International Concerns with Holding Therapy

The following material summarizes the work of a conference that discussed Holding Therapy and similar interventions as they continue to be used and in fact spread into new territory. The report has been sent to a list of professionals and officials involved with child welfare. Readers are invited to comment and to send a link to persons who may be interested.   

                                  Summary Report of the Meeting

 of the International Working Group on Abuses in Child Psychotherapy, 20 April 2013

            All over the world, psychologists and social workers deplore child abuse and work to prevent it. Paradoxically, however, a small number of mental health practitioners choose to use a treatment that has been described as abusive and has been associated with a number of child injuries and deaths. This treatment, usually called “holding therapy” (HT) (or “attachment therapy” [AT]), uses prolonged physical restraint in various forms as a therapeutic method. HT appears to have originated in the United States but has spread internationally as a treatment for autism and for attachment disorders. In response to the spread of HT, concerned individuals from the United States, the United Kingdom, the Czech Republic, and Russia have formed the International Working Group on Abuses in Child Psychotherapy with the goal of public and professional education about HT and prevention of its use. The group met in London on 20 April 2013. This document summarizes background information and the presentations made at the conference, which without exception argued against the use of HT.

Background

            International attention was attracted to the problem of HT in 2000 when a 10-year-old American girl died in the course of treatment. Other deaths, caused by parents following the advice of therapists, have been less well publicized (Mercer, Sarner, & Rosa, 2003). In the United States, a Congressional resolution rejected the use of one component of HT; the American Psychological Association, the American Psychiatric Association, the National Association of Social Workers, and other groups joined in this opinion. In the United Kingdom, the British Association for Adoption and Fostering passed a similar resolution in 2004. The American Professional Society on Abuse of Children (APSAC) mounted a task force to investigate the use of HT and published a report (Chaffin et al., 2006) rejecting the use of the treatment or related methods. The absence of an evidence basis for HT has been noted (Mercer, 2013).

            In spite of these rejections, practitioners in several countries have continued to use or support HT in its various forms.  The U.S. organization Association for Treatment and Training of Attachment in Children (ATTACh), at one time the leading advocacy group for intrusive HT, has now redefined holding of children as a nurturing approach. In 2010,  Adam Pertman, executive director of the Evan B. Donaldson Adoption Institute, a leading U.S. adoption organization, stated approval in an Institute publication of a HT-based treatment publicized in a made-for-TV movie. In the U.K., professional publications (Howe & Fearnley, 2003; Sudbery, Shardlow, & Huntington, 2010) have argued in favor of HT, and a survivor of the treatment has come forward to describe his experiences (Chaika, 2012) . In the Czech Republic, a form of HT has been promoted by the psychologist Jirina Prekopova, who practiced the method in Germany for 20 years, and who has the support of Jaroslav Sturma of the Czech-Moravian Association of Psychologists. A Russian adoption group recently invited a well-known U.S. HT proponent to visit, and HT books have been translated into Russian.

Forms of HT and their implications

            HT exists in several forms, all of which involve physical restraint of children by adults. The original form practiced in the U.S. (Zaslow & Menta, 1975) was brutally intrusive and is known to have caused at least one adult death as well as death and injury to children. It was originally directed toward treatment of autism but later focused on disorders of attachment as defined by HT proponents. Following the 2000 child death mentioned earlier, HT advocates reworked their methods and reported that holding was done only with the child’s agreement. Both the original and the revised forms were often accompanied by parent and foster parent practices that involved withholding of food and water, limitation of toilet use, demands for hard physical tasks, and other efforts to demonstrate adult authority.

            An alternative form of HT was advocated by Welch (1989) with the encouragement of the Nobel laureate Nikolaas Tinbergen and was adopted by Jirina Prekopova. This method involves restraint of a child by the mother, either in a face-to-face embrace for smaller children or with the mother lying prone on the supine child. The period of restraint lasts an hour or more and is to be carried out every day as a treatment for autism or oppositional behavior. As far as is known, Prekopova’s method is not accompanied by the parenting practices described in the previous paragraph.

            No acceptable outcome research has provided evidence to support the use of any HT form. Use of HT methods involves risk of physical harm in some cases, and risk of a failure to treat serious emotional problems by means of evidence-based practices in all cases.

Presentations at the London conference

            At the meeting of the International Working Group in London, presentations were made by a British social worker and a British barrister, a Czech psychologist and a Czech activist, an American psychologist, and a Russian biochemist with an interest in cult-like activities. It will be notable in the summaries to follow, that two presenters chose to be identified by assumed names out of concern for professional and personal repercussions that might follow their speaking out.

1. “Anya Chaika”, a British social worker and author of Invisible England, discussed a British case in which a boy had been subjected to HT while under the care of a major provider of residential children’s homes. As a teenager, the boy was moved from the residential treatment center to foster care provided by the person who had been his therapist in the center, and was persuaded by her to change his surname to hers. “Chaika” was contacted by the now-adult former patient after becoming aware that the organization was using HT and starting a blog to try to collect information about the practice. The former patient has been able to bring a lawsuit against the children’s homes organization and this suit is in progress.
2. Lucinda Davis, a British barrister, commented on legal issues concerning child abuse of any kind, and ways in which child abuse laws could be used against the practice of HT. Discussing the differences between tort law and human rights law, she noted that British or Czech cases needed to be approached initially as involving torts, with appeal to the European Court of Human Rights possible only after all other appeals were exhausted. As is the case in all the common law countries, the practice of HT can be attacked legally in Britain only when actual harm to the child can be demonstrated or assumed. Physical restraint methods are not in themselves prohibited by law.
3. “Mrs. Alena”, a Czech autism activist, described the history of HT as performed by Jirina Prekopova and her students. Prekopova, who had practiced HT in Germany (where she worked with the alternative psychotherapist Bert Hellinger), returned to the Czech Republic in the 1990s and in 2001 developed a HT working group as part of the Czech-Moravian Psychological Society. A movement against HT began following the broadcast of a documentary film praising the method, but Prekopova has continued to receive the support of the Catholic Church, government officials, the Ministry of Education, the  “Our Child” Foundation, and the president of the Czech-Moravian Psychological Society. Prekopova has created outreach programs in Slovakia, Austria, Mexico, Venezuela, Spain, and Italy.
4. Katerina Thorova, a Czech psychologist, discussed psychological mechanisms that might lead parents to the choice of alternative psychotherapies like HT. Thorova emphasized the role of a social climate that is friendly to occult and pseudoscientific beliefs. She described a wide range of problems for which Prekopova recommends HT, including autism, attachment disorders, attention deficit hyperactivity disorder, oppositional and defiant disorder, and conduct disorder. Prekopova’s presentation of HT has cult-like features, attracts the public by manipulative techniques involving logical fallacies, “global truths”, and false analogies. HT propaganda appeals to emotion and proposes a universal solution of “love” for most problems. Because people are subject to cognitive and confirmation biases, cognitive dissonance, and the desire to comply with authority, they find it difficult to resist the appeal of HT.
5. Jean Mercer, an American psychologist, discussed claims that Prekopova’s HT method was based on scientific evidence. These claims were originally based on the support for HT given by the Nobel laureate Nikolaas Tinbergen, whose ethological studies suggested that specific experiences could direct personality development. In the 1980s, Prekopova and German colleagues published several articles concluding that HT was demonstrated to be an effective treatment, but all of the studies were inadequate in that they had small Ns, the outcome measures were vaguely defined, and the outcome measures depended on parent judgments. Scientific support for Prekopova’s HT method, like that for other HT techniques, is extremely weak, and indeed Prekopova has dropped claims about scientific evidence and today presents religious and spiritual arguments in favor of her practices.
6. On behalf of Yulia Massino, a Russian biochemist who attended by Skype, Jean Mercer discussed the intrusion of U.S. HT advocates into Russia at the invitation of some cult-like groups. The major concern of this presentation was the use of “parenting” techniques adjuvant to HT, as recommended by the HT advocate Nancy Thomas, who recommends the establishment of adult authority by parental control of a child’s food, drink, toilet use, and exposure to cold, heat, or darkness. These methods have been associated with malnutrition and in some cases with child death. Books by Thomas and other HT proponents have been translated into Russian. Nancy Thomas visited and lectured in Russia in 2012 at the invitation of an American Pentecostal minister.

Conclusion

            The International Working Group concluded that HT methods are neither safe nor effective as treatments of childhood mental illness, and that their spread internationally is an alarming phenomenon that should be recognized and countered by professional and parent groups. What can and cannot be done about this problem?

Legal challenges to HT have so far been ineffective in common law countries, where freedom of speech issues are privileged. Professional groups have opposed specific legislation about HT methods, claiming that they can regulate members of their own disciplines. In addition, it is difficult to write legislation that describes HT methods in such a way that a change of language or a minor change in methods cannot evade a prohibition. Where government appears to support HT, as in the Czech Republic, legal challenges would seem of little use.

            Professional and public education on the existence and nature of HT methods may be the most effective way to reduce the use of these treatments. However, in the U.S., efforts by professional groups occurred after a well-publicized child death and diminished within a few years. With respect to the almost-nonexistent public education about the HT problem, it should be noted that HT proponents in several countries have for years bombarded the public with propaganda in the form of television “documentaries” and films, and that journalists have contributed to these persuasive efforts by assuming that statements by HT advocates are accurate.   

            What is really needed is for professional groups to mount a proactive campaign of education about HT, rather than waiting for harm to another “poster child”. This will require the kind of political will that usually exists only when a few members of a group are convinced of the need to solve a problem. Such a campaign needs to direct accurate information to mental health professionals and to take into consideration the emotional arguments to the public that, as Dr. Thorova noted, have been effective in persuading parents to accept HT.   

            The International Working Group has taken a small step in the direction of professional and public education and is now asking mental health professionals and professional organizations to join in this work.

References

Chaffin, M., Hanson, R., Saunders, B.E., Nichols,T., Barnett, D., et al. (2006). Report of the APSAC task force on attachment therapy, Reactive Attachment Disorder, and attachment problems. Child Maltreatment, 11, 76-89.

Chaika, A. (2012). Invisible England. Charleston, South Carolina: Chalk Circle.

Howe, D., & Fearnley, S. (2003). Disorders of attachment in adopted and foster children: Recognition and treatment. Clinical child Psychology and Psychiatry, 8, 369-387.

Mercer, J., Sarner, L., & Rosa, L. (2003). Attachment therapy on trial. Westport, CT: Praeger.

Mercer, J. (2013). Holding therapy: A harmful mental health intervention. Focus on Alternative and Complementary Therapies, 18(2), 70-76..

Sudbery, J., Shardlow, S.M.,& Huntington, A.E. (2010). To have and to hold: Questions about a therapeutic service for children. British Journal of Social Work, 40, 1534-1552.

Welch, M. (1989). Holding time. New York: Fireside.

Zaslow, R., & Menta, M. (1975).The psychology of the Z-process: Attachment and activity. San Jose, CA: San Jose State University Press.

Kathryn Joyce's "The Child Catchers": International Adoption Revisited

I am writing this on an appropriate day in the church calendar, Pentecost--  a day that has connections to the topic of international adoption. What are the connections? I think I’ll save that explanation until after I review Kathryn Joyce’s new book.

The Child Catchers is a serious piece of investigative journalism, and as such follows a number of threads in its analysis of the American enthusiasm for adoption in general and adoption from abroad in particular. In the course of this analysis, Joyce reveals not only the excellent intentions of adoptive families, but the corruption that easily followed when the demand for adoptees grew and the supply of orphans did not.

Adoption, both domestic and international, has a long history. For centuries, families have cared for children who were distantly or not at all  biologically related to them, sometimes out of genuine love, sometimes with the intention of using the child’s services, sometimes in order to insure an heir to family property or position. In Western countries, adoption was formalized legally in the 19^th century and involved laws based on those governing property transfer. Those laws guaranteed that a child could have parents but not two families, just as a house cannot have two owners who are not joint owners.

This was the legal situation in the U.S. when in 1954 Harry and Bess Holt, evangelicals from Oregon, became aware of children in Korea abandoned because they were biracial offspring of non-Korean soldiers. The Holts, who adopted eight of those children themselves, encouraged and facilitated large numbers of adoptions, stating their hope that all the children would become born-again Christians and giving preference to fundamentalist parent candidates. The Holts' efforts eventually gave rise to Holt International Children’s Services, now a major adoption agency and one respected for its ethical practices. As Joyce points out, however, the Holts cut some corners and seemed unconcerned about some bad outcomes for children, as well as accusing critics of being “anti-adoption”. The Holts’ attitudes, Joyce says, began “a long-standing narrative of adoption as a battle between saviors and obstructionists who think they know better”.

This battle intensified after the turn of the 21^st century as evangelical groups in the U.S. began to foster an “adoption theology”. This approach stated an analogy between adoption of children and God’s acceptance (“adoption”) of sinners as part of a divine family. Imitation of God’s acceptance was seen as a Christ-like action and a critical part of a Christian life. The adoption theme derived in part from two important tenets of American religious fundamentalism. The first, the “Great Commission”, referred to the obligation of Christians to spread their beliefs and seek converts, not just to Christianity in general, but to Christianity as they themselves defined it. This obligation for evangelism could be partly satisfied by adopting of children whose birth families were not Christian fundamentalists, and bringing up those children in the belief system of the adoptive family. A second tenet came from the New Testament injunction to care for widows and orphans --  an injunction that was easily adapted to stress caring for orphans by adopting them, rather than providing other kinds of help to poor families. (Incidentally, such children could be counted as orphans if they were without fathers, however many other relatives were caring for them.) Some adoption proponents stated that the connection between a child and an adoptive family had been created by God before the world began, and that seeking the intended child was following divine law.       

Evangelical groups declared that there were more than 100 million orphans world-wide, and that their mission must be to bring these children “home”. The picture painted by this statement was that there were children simply waiting to be taken by adoptive families who would do the work and spend the money to get them. This, of course, turned out not to be the case. Many of the children being counted were in fact living with family members who cared for them. In particular, there were few infants or toddlers, the age group that many parent candidates would prefer to take. Some of the children being counted were street children, some already involved in crime and prostitution. Others were victims of disabilities that could not receive effective treatment in their own countries, but who often had concerned families. When children really had been abandoned, their health was sometimes so poor as to make them unlikely choices for adoption, especially for U.S parents without access to public health care programs.

As the demand for children encouraged by “adoption theology” mounted, and the supply did not, the motivation for corruption increased, and the Hague Convention  and UNICEF attempted to fight this tendency. Joyce describes in detail the problems seen in Haiti following the earthquake, as American evangelical individuals or groups tried to circumvent laws about taking children out of the country.  In Ethiopia, a later popular adoption source, difficulties and abuses arose because of communication problems. Like parents in many other cultures, too, Ethiopians had a very different view of adoption than that established in U.S. law, and neither the parents nor the children necessarily expected the visit to the U.S. to be more than a few years in length. Conflict and resistance to adoption to the U.S. soon developed. As Joyce points out, cultural differences (and perhaps observation) insured that Rwanda did not become “the next big thing” for adoption after Ethiopia.

The Child Catchers focuses on evangelical influences in international adoption because “adoption theology” codified and publicized an act that had been a private family matter in the past. But Joyce does not ignore other factors in the rise in international adoption. One of these was an alteration in attitudes toward single mothers such that few who now give birth in the U.S. relinquish their children for adoption. Changes in laws and attitudes about abortion have also had complex effects on adoption; women who do not terminate an unplanned pregnancy have usually chosen not only to have but to keep the baby, and in addition anti-abortion religious groups have been pressured to offer help to women who might otherwise abort. It may also be the case that relaxation of standards about discussing sexuality has freed infertile couples to adopt children who do not look like them, whereas in the past most sought babies who could “pass’ as biologically related and allow them to keep fertility problems private.

Joyce does not emphasize, but does refer to, abusive treatment of some internationally-adopted children. (She is planning to attend the trial of the parents whose treatment killed Hana Williams, an Ethiopian adoptee, so there may be a book on this topic in the future). Although she mentions some extremely large adoptive families, she says little about the possibilities for neglect and exploitation of children in such large family groups, or about the romanticization of large families by the press, where it’s often suggested that huge families represent some sort of Golden Age of family life and happiness. Another topic that I did not see mentioned was the outcome of the practice of keeping together sibling groups of quite young children, with whom it may be impossible for parents to have enough individual interaction for good development.

Joyce has written about evangelicals and family life in a past book, and I thought that in The Child Catchers she might discuss how adoption may provide a socially-acceptable outlet for the talents and energies of women who are not expected to work outside the home. I did not see any comment on this point and was left wondering what the author thought about it. I would have preferred that discussion to the chapter on attitudes in Korea, which was of interest in itself but did not tie in perfectly with the rest of the book.

So, what about Pentecost? The New Testament describes the first celebration of this traditional festival as including the descent of the Holy Spirit on the small number of early Christians and the giving to them of spiritual gifts shown in their “speaking in tongues”. Most mainstream Christians, and some evangelicals, consider this event to have occurred at the time, but not to be a possibility today. (Secular humanists, of course, consider it not to have happened at all, or at most to be a description of events that had natural causes.) But some evangelicals, as well as a few members of the liturgical churches, believe that the gifts of the Holy Spirit, such as speaking in tongues, discernment of  evil spirits, and deliverance (casting out of evil spirits) are possible today, and as a result they refer to themselves as Pentecostals. Like other evangelicals, Pentecostals have been involved in international adoption, and Joyce references a few of them. She does not point out, however, that Pentecostals may believe that adoption “attracts demons” and makes it likely that an adopted child will need to be “delivered” (exorcised) in order to be mentally and physically healthy. Demons are thought to be attracted to the adopted child, not because of the adoption itself, but because of offenses committed by the child’s biological parents and even grandparents, or because of grief and distress felt by them or by the child. Deliverance of the adopted child from indwelling demons may be a relatively gentle process, but it may also be physically abusive. I look forward to Kathryn Joyce’s report about the death of Hana Williams and hope it will show whether these Pentecostal beliefs about adoption were a factor.     

When Children Lie, Evade, Misrepresent,or Exercise Tact: What's Going On With This "Little Liar"?

Nobody really likes a liar. When an adult lies to us we often have a variety of unpleasant feelings and thoughts: He must think I’m a complete fool! She’s just trying to get her own way dishonestly! They must be crazy to think anybody would believe that story!  Or, more forgivingly, we think: This poor soul is completely mistaken! I should treat him very cautiously, as he must be mentally ill to believe what he’s just said!

On the other hand, we appreciate and approve some forms of lying. A neighbor asks another neighbor how she likes her quite hideous hat, and the second neighbor replies that it’s “interesting” or “really different”. We, who are glad we didn’t get asked this difficult question, may admire the evasive response, which is actually a lie: that hat isn’t interesting, it’s just horrible!

Successful lying requires quite a bit of cognitive skill. The good liar has to think about what the recipient of the lie knows or could know, about how likely the lying statement is to actually be true, and about how people act when telling the truth. He or she also has to be prepared for follow-up questions and be able to answer with verisimilitude. No wonder children are not very good at lying!

When children lie, we are relieved when they are [infrequently] just being tactful. But if it’s not tact, we have the same unpleasant feelings we’d have about an adult, and some extra ones too. In complicated ways, we are deeply disturbed by child lies. We think that children should trust us and be not just candid but transparent in their thoughts when we want to know something about them. When they tell us lies, we think that they don’t trust us, or that in some way they are “not really children”--  not the innocent creatures of our fantasies. Some of us begin to think that if a child lies, there are terrible things in store--  not just lying, but stealing and violence and of course sexual behavior. As a result, people sometimes freak out when they detect a child’s lie.

Here’s an example, sent to me by an acquaintance who is part of a Facebook group that focuses on Reactive Attachment Disorder. The example appears from context to involve an adopted or foster child:

“So the lying in our house is reaching new heights. The last couple weeks have been very interesting. I started using the suggested phrase, ‘You can do X (what we want her to do) or you can choose Y (the consequences of not doing it)’. On Monday she lied to me again and got caught thus she had to walk home from school. I was within 100 yards at all times but she did not know that. We live about 1 km from her school and she was home within 15 minutes.  She was scared poopless!! Both yesterday and today, she tried to lie to me  but I could see it all over her face and I pushed until I got the truth.  It took about 46 mins yesterday and 30 mins plus missed swimming today. She is more afraid of the trouble she will get for doing something wrong than she is of the consequences of lying. Clearly we need to step up the lying consequences!! Tonight’s conclusion got me tho. Remember she is just turning 6. Her response tonight as to why she did what she did was, “Because I wanted to and you weren’t there.” In other words, I did what I wanted regardless of what I knew I should do simply because my mom was not watching me for 2 mins. The action was beyond juvenile and reminded me of when I couldn’t leave a toddler unattended for more than 30 seconds.”

There are so many issues in this statement that I hardly know where to begin. First, when I initially skimmed this, I assumed up until almost the end that the child was 12 or 13. Instead, she is going on six, an age at which most actions are “juvenile” by definition and at which many children have the cognitive breakthroughs to Theory of Mind that let them know  how other people can be confused or distracted by what is said to them--  i.e., how to lie. It’s also an age when children have begun to discriminate between what they want and what their parents want, and to think they should get their own way sometimes. John Bowlby, the developer of attachment theory (not therapy) spoke of this period of family relationships as ideally working toward “goal-corrected partnerships”, in which parent and child negotiate or modify what they each want because they also want to maintain their relationship. It is clear that the mother of the “little liar” was not about to enter into a goal-corrected partnership, however, and my guess is that she believes that her child must submit completely to parental authority in order to “become attached” and develop normally. 

Let’s look at some other problems here. Presumably it was safe for “little liar” to walk a short distance home by herself. It might actually be a good thing for her to develop self-reliance by doing this regularly. But mother has framed this as a “consequence” (read: punishment) and therefore something to be disliked. The child is “scared poopless” as the mother announces dramatically with a couple of exclamation marks that would appear to indicate her own gratification at this. Why is the child so scared, other than the fact that she has been told walking home alone is a bad thing being done to her because she was bad? The obvious answer is that this “consequence” is essentially a threat of abandonment, and thus has terrible implications for an adopted or foster child, who has already experienced at least one abandonment. Mother has chosen something she can envision as a harmless punishment, but it is one that resonates with the child’s deepest concerns and needs--  and mother appears to congratulate herself on having found a perfectly legal way to wreak  serious pain.   

   

When people rely on punishment to manage children’s behavior--  and let’s not beat around the bush, “consequence” means punishment--  they (the parents) often paint themselves into a corner. If they find that punishment doesn’t do the job, they can only think of one alternative: to escalate the punishment. The “little liar’s” mother says so. If the child is more afraid of being caught doing something wrong than of the consequences of lying--  voila, the answer is to step up the consequences of lying. (She would certainly not want to step down whatever punishment the child is so afraid of, would she?)  Whatever punishment people use, and however effective it may be at times, the problem arises when it does not work, or the results are not as quick and complete as desired. Very few parents who are believers in punishment can think of any answer other than intensifying the ineffective punishment. Like “little liar’s” mother, they seek a level of punishment that will be truly distressing to the child, and regrettably may be satisfied by seeing that the child is miserable (“scared poopless!!”) rather than evaluating whether the desired behavior change was brought about by the parental action.

One other thing, before I yield to the temptation to become sarcastic here—what about the mother’s interpretation of the child’s statement that she wanted to do something and “you weren’t here”? Mother has read this to mean that “you must always spend all your time watching me and never have a relaxed moment.” I would suggest reframing this as meaning something like “I want to control what I do, but when there’s no caring adult here I just can’t manage it yet”. Readers who have been teachers may remember Vygotsky’s “zone of proximal development”--  when a child is beginning to master a skill but hasn’t yet got it under control, he or she may be able to do it when an interested, familiar adult is nearby to give support, but not when alone. We often think about this as applying to tying shoes or doing simple arithmetic.but it applies to “behaving well” too.

It seems that “little liar” has told her mother “I need you!” by her fear when walking alone and by her statement that she cannot behave as asked without plenty of support. The mother does not seem to have heard these messages. Instead, she has framed the relationship as a fight to the finish between the child and herself. Unfortunately, whatever the outcome in such a fight, it is the child who loses.

 

Guiding children to understand rules about lying is an important parental job. But, it can’t be done with the approach used by “little liar’s” mother. 

Systematic Maltreatment of Adopted Children: A Federal Case At Last

Many posts on this blog—as well as plenty of other sources--- have described how some adoptive parents in the United States use planful and systematic maltreatment of children in the mistaken belief that painful experiences will teach children to “behave” and to love their caregivers.

The maltreatment in question goes far beyond spanking and may cause real injury or even death. For example, some parents withhold food and drink or severely limit the amount and type of food and liquid available to the child. The same parents may under some circumstances force the child to drink large amounts of fluid or to eat food laced painfully with red pepper or hot sauce. Children may be confined to cages and have their access to toilet facilities limited. Exposure to excessive cold or heat and to hard and tedious manual work may be part of the treatment.  In some cases, beating or whipping are also practiced. This range of “parenting” methods would be judged to be torture if used in adult prisons. The parents, however, appear to be convinced that  these techniques are suitable methods of child guidance and discipline and indeed are necessary to shape acceptable behavior in adopted children from risky backgrounds.

When children are not badly hurt by these forms of maltreatment, it is likely that no one outside the family circle knows what is happening--  especially if children are homeschooled so the surrounding community does not see or hear them. When serious injuries or deaths occur, it becomes much less possible to conceal systematic maltreatment, and parents who have participated in maltreatment have in a number of cases been arrested, charged, tried, and imprisoned. In all cases known to me before now, the cases have been brought in state courts in response to the breaking of state child abuse laws. Frequently, neighbors, relatives, clergy, and social workers or therapists have testified on behalf of the adoptive parents. Over the last 15 years, there have been a number of cases in which a “RAD defense” was mounted, as defense attorneys claimed that the parents’ responsibility should be mitigated because of the challenging mental illness of the children. Without wishing to cast aspersions on state courts, I think it is reasonable to suggest that the local nature of these trials, and the level of misinformation about childhood mental illness, made it possible for public opinion to play a role in reducing the sentences of parents who had done serious harm to adopted children.

As of this last week, a case of systematic maltreatment of adopted children has resulted in the indictment in Federal court of Carolyn and John Jackson, a couple presently living in Mount Holly, NJ. The indictment (www.justice.gov/usao/nj/files/pdffiles/2013/Jackson,%20Carolyn%20and%20John%20Indictment.pdf) charges the Jacksons with one count of conspiracy to endanger the welfare of a child, 13 counts of endangering the welfare of a child, and three counts of assault. The U.S attorney, Paul Fishman, described the Jacksons’ treatment of the children as “unimaginable cruelty”, but regrettably it is all too easy to imagine for those of us who have been attentive to these issues and have seen the same methods used over and over again. The Jacksons employed all the usual ones, withholding food, water, and medical care, forcing red pepper and hot sauce ingestion, and using forced salt ingestion to increase the effect of withholding water. In addition, at least one child was beaten to the point of broken bones. In addition, as has occurred in other cases, the Jacksons’ biological children were maltreated as a result of their parents’ demand that they participate in tormenting the adopted siblings by preventing them from drinking. The children did not attend school, needless to say.

Why Federal court for the Jacksons, when ordinarily child abuse charges are the business of state courts? As it happens, John Jackson was a major in the U.S. Army, and at the time of the maltreatment of the children the family lived at the Picatinny Arsenal Installation in Morris County, NJ. Their actions were thus on Federal property and subject to Federal law. This fact provided the one desirable circumstance in this tragic situation. It is much to be hoped that a trial in Federal court, with all its related resources, will lay bare the realities of systematic maltreatment of adopted children by misguided adults.

It is, of course, probably too much to hope for, that those who advised the parents will also be pointed out to the public. But it is possible that any collusion of adoption caseworkers and the Jacksons (if any occurred) will be revealed. The Jacksons originally fostered the children and later adopted them, presumably giving caseworkers opportunities to understand their belief system before recommending adoption; approval of the adoptions suggests that caseworkers either failed to understand the Jacksons’ beliefs and methods--  or, alternatively, agreed with them. It would be a great mistake to assume that the Jacksons’ system was disapproved by all, as can be seen in the support given them over the last two years by some contributors at www.facebook.com/pages/Support-for-the-Major-John-Carolyn-Jackson-Family-of-New-Jersey/183604398328648.

Got RAD? DSM-V Rethinks the Diagnosis; Maybe You Should Too

As most readers will know, the American Psychiatric Association periodically publishes a new edition of the Diagnostic and statistical manual of mental disorders. Years of work between editions contribute to removal or addition of diagnostic categories, and revision of criteria for particular diagnoses. The differences between older and newer standards make it very clear that mental illnesses--  while very real--  are understood through construction and re-construction of ideas about mood and behavior. Childhood mental illness is particularly subject to construction, because most of our thoughts about it have to do with what we adults expect of children, not how children expect or want to feel.

There  is now a new edition of the Diagnostic and statistical manual of mental disorders. Known as DSM-V, it differs in a number of ways from the previous edition, DSM-IV-TR, which came out in 2000. It’s especially interesting to see what changes have been made in the diagnosis of Reactive Attachment Disorder, a childhood emotional problem. DSM-IV-TR (and two editions before that) described two variations in which RAD could appear. One of them, the inhibited form, involved clinging to caregivers and being unusually shy with strangers. The other, disinhibited form, was one in which toddlers and preschoolers did not seem to have the usual strong preferences for familiar people that most children their age show. They did not seem especially interested in or dependent on familiar adults, and were quite happy to interact with unfamiliar people. Both forms were associated with neglectful or abusive early parenting and with frequent changes of caregivers. The problem behaviors appeared before the children were five years old.

How severe are the problem behaviors? There has been enough research to show that they are not very severe (although of course any child may have multiple disorders, some associated with severe mood and behavior problems). Basically, no significant association has been shown between the “clingy” type and externalizing problems like aggressive behavior. Neither has there been a significant association between the “too friendly” category and aggression. The “too friendly” category is moderately associated with inattention and hyperactivity (see http://sti.mimhtraining.com).

Thus, as is the case for some other difficulties of early development, these two versions of RAD were not so much problematic in themselves as in the developmental trajectories they shaped. That is, except for the possibility of abduction, there are no immediate dangers associated either with being “too friendly” or “too clingy”. However, the clingy child misses many opportunities to learn and develop through contacts with other people, and may find school too anxiety-producing to benefit from attendance, thus getting farther and farther behind in social and intellectual skills, compared to more typical children. The disinhibited, “too friendly” child may miss out on learning about family values and attitudes because of his or her willingness to pay as much attention to outsiders as to familiar caregivers. Over the years of development, either of these extremes will probably produce less than ideal social and intellectual development--  although it’s possible that new experiences may help an individual child move in the direction of typical development.

As DSM-V was prepared, committee members working on diagnostic categories consulted professional discussions of diagnostic approaches and examined empirical work--  in the case of RAD, research on the characteristics of children diagnosed with RAD. They received comments from interested members of the public as well as considering diagnostic categories used outside the U.S. The comments are interesting to examine, as in some cases they were concerned with issues outside the matters the DSM committees focused on. For example, at http://blog.radzebra.org/?p=12, the author Julie Beem stated her objection to a proposed change in the RAD category, the addition of a diagnosis called Disinihibited Social Engagement Disorder:  “The criterion…’persistent harsh punishment or other types of grossly inept parenting’ is alarming… The danger of using ‘grossly inept parenting’ as a criterion is the blame it places on whoever is currently parenting the child. Grossly inept parenting is difficult to define and the words are emotionally loaded. This criterion could actually make it harder for children to be correctly treated, served, or diagnosed because of the stigma of bad parenting. It could lead to the removal of children from safe, loving homes where they are exhibiting these symptoms with their new, appropriate caregivers.” Ms. Beem, like a number of commenters, seems to have missed the point that DSM categories are supposed to be based on systematic research, rather than on the possible impact on caregivers of naïve application of these categories; she may also have been concerned about whether some of the methods encouraged by radzebra.org could themselves be classed as grossly inept parenting. Like some others (see http://center4familydevelopment.blogspot.com), Ms. Beem wanted  the DSM committee to add a new category, Developmental Trauma Disorder, rather than altering the RAD criteria, but although this proposed diagnosis has received much discussion in certain quarters, the research evidence to support its inclusion does not exist.

What did DSM-V actually do in its construction of Reactive Attachment Disorder? The final decision was to split the previously-existing category into two separate diagnoses. Reactive Attachment Disorder is now defined as a lack of or incomplete formation of preferred attachments to familiar people, with a dampening of positive affect that resembles internalizing disorders (for example, anxiety). Disinhibited Social Engagement Disorder is more like ADHD and may occur in children who have clearly formed, even secure, attachments. This fact suggests strongly that treatment for the second disorder need not focus on attachment (although any mental health intervention has a basis in relationship-building).

Has your child been diagnosed with RAD by someone who claims that the untreated disorder will  lead to serial killing? Do you have an inattentive child who has been said to have an attachment disorder?  It’s time for a new diagnosis by someone who understands and uses evidence-based categories.

"Chronic Biting Extinguished": Some Useful Ideas About Toddler Aggression

I want to comment today on a most interesting presentation I attended at a meeting of the Delaware Valley Group chapter of the World Association for Infant Mental Health. Lisa Poelle, author of The Biting Solution (see www.stopthefightingandbiting.com) discussed the complexities of toddler biting and offered some approaches to solving this often-difficult problem. Biting is a behavior that deeply distresses parents and caregivers of toddlers . It can be medically dangerous to the bitee, but even beyond that it has an out-of-control, “animal-like” vibe that causes some degree of panic--  and if it can’t be stopped, children are often kicked out of child care programs when care is essential to the family’s working hours and income.

Lisa differentiated between “garden variety biting”--  the occasional chomp that any infant or toddler may take when teething or just experimenting--  and the chronic biting in anger or frustration that may occur many times a day and that gets children thrown out of child care programs. The first will probably resolve by itself; the second needs help and guidance to help the child get back on track developmentally and to prevent either chronic aggressive behavior or other problems that can stem from constant disapproval and punishment.

Why do children bite, not just once but chronically? It’s all too easy for adults asking this question to fall into the “fundamental attribution error”--  the belief that people do things because of their own internal characteristics. They want to bite! They like to hurt people! They want to control everybody and everything! If we think that these are the reasons why toddlers bite, we probably won’t be able to think of any solution except to make them not want to bite, and to accomplish this by punishing them--  even, classically, by “biting them back”.

The title of Lisa Poelle’s talk, “Chronic Biting Extinguished”, immediately puts a very different spin on the biting problem. By talking about extinction of a behavior (the reduction in its frequency when it is not reinforced), she positions problem biting as a learned behavior. From that point she is able to consider not only how a child has learned to bite, but how he or she can be helped to learn not to bite, but to use more mature social skills instead.

Thinking about chronic biting as learned (rather than something fundamental to a child) also opens up the option of considering the difference between learning and performance. There are many things each of us has learned to do, but we don’t do them all the time. We can perform an action under the right circumstances or refrain from performing it under the wrong circumstances, and all this without having to forget how to do it. If the circumstances--  the environmental characteristics—are altered, our learned behavior can become more or less likely to occur. In driving a car, we ordinarily apply the brake only when we want to slow or stop, but if the rear-view mirror shows a truck barreling down on us, we may tap the brake several times to get the attention of the truck driver.  

Because children too perform in different ways in response to the environment, Lisa Poelle discussed many factors that influence the performance of a learned behavior, over and above the fact that it was learned rather than innate. Her handout (and her book) provided an action plan worksheet that guides caregivers to observe multiple factors that can influence the occurrence of biting--- factors that may not be easily observed by busy adults who are responsible for a number of children. Lisa suggested that only by careful observation of contributing factors can anyone create an action plan that will help a child not only stop biting, but start using more appropriate behaviors when frustrated.

Lisa’s action plan worksheet begins with examining the child’s developmental status. Does he  know how to share or take turns? Was the child premature, or is she tall, giving the impression of being more mature than she really is? Do adults expect too much of the child, and do they need to offer guidance in social skills?

A second issue is the child’s recent experience of changes and previous experiences in general. Are the parents either excessively strict or very lax at setting limits? Have they moved to a new house, had Grandma come to live with them, had a new baby, had parent conflict rise to high levels? Has there been a change in child care providers?

What are the child’s verbal skills like? There may be good receptive language but limited expressive language, and there may also be facial expressions that are hard for other children to read.

The child’s physical condition may be an important factor that increases or decreases biting. Toddlers need plenty of sleep and may not get it for various reasons. They may be hungry or thirsty more frequently than many day care centers plan for.

Temperamental differences can make some children need extra guidance with respect to biting. Children who are low in adaptability can be easily frustrated and need extra help around transitions or other challenging situations. Low thresholds of sensory responsiveness can make children generally irritable, as they quickly notice small differences in temperature or taste and are bothered by constricting clothing or tags on clothes. Those with negative mood quality may have blank or sulky expressions that discourage other children (and some adults) from approaching them in friendly ways.

The physical environment of the day care center may create problems for children and make biting more likely. Overcrowding, colors and sounds that are too stimulating, a lack of novelty or challenge in the toys available, a lack of soft things to sit on or play with, too few play spaces--  all of these may cause a vulnerable child to respond with biting to another child who is too close or who interferes with play.

Finally, the child care setting and the parents may be using ineffective practices for limit-setting. Forcing children to apologize may simply lead to continued biting followed by “sorry”. Time-outs may be ineffective and may simply raise the child’s frustration level. Lisa suggested “instructive intervention” both at the time of a bite and planfully at other times, with much emphasis on the child’s understanding how he feels himself--  not so much on the “how did you make Tommy feel?”--  and what he can do to express this without biting or other aggression. (One very practical idea was to provide a damp washcloth or teether that the child can bit on when tense.)

Just a couple of comments from me about the limit-setting issue: one point is that it’s much easier to get someone to do something different than to “just stop”. What do you do when you’ve stopped? That question is more than a toddler can answer. A second point is that when setting limits for toddlers, we need to go to the toddler and get down face-to-face with him or her. Calling from across the room, or looming over the child, is likely to have a frightening and frustrating impact if it has any impact at all. Finally, a little more about “how you feel” rather than “how he feels”: toddlers show the beginnings of empathy and of Theory of Mind, the understanding that other people think, feel, or know things other than what the toddler thinks, feels, or knows--  but they are not very good at this, and months and years will have to pass before they get much better. They cannot effectively perform the mental gymnastics of thinking, “I don’t like to be bitten. Tommy is like me. Therefore, Tommy also does not like to be bitten”. In any case, it doesn’t really matter whether they know how Tommy feels, if the issue is development of their own impulse control and social skills. Those are abilities they can develop best if they are aware of--  and have words to describe and talk about—their own feelings. They didn’t bite Tommy because Tommy felt good or bad, they did it because they themselves were  angry and frustrated. While “thinking how he feels” can be an excellent learning device for 6-year-olds, “thinking how you feel”—and knowing what you can do about it--  is developmentally appropriate for toddlers.

The late, great Sally Provence used to say “Don’t just do something; stand there and watch”. Unless we stand and watch in the ways Lisa Poelle has suggested, chances are that we will not be able to figure out what factors are encouraging a child to bite. And, by the way, unless parents and child care providers can work together cooperatively, and be candid and open about the situations at home and in child care, they will not be able to put together all the information that’s needed to solve the problem of chronic biting.

N.B. I hope everyone has noticed that there is no mention here of “therapeutic restraint” as a solution for toddler aggression.

The Investigation of the Death of Maxim Kuzmin (Shatto)

Yulia Massino has called my attention to a report on the autopsy of Maxim Kuzmin (Shatto), the Russian-adopted three-year-old who died in Texas last January (http://www.oaoa.com/news/crime_justice/law_enforcement/article_53ef4076-9663-11e2-9e1b-0019bb30f31a.html). The autopsy report was released following a request under the Freedom of Information Act.

The report does not answer a great many significant questions, but it does clarify some points that have been made, denied, and then made again. It includes the fact that although Maxim showed a few bruises and scratches when first seen by a pediatrician in the U.S., at the time of his death from internal bleeding he had many bruises at different stages of healing. It also explains that the pediatrician had indeed prescribed an antipsychotic drug after concluding that Maxim was schizophrenic, and that Mr. and Mrs. Shatto, the adoptive parents, had stopped administering the drug three days before the child’s death, because it appeared to them that the medication made it difficult for Maxim to swallow.

The report also notes that Maxim had “breath-holding” incidents and had fallen off a chair after choking on a bite of cooked carrot. When Mrs. Shatto came out of the house and saw Maxim lying on the ground, she believed that he had “held his breath” and lost consciousness. According to the report, she grabbed and shook him while calling out his name. When this had no result, she grabbed him by the neck with both hands and shook hard until bubbles of blood came out of his mouth.

On the day of Maxim’s death, according to the report, he woke at a normal time in the morning but resisted Mrs. Shatto’s efforts to take him to the bathroom. According to her, he “had a fit” and went back to bed, where he remained until she woke him and his napping brother in mid-afternoon.

There is much to talk about here. An important unanswered question about this tragic story has to do with the diagnosis of schizophrenia and the treatment prescribed. Again, the report does not tell everything, and there may be a reasonable answer to this question--  but, are we to take it that the pediatrician made a diagnosis of schizophrenia (very rare in young children) on the basis of the parents’ comments alone? I certainly agree that parents know their children better than anyone else, but in the case of two months’ acquaintance with a child accustomed to a different language, even those who know him best may not know very much. A home visitor or other observer could have contributed much of importance to the diagnosis, for example whether any disturbing child behavior was related to adult actions or other events. Did the adoption agency (still unidentified as far as I know) not provide home visiting as part of post-adoption support? Did the physician not seek more objective evidence than the parents could provide?

Given the surprising diagnosis of schizophrenia, surely there must have been some uncertainty about both diagnosis and treatment. Were there any efforts at professional parent education and social support before medication was prescribed? When there is an unlikely diagnosis like schizophrenia, and when medication specifically approved for children does not exist, why was this treatment given without any attempts at less dangerous approaches? Or, were there other approaches taken, and these have not been included in the report because the right questions were not asked?

Side effects of antipsychotics (and of course we do not seem to know exactly which one was used here) include constipation, difficulty in urinating, and drowsiness. Maxim was reported as resisting toileting and being drowsy on the day of his death. He had been withdrawn, apparently abruptly, from the drug three days before. Did he have persisting effects from the drug? Or was the abrupt withdrawal in some way implicated in his death? Were the Shattos in touch with the prescribing doctor about side effects--  and did they discontinue the medication on their own decision, or did they have guidance in how to do this gradually?

A few weeks ago I commented on this blog that permission for adoption from abroad should be based in part on availability of a range of services that may be needed. The Shatto case exemplifies the problems I was talking about. As far as one can see from the report, their pediatrician not only prescribed in a possibly questionable way, but may have failed in his responsibility for parent education about the use of powerful drugs.

The adoption agency also appears to have failed in both post-adoption services like home visiting and in pre-adoption education. So far, it does not appear that the Shattos learned any Russian or any other means of communicating (like signing) with children who were likely to be language-delayed because of their care history. Mrs. Shatto appears to have misunderstood Maxim’s episodes of “breath-holding” which is an involuntary response to being startled or alarmed, sometimes seen in young children. (Falling off his chair when choking may have been an episode of this.) When she thought he was “holding his breath”, she shook him and shouted, responses which are neither necessary nor beneficial when a child has temporarily lost consciousness in this way. Why she subsequently seized him by the neck with both hands and shook him is incomprehensible except as the panic reaction of a person without the first-aid training that she should have received from the adoption agency.

Perhaps there was some sort of sexual abuse in Russia, as suggested, but if there was, it is hardly relevant except as a way of distracting from the central issues. Sexual abuse, repugnant though it is, does not cause schizophrenia or make young children injure themselves. My question about what happened in Russia is this: who decided that an older couple should take two young children, a year apart in age, and at developmental stages that require even more skill and attentiveness than are needed by infants? This is not the first time I’ve heard of this arrangement being encouraged, or even pressed, by Russian institutions, and permitted by U.S. adoption agencies who ought to know the difficulty being created for the naïve adoptive family.

Murder mysteries sometimes feature a situation in which each of many people contributes to a death, making it difficult to know who is to blame. Maxim’s death is similar, it would seem. A dozen people, perhaps, each made some contribution to the outcome. There is no point thinking of any of them as “a murderer”. But if Russians want to understand what happened, and if we in the U.S. want to keep adopted children safe, we need to know the whole truth and to answer all the questions I’ve posed here.