf.) The transporters responded to Polly’s crying and lying down on the ground by telling her that her father would go to jail if she didn’t go, and hinting that she herself would be confined in a residential treatment center. The two girls were taken to a town in California, where they were met by their mother, the mother’s boyfriend, and several psychologists, who met them in a hotel room and apparently do not have an office. The plan was to provide the girls with treatment that would convince them that their father had made them think that their mother was abusive.

The treatment, or “psychoeducation”, consisted of watching and discussing a number of video presentations. These included material about visual illusions, about how people may express opinions that are not really their own because of social pressures, and about the well-known study by Milgram in which participants who believed they were giving other people serious electric shocks often continued to do so when ordered by an authoritative experimenter. The implications of these presentations were apparently that the girls should understand that opinions they thought were their own had actually been created in their minds by their father—a plan with its own logic, perhaps, but not one based on any evidence that deeply emotional beliefs can easily be changed, nor indeed on any evidence that they had been influenced in their opinions by the father.

At almost 18, Polly was almost four years past the age when adolescents are normally given the chance for informed consent to medical or other therapeutic procedures. Instead, threats were used to force her cooperation, and her concerns and opinions were ignored. The threats came into the picture when Polly continued to be resistant and to speak rejectingly to her mother in spite of this “treatment”. According to Polly, one of the psychologists told her, “If you continue that behavior, you will be sent somewhere else. You seem like you need more help than we can give you”—superficially an offer of help for a vulnerable person, but in essence a threat of further disruption to her life. Arrest was threatened if she did not mind her mother, and for several days both girls were told that if they did not cooperate they would go to a treatment facility for juvenile offenders or to wilderness therapy--  these both being situations where teenagers are held incommunicado, have no opportunity to report abuse, and live in austere, even dangerous conditions. Back at the mother’s house, too, incarceration in a residential treatment center was the threat used to obtain obedience.

If Polly had not succeeded in her emancipation petition, or if she had been much younger, no doubt her behavior would have continued to be manipulated by threats--  and perhaps some of the threats would even have been acted upon. What if her behavior had changed in response to those threats? Would that have indicated that the “treatment” was effective—or simply that people respond at least temporarily to sufficiently serious threats?

One other question: when people are trained to do interventions that in practice include threats, are they trained in effective threatening?



Wednesday, September 14, 2016

If It's Not RAD, What Is It? Disturbing and Aggressive Child Behavior

For some years now, this blog has featured correspondents and me going around in circles about Reactive Attachment Disorder. I comment that symptoms of RAD do not include aggressive or dangerous behavior; correspondents then reply, “Are you saying my child does not behave aggressively? Of course he does! That’s how I know he has RAD.” I then say I am not arguing about the child’s behavior, just saying that this behavior has nothing to do with attachment and can’t be treated with efforts to strengthen attachment, even effective ones--  and around and around we go in our merry disagreement.

Occasionally I’ve pointed out that the behaviors these parents mention actually belong to disorders other than RAD, for example Oppositional Defiant Disorder, and that they may be associated with ADHD too. I haven’t really gone into much detail on this, but today I would like to say more about it, drawing information from an article titled “Narcissism and callous-unemotional traits prospectively predict child conduct problems” (Jezior, McKenzie, & Lee [2016], Journal of Clinical Child and Adolescent Psychology, 45(5), 579-590). Jezior and her colleagues focused on conduct problems (CP), which include oppositional defiant disorder (ODD) and conduct disorder (CD). These problems involve behavior like hostility, defiance, aggression, and property destruction. They are associated with callous-unemotional (CU) personality traits such as low empathy, lack of guilt, and shallow emotions, which also tend to go along with severe and persistent externalizing problems—behavior that expresses anger and resentment. CU traits are highly heritable, a fact that helps to explain how difficult they are to correct—if these problems did not result from experience, a change in experience will not so readily alter them.

Jezior and her colleagues also looked at narcissism in childhood as a factor in conduct problems. This disorder is characterized by bragging, thinking oneself better or more important than other people, and making fun of others, behaviors that are associated with ADHD, ODD, and conduct disorders.
Jezior’s group looked at boys (mostly) between  6 and 10 years of age to see whether their behavior at a first measurement was a good predictor of  conduct problems some years later. In fact, two years after the first measure ,increases in ODD and CD symptoms were related to earlier narcissism and CU traits.

 *** But let me make one note for readers of this blog: these researchers were not looking at preschool children. Younger children are well-known to their parents and teachers for their ready anger and aggression, their selfishness, their inappropriate bragging, their self-importance, and their tendency to ignore or fail to recognize other people’s needs. By age 4 or 5, some children may be more noticeable for their delays in mastering all these undesirable, antisocial characteristics, but the great majority will also still be struggling with their impulsive natures. It is not until school age that we begin to see real individual differences in narcissistic or callous-unemotional traits, so parents should not generalize from Jezior’s study results to thinking about preschool children. It remains to be seen whether preschoolers’ characteristics can predict their later antisocial behavior.

Jezior and her colleagues suggested that early assessment of CU and narcissistic characteristics could be beneficial, in that with early diagnosis, early treatment could begin before adolescence. They noted that detailed assessments might help determine the best form of treatment for conduct disorders. But do existing treatments actually help mitigate conduct disorders and help to decrease further development of problems? Ollendick et al carried out a randomized controlled trial of two treatments, Parent Management Training (PMT) and Collaborative & Proactive Solutions (CPS). Readers should note that each of these interventions works with parents and children together to diminish oppositional behavior--  these are not just attempts to “fix” the child and to give the parent a break. Children aged 7 to 14 were randomly assigned to either PMT or CPS or to a waiting list control group. Both PMT and CPS had better outcomes than the waiting list group, with about 50% judged to be either  much or very much improved, and maintaining their gains six months later. But not only is it notable that about 50% did not improve—in addition, Ollendick et al referred to such weaknesses of the study as the small groups and the number of families who dropped out of treatment. They noted also that younger children responded better to treatment than older ones.
A review by Bakker et al (“Practitioner review: Psychological treatments for children and adolescents with conduct disorder problems—A systematic review and meta-analysis.” Journal of Child Psychology & Psychiatry, 2016; epub Aug. 8) looked at 17 research articles dealing with 19 interventions and reported small effects on reduction of conduct disorder, but pointed out that many of the reports did not provide enough information to assess.

This is all a bit discouraging, of course. It seems that conduct problems can be identified early (although not in the preschool period, when antisocial behavior is to some extent the norm), and that some interventions working with children and parents together can have positive effects. However, the nature of the problems, with their genetic component, means that a “cure” is not likely to emerge. What can be helpful is to realize that these behavioral difficulties are not associated with attachment experiences, are not part of Reactive Attachment Disorder (though they may exist side-by-side with RAD), and are most unlikely to respond to efforts to change or strengthen attachment.  


Sunday, September 4, 2016

Worried About Whether Your Baby Looks at You? Take a Developmental Perspective

Dr. Seuss was so right when he said “a person’s a person, no matter how small.” But he forgot to say that a person who is small is not exactly the same person he will be when he gets bigger. Remembering that fact can help parents of young babies who get worried sick when their babies don’t behave in ways that are much more characteristic of older people. To know what’s going on with any big or small person, we need to know where that person is developmentally.

Every week or two, I get a query from a frantic young parent who is terribly concerned that her baby, somewhere in age between birth and three months, does not make enough eye contact or even seem to be interested in looking at the parent. Mothers particularly seem inclined to jump to a conclusion that a young baby will not look at the mother because he does not like her face.


The anthropologist Ashley Montague recognized that babies in the first few months do not pay a lot of attention to what is going on around them. He referred to the first months after birth as a period of “exterogestation”--  when babies continue to develop along the lines they followed in the uterus, but now do their developing outside the mother’s body. Montague pointed out that in fact humans, with our large and complex brains, need a year to develop after conception, but have to be born too early because our big heads could not otherwise fit through the mother’s pelvic bones, thickened as those bones are by our walking upright. Other authors, like Margaret Mahler, have referred to this period as one of “normal autism” because young infants seem to be so self-focused and inattentive while they continue through their first months of development.

During this early period, infants’ behavior is very much affected by what is called their state. This term refers to the effects of a group of variables in the nervous system that determine what behavior a baby is likely to carry out. We adults have “states”, too, but we usually think of them just as being asleep or being awake—though we may also understand differences between REM (rapid eye movement) and non-REM sleep. For babies, there are six states that make a difference to behavior. These are 1. active or REM sleep, 2. quiet or non-REM sleep,3.  drowsy awakeness, 4. quiet but alert awakeness,5.  fussing and high activity, and 6. crying. Of these six states the fourth, quiet alert awakeness, is the one in which attentiveness and learning are most likely to occur.

 For very young babies, states shift rapidly and are poorly organized. There is a lot of sleep, and periods of quiet alertness, when looking at faces and interacting with people might occur, are brief. It can be hard to get a baby’s attention even during one of these brief quiet alert periods, even if some parenting “tricks” like opening eyes and mouth wide while moving toward the baby’s face are deployed. After about three or four months, babies spend more time in the quiet alert state and are more attentive to adults. Their vision also improves over this period of time and they are more able to see in low-contrast situations like dim light or light coming from behind a person’s face.

State issues mean that young babies do not spend much time looking around them, at people or -in looking at other things, but this fact needs to be interpreted in light of the reality that they do not spend much time looking at anything. This changes with further development--  they look more, and it’s more evident that they like faces, as time goes on.

Most of us feel that we’re aware of a special experience when someone makes eye contact with us—a sort of “zap” that’s different from how it feels when they just look in our general direction. But that “zap” is not necessarily a good way to measure whether a young baby has actually looked at somebody. It used to be difficult to measure and record whether a baby did look at a face, so for a long time we did not have really good information about the developmental progress of this behavior. Nowadays, though, there are much better baby-friendly devices that can measure where a baby is looking.

Writing in the publication Child Development Perspectives, the Finnish psychologist Jukka Leppanen  recently reviewed what is known about developmental changes in babies’ looking at faces(“Using eye tracking to understand infants’ attentional bias for faces”, Child Development Perspectives, 2016, Vol. 10 (3), pp. 161-165). The review reported that when babies were given several things to look at, 4-month-olds looked at a face only on 15% of the exposures, but by six months the proportion was 50%. (Adults looked at the face preferentially 90% of the time, not 100%.) Three-to-six-month-olds did not look particularly at faces when face pictures were given in shades of grey. At 6 months, when looking at faces rather than other things 50%, babies did not act as if everything besides faces was the same--  they also showed a lesser preference for looking at upside-down faces, at pictures of body parts, and at animals.

Leppanen also reviewed information about how long babies looked at faces once they had noticed them. Before five months, babies easily move from looking at a face to some other interesting and distracting object. For 5-month-olds, continuing to look at a face when something distracting comes into the picture is done, and happens in the same way whether the face has a neutral or an emotional expression. By 7 months, babies look longer at a fearful face even though some other interesting distracting sight is available. Compared to what a newborn can do, these older babies show great progress in finding faces visually and continuing to look at them without getting distracted.

Parents who are worried about what they think is a delay in looking at faces have often been influenced by Internet material warning them of signs of autism. As we have seen here, it is quite typical for young babies not to look much at faces or “make eye contact”. It’s not until six months or more that this kind of looking becomes more like what adults do and expect, so it’s best not to be too concerned about whether young babies seem to look at faces or eyes.

As for detecting autism in those early months--  well, there is work being done to try to measure whether there are characteristics of very early looking that can tell us whether a baby is likely to be diagnosed as autistic a couple of years in the future, but the work is not finished yet, and this may not prove to be possible.  While we wait, let’s just remind ourselves that babies of all kinds benefit from having cheerful, affectionate caregivers who understand that a small person is not exactly the same as a bigger one.




Wednesday, August 31, 2016

Birds of a Feather: Are Childress and Becker-Weidman Flocking Together?

An interesting remark concerning me has been passed along from someone else’s blog—www.drcraigchildressblog.com. The author of this statement signs himself “Art”. Here is what he says:

Mercer is a founding member of the fringe advocacy group, Advocates for Children in Therapy. See:
http://psychology.wikia.com/wiki/Advocates_for_Children_in_Therapy
It is not worthwhile addressing her “concerns,” as all she wishes to do is have a forum to express her fringe ideas and is never open to a real dialogue, evidence, or support of views other than her own biases.

Now, could it be that this “Art” is Arthur Becker-Weidman, whom I had occasion to mention on this blog a few days ago (http://childmyths.blogspot.com/2016/08/lifes-little-ironies-arthur-becker.html)? Yes, as we used to say in my childhood, it might could be. Of course there are lots of people named Arthur, or even watercolorists who take “Art” as their nom d’Internet. But this one makes an unusual reference to a “wikia” outfit which has allowed Becker-Weidman, often writing as AWeidman, to say whatever he likes about topics like Dyadic Developmental Psychotherapy, which he claims (contrary to all existing evidence) to be an evidence-based treatment. Psychology.wikia is not a part of Wikipedia and does not require the “neutral point of view” (NPOV) that is one of Wikipedia’s characteristics, nor in my experience does it permit editing by all readers.  Interested readers of this blog may like to compare the psychology.wikia articles on Advocates for Children in Therapy and on Dyadic Developmental Psychotherapy with the articles on those topics on Wikipedia.

For the sake of argument, then, let’s assume that the writer “Art” is indeed Arthur Becker-Weidman (curious, though, because he was once quite sniffy when I addressed him as “Art”). What’s he up to? Is he getting into Parental Alienation, like Craig Childress (see http://childmyths.blogspot.com/2015/08/craig-childress-tries-to-drag.html), the advocate of a not-very-plausible connection between parental narcissism and a child’s refusal to visit an estranged parent? Or is he just cross because I called attention to the fact that he is giving a conference continuing education presentation on a topic that all evidence suggests he misunderstands badly?

I don’t know what the story is, nor do I know whether Childress and Becker-Weidman have ever met. It may just be that Becker-Weidman looked around for someone else who objected to criticism from me, and then got on board with what that person was writing on his blog—the basic idea being to answer criticism with a personal counterattack rather than with a factual response. Nevertheless, it’s interesting to think about what these two have in common.

Here are some characteristics shared by these fellows.

1.     1.  Advocacy for treatments that are either little-known or seriously questioned by most professional psychologists.  Childress’ “attachment-based” parental alienation treatment program is not listed either by the National Registry of Evidence-based Programs and Practices (NREPP; www.nrepp.samhsa.gov) or by the California Evidence Based Clearinghouse for Child Welfare (CEBC: www.cebc4cw.org), at least under any name I can think of for it. Dyadic Developmental Psychotherapy, which Becker-Weidman has written about, is not listed by NREPP and received from CEBC a rating of 3 (promising, but not presenting strong scientific evidence).

2.     2.  Publications with problems. Some lack peer review or editorial management and are essentially self-published. Childress’ publisher shares an address with his office. Becker-Weidman’s first publication was with Nova Scientific, an outfit that sends out emails asking people if they would like to edit a book and apparently gets graduate students to do this (I intermittently get mailings from them, usually dealing with topics I know nothing about.) He later went on to the interestingly named “specialty” publisher Wood ‘n’ Barnes. I have to give him credit for finally working his way up to Jason Aronson, though this may be more to do with difficulties of that publishing house than improved material. Becker-Weidman’s history of seriously criticized and indeed retracted journal publications is something I’ve discussed elsewhere. Childress does not appear to have published in professional journals.

3.    3.   Ambiguous backgrounds. Childress’ CV, which he used to have on line but seems to have taken down, shows a lengthy gap in employment and educational enrollment before he emerged as an advocate of Parental Alienation concerns. Becker-Weidman presents or allows himself to be presented as a psychologist, although he is licensed as a clinical social worker. He has a doctorate in human development, a perfectly respectable achievement, but not one that leads to licensure in clinical psychology.  

The two do seem to be birds of a feather, don’t they? I will be watching with interest to see whether Becker-Weidman introduces PA to DDP, or whether Childress gets on the DDP bandwagon.




Wednesday, August 17, 2016

Life's Little Ironies: Arthur Becker-Weidman Instructs ATTACh About Evidence-Based Treatment

I usually avoid looking at the website of ATTACh (Association for the Treatment and Training of Attachment in Children), the parent-professional organization that pushes the belief that emotional attachment is behind most unwanted behavior--  also, that they know how to “fix” this. However, my attention was called to the brochure for ATTACh’s September 2016 conference by a prospective adoptive parent who is being strong-armed to attend. I had a look at it to see what speakers were scheduled. There were some goodies:

Lark Eshleman-- was the therapist for the family of Nathaniel Craver, a Russian adoptee who died, apparently as the result of abuse.

Terry Levy-- one of the old school of holding therapists. He edited a book that included advice to limit quantity and variety of food as part of treatment for Reactive Attachment Disorder.

Michael Trout-- according to lectures he gave for the Association for Pre- and Perinatal Psychology and Health (APPPAH), he believes that attachment occurs before birth and that the fetus is conscious of what the mother says, does, and thinks about. (Yes, just what Scientologists think.)

But the cream of the brochure is that Arthur Becker-Weidman is presenting about evidence-based treatments! This is really quite unbelievable, because B-W has repeatedly published the claim that Dyadic Developmental Psychotherapy is an evidence-based treatment when it is quite clearly not eligible for that category. I won’t get into the whole story here, but it is recounted in detail at http://www.springer.com/psychology/personality+%26+social+psychology/journal/10560/PS2.  (This is free to readers and is the last article in the table of contents you will see.)  I don’t know whether the problem between them was this tendency to make unfounded claims, or what, but it is clear that Daniel Hughes, the originator of Dyadic Developmental Psychotherapy, has cut his former colleague B-W adrift and no longer even mentions their co-authored publications about DDP. I am not sure Hughes ever mentioned B-W’s retracted papers.

 I’ve never completely understood why B-W has made and repeated his unfounded statements about the evidence basis of DDP. Does he actually not know what is required before a treatment can be said to be evidence-based? Or can it be that (not unlike some others) he simply regards the evidence-based designation as a marketing tool that can be used to sell a treatment—and to sell himself as a lecturer and trainer?

 In either case, what on earth is ATTACh doing, allowing him to further entrench himself as a therapist and adviser to adoptive families?  Well… I suppose the answer is obvious. ATTACh is using its annual conference to attract parents and quasiprofessionals and to make them more willing to purchase the organization’s services and publications. ATTACh used to do this by talking about attachment all the time; now they do it might repeating current buzzwords like “trauma” and “evidence-based treatment” (EBT). The connection between EBT and treatment funding /insurance coverage is a value-added factor for ATTACh’s sponsorship of a presentation on EBT—especially one whose past approaches to the issue have been highly problematic.

Is it important for people attending the ATTACh conference to understand what an EBT is? It would be good in a general way if they knew this, of course, but I find it difficult to imagine taking a mixed audience of people who just want to know how to raise adopted children, and trying to convey to them the nature of random assignment to groups, the problem of confounded variables, statistical significance and effect size, and quite a few other things that are involved in deciding whether a treatment should be called evidence-based—in an hour or two. (I make this statement as one who spent some 30 years teaching psychological research methods.) Most people are quite willing to accept testimonials and anecdotes as “evidence” and become bored very soon with any argument saying there is evidence that is more important than personal experience. Also, they don’t like math, and to teach this properly there has to be some math.

If I were running the ATTACh conference—an idea that no doubt would draw gasps of horror from the ATTACh board--  I would organize a presentation about the use of Internet sources to look up evaluations of the evidence for a treatment. Although they are far from perfect, the California Evidence Based Clearinghouse for Child Welfare, the National Registry of Evidence-based Programs and Practices, and Effective Child Therapy all provide extensive resources for checking into whether a child mental health intervention has been strongly supported by empirical work. Adoptive parents who know how to use these websites can spare themselves and their children some regrettable tangles with ineffective or even harmful treatments.

But if ATTACh simply must get EBT into the discussion, let them get a presenter whose history shows that he or she can do the job properly.  




Tuesday, August 16, 2016

Nurture, WEIRDness, and Complications: Do We Influence Our Children?

In 1998, Judith Rich Harris published The nurture assumption, a book that argued that parents had
little impact on their children’s development. This position was most annoying to many parents who
 had worked and worried to provide their children with parenting that (they hoped) would assure them
 with later happiness and success. Like most apparently simple positions, of course, Harris’s claim
 worked well only within certain boundaries. She did not argue that abusive parents and kind parents
 created the same outcomes, just that within a normal range of parenting behavior, what the parents did
was not the major factor determining child outcomes. Other important factors were the child’s and the
 parents’ genetic characteristics, school experiences, peer influences, extended-family influences,
religion, and community and national events.  In other words, Harris argued, on the basis of considerable research, not that parents were not important, but that other factors were quite important at all times and became more important as children got older.

It’s a common mistake to assume that whatever is true at one stage of life will necessarily continue to be true at other stages. Some rules of development seem consistent, but others change a good deal with age.

In addition, the term “developmental bias” is sometimes used to describe the assumption that whatever is happening now is based on events that happened early in life.  Later events can be caused by earlier events, of course, but it’s also possible that some experiences that make a lot of difference to a baby’s behavior may have nothing at all to do with later behavior and development. It might be that later experiences are so powerful that they just wipe out the early effects, or that maturational change causes reorganizations of behavior that leave behind any early events or experiences.  An example is the fact that babies who walk early and who walk relatively late (but within the normal range) really can’t be told apart later--  their walking and other movements are similar, and their early development and experience don’t seem to make any difference. Or, for another example, there are the descriptions from years ago of Russian babies who were swaddled a lot of the time until they were a year old and didn’t get much chance to crawl or pull to stand, yet it was reported that they walked at about the same time as babies who were encouraged to move around. 

The idea that it may be a mistake to assume that early experiences determine development is an important one as we argue about whether parents do or don’t influence children’s development. As Harris noted, there is a lot of evidence that events other than parenting are powerful shapers of children’s behavior and abilities. But at the same time we see increasing research reports that show how parenting may influence very young children.

Here’s an example of this kind of research, by Emily Little, Leslie Carver, and Cristine Legare (“Cultural variations in triadic infant-caregiver object exploration”, Child Development, 87, 1130-1145). Little and her colleagues were interested in the ways parents play with babies by using toys and objects—holding a toy for the baby to see, or helping the baby grasp it. Most of the research on this has been on people in the “WEIRD” population (Western, Educated, Industrialized, Rich, and Democratic), and “WEIRD” adults are known to choose to be face-to-face with babies while playing and to use object play as a teaching tool. Western psychologists have focused on this kind of interaction to the point where we look at babies’ use of social referencing (gazing toward an adult for a cue about a strange object) and joint attention as  essential developmental steps. But Little and her colleagues were curious about whether the rest of the world—the non-WEIRD part—behaved in the same way, and how children might be influenced differently.

Little and her colleagues decided to compare caregivers in the United States with caregivers on the island of Tanna in the Melanesian archipelago, a quite non-WEIRD place where subsistence farming and traditional life go on without compulsory schooling. (Other researchers like Barbara Rogoff have shown how children in this kind of society learn by watching adults more than by instruction.) The researchers looked at three ways the caregivers could interact with the children: using their voices, getting face-to-face and using the gaze to signal, or by physical contact (touching or holding the child, moving the child’s whole body and head, moving the body while holding the head still, moving the child’s body parts). As they played with the babies and the toys for three minutes, the U.S. group used their voices at about the same rate as the Tanna caregivers did. But the two groups reversed their use of visual and physical contacts--  the U.S. group used visual interaction more than twice as often as the Tanna group, and the Tanna group used physical interaction more than twice as often as the U.S. group. And what were the effects on the babies? There were not as many differences in infant behavior as Little and her colleagues had predicted, but the U.S. babies did look at the toy more often than the Tanna babies did—perhaps because of their previous experiences with caregivers who used their gaze to give and receive information. 

When Tanna babies and children later behave in ways that seem to reflect their caregivers’ early behavior, does that happen because of their experiences in infancy? Or are those experiences not nearly as important as their many later experiences, which will reflect the culture they live in? Either of these conclusions is possible in light of our limited information… limited because we see only a few people who move from a non-WEIRD infancy to a WEIRD childhood, and almost none who do the reverse. In either case, we need to remember that early experiences could be overwhelmingly important, or completely unimportant, or any point between—and what’s more, how that works could be different for each aspect of development. Like everything else about development, it’s complicated!
   

        

An Article About Dyadic Developmental Psychotherapy-- Read for Free

The editors of Child and Adolescent Social Work Journal have very kindly selected one of my publications to include in a free on line issue of their journal. The paper is about the growth and development of "woozles"--  ideas that we think are supported by evidence, simply because we've heard about them so often. The woozle example I used is Dyadic Developmental Psychotherapy.

Read it here:

http://www.springer.com/psychology/personality+%26+social+psychology/journal/10560/PS2

Friday, July 22, 2016

Nancy Thomas' Inaccurate Statements About Children and Mental Health

Usually I avoid looking at Nancy Thomas’ website, www.attachment.org, but I was reminded of it the other day and had a look—several looks. And of course, having looked, I want to point out a few of the flaws therein.

Let’s start by looking at Thomas’ comments about Attachment Therapy (www.attachment.org/what-is-attachment-therapy/), which, she says, consists of eye contact, touch, smiles, and the “sharing of sugar between the mother and child”. Yes, folks, it appears that Thomas is still committed to the idea she put forward in the 2000 book edited by Terry Levy (and published, to its shame, by Academic Press). She suggested there that attachment can be created by hand-feeding caramels to a child. Logical? You bet, if you can accept Thomas’ premises. These are 1) that attachment normally occurs soon after birth, 2) that breastfeeding contributes to attachment, 3) that because human milk is slightly sweeter than cow’s milk, milk sugars play a role in attachment, 4) that caramels, which contain milk and sugar, are analogous to human milk, 5) that when a woman hand-feeds caramels to a child, the effect on the child is like that of being breastfed. Of course, attachment does not begin shortly after birth, nor is it especially related to breastfeeding. Although it’s true that human milk is sweeter than cow’s milk, there is no reason to think that its sweetness has more to do with an emotional effect on the child than its protein or calcium contents or the individual flavors that come from what the mother has eaten (and anyway, as I just said, there is no particular connection between breastfeeding and attachment). In fact, this whole argument is simply based on sympathetic magic mixed with the assumption that a mother’s early positive feelings toward her infant are immediately mirrored by similar feelings on the part of the infant.

Attachment Therapy, as discussed by Thomas, requires, in addition to sugar, a “release of rage” over a period of several hours. Thomas’ hero Foster Cline supposed that children in this kind of treatment are angry because of the loss of the birthmother and that their rage blocks the development of a new attachment. He used a hydraulic analogy to suggest that when the children express rage, they then become able to form an attachment. This belief unfortunately contradicts research evidence that expression of anger actually intensifies the anger rather than diminishing it. In addition, the belief that a newborn separated from the birthmother will be angry is in contradiction to everything known about early cognitive and emotional development. On this topic, of course, we need to ask how the “release of rage” would be brought about, and the most likely guess is that it is to be done by physical restraint, shouting, and terrifying the child, as per the rage-reduction therapy of the ‘90s. Although Thomas does not define Attachment Therapy directly in this way, she provides enough cues to convey what she is actually talking about, and allows us to guess what she does in her camps when she takes a child aside for a “tune-up”.

The same page reveals two other incorrect assumptions--  unstated, as presumably the wished-for reader already agrees with them. One is that unwanted behavior of children is of necessity associated with difficulties of attachment--  difficulties that, we are told, can be fixed with caramels and other equally likely methods. The second is that the diagnosis Reactive Attachment Disorder  means that a child is manipulative, aggressive, untruthful, exploitative, and so on. Neither of these positions is correct. Certainly children who show risky behavior may have had few opportunities for attachment, but the same kinds of behavior can appear in children with a good attachment history and clear attachment behavior in earlier life. Also, certainly there are children who are manipulative, etc. etc., and they may have at one time also shown symptoms of Reactive Attachment Disorder (although there is no clear method for diagnosing that disorder in school-age children), but the various undesirable behaviors named are not symptoms of Reactive Attachment Disorder.   
Thomas also repeats a claim that was common among members of Cline’s group in Evergreen in years gone by. She proposes that “traditional therapies” are not only ineffective but actually harmful in cases of undesirable child behavior. On another page, www.attachment.org/therapy-goals/ , Thomas states that “Non-directive play therapy, traditional talk therapy, and sand tray therapy have been proven to either be ineffective with children with RAD or make them sicker.” This is, of course, completely untrue with respect to any usual use of the term “proven”. In order for such proof to exist, someone needs to have systematically compared the outcomes of Attachment Therapy with those of the methods Thomas references, and I can assure you that this has not been done. Indeed, there has never been a systematic study of the outcomes of Attachment Therapy alone. Thomas’ argument is not based on the existence of systematic research, but instead on her belief that if a possible mechanism for an effect can be named, this is as good as having found evidence that the effect occurs. She states on both pages the unsupported belief that being alone with a therapist enables a child to become more manipulative, etc., and thus “sicker”, and that the presence of the mother is essential to prevent this. These assumptions are put forward as evidence that the claimed outcomes occur.

It’s a bit mind-boggling to try to unravel the logical and factual mess presented on www.attachment.org. Unfortunately for their children, those who can’t bear a bit of mind-boggling may fall for the claims of this purveyor of snake oil. And just as regrettably for all of us, reporters who hastily copy Thomas’ claims can and do spread these misconceptions and give free advertising to Attachment Therapists.
   
  



Missouri and Wyoming Take the Wrong Path on Fostering and Adoption

Twenty years ago, the state of Utah opened a can of worms by hiring trainers for adoption caseworkers from a Colorado group who advocated Attachment Therapy (AT) in its “rage reduction” form. Caseworkers were trained to teach adoptive parents that any resistance or disobedience in the children had to be met with physical force in the form of lying with the adult’s whole weight on the supine child. In the case of  Don. L. Tibbets’ adopted  preschool daughter, the child stopped breathing briefly under this treatment, and although Don reported this to the caseworker, he was told that he and his wife had to continue the restraint practice--  on pain of having the adoption stopped. Don (a registered nurse) did as he was told, but when the child stopped breathing again, she could not be resuscitated. Don was sentenced to six years in prison for his role in the death, but as I am sure you can guess, the caseworkers were not punished. 

The Colorado trainers hired by Utah left behind them the seeds of a number of catastrophes, child deaths, and injuries later caused by AT. Efforts at legislation prohibiting this type of treatment for children were successfully fought by “parents’ rights” groups and by AT therapists and clinics that had sprung up. Nevertheless,  the national furor among professional psychologists and social workers, culminating in a task force report strongly rejecting AT in the journal Child Maltreatment in 2006, helped to limit some of the more egregious AT practices in Utah and elsewhere.

But how soon they forget, right? Wyoming has recently arranged for social services training by the Institute for Attachment and Child Development of Evergreen, CO, home of at least one practitioner with AT roots going way back. The IACD website includes a requirement for parents sending their children to this residential treatment center: if the child has ever accused an adult of abusive treatment, a document to this effect must be provided, so that law enforcement and others will know how to respond to claims a child may make while at IACD.   This precaution must cut out a lot of problems like having to investigate whether a child was actually abused while at IACD, and may have appealed to Wyoming social services bureaucrats. As far as can be told from the website and from reports of personal experiences. IACD does not use any evidence-based treatments, so other than convenience and shared philosophies, reasons for choosing IACD training are difficult to find.


According to the article linked here (thanks to Linda Rosa!),

Missouri is now spending public money to send adoptive parents to an ATTACh conference, where they will receive instruction in a range of beliefs advocated by that organization. Although ATTACh, a parent/professional organization that taught AT concepts years ago, has apparently retreated from the belief in physical restraint as an appropriate way to create attachment, nevertheless the organization continues to teach that behavior problems in foster and adopted children are largely based on a failure of attachment, resulting in Reactive Attachment Disorder. Treatment of disruptive behavior, according to ATTACh, requires “fixing” a child’s attachment to an adult caregiver, even though the child in question is years beyond the developmental stage which is the focus of evidence-based therapies that nurture relationships between adults and children. These views are strongly opposed to positions taken by conventional psychologists and certainly do not provide the evidentiary basis that should be required before public funds are expended. Like Wyoming, Missouri is making a big mistake; people in both states have been conned by AT proponents.


I want to comment on one other aspect of the St. Louis Post-Dispatch article. In addition to reporting that parents will be treated to attendance at the ATTACh conference, the piece refers to a program called Extreme Recruitment, which is said to aim at adoption within 12 to 20 weeks for difficult-to-place children, including older and special needs children. Given that it is very hard on children to be unsure of their position in a family, or even where they will be sleeping the next day, and that frequent changes of foster care are to be avoided if at all possible, this rapid path to adoption nevertheless seems to be an invitation to trouble and disruption. Can either parents or children rationally know that they want to proceed to adoption after such a short period? Especially in the case of special needs children, can parents during that time period learn what they should know about a child’s medical, psychological, or educational needs?  Much as a caseworker or a parent may want to close a file, they need to consider the number of cases in which parents say that the child “came home”, all was well, then suddenly the honeymoon was over and the parents complain that no one gave them all the information they needed. Hastening to reach adoption decisions seems like a way to guarantee those kinds of difficulties, with possible dissolution of adoptions, or in the worst cases the informal Internet “rehoming” that has had such ill effects for children. When people are convinced that all problems of fostered or adopted children are attachment problems, and when they believe that they can “fix” attachment and therefore all the other troubles as well, it is easy for them to fall for the idea that speedy adoption will have positive results.  Extreme Recruitment is associated with the Carleen Goddard-Mazur Training Institute, which on its website offers no evidence of any evaluation of the outcomes of this practice, although it uses the word “replication” which would suggest to professionals that some outcome studies have been done--  but in fact seems to mean only that this approach is being tried in several places. Someone in Missouri needs to examine this program under a strong light.