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Concerned About Unconventional Mental Health Interventions?

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

Saturday, May 19, 2018

Looking at the Claimed Symptoms of "Parental Alienation" : Developmentally Appropriate Characteritics?


Proponents of “parental alienation” (PA) have generally not been in a position to know whether, when a child of divorce resists or refuses contact with one parent, the other parent has actually worked to manipulate the child’s attitudes. The posited “alienating” behavior would be hard to observe for anyone outside the household, and even parents who have behaved in that way are likely to deny it if taxed with it.

PA proponents generally point to child behaviors as evidence that the preferred parent must have influenced the child’s attitude toward the other parent. Following Richard Gardner, they state that a list of symptoms indicates that the child has been “alienated” from one parent. Naturally this list is headed by resistance to or refusal of contact with the non-preferred parent—although oddly enough, PA has been claimed in cases where a child does not resist or refuse contact at all.

Gardner listed other symptoms of PA, based on his clinical experience, and as far as I can see no systematic empirical work has been done to show that these symptoms are more common in children who resist or refuse contact than in any other children of similar age. Indeed, PA advocates do not seem to have done any systematic testing of children to indicate that the claimed symptoms are reliably found. This lack of evidence raises the possibility that the child behaviors said to indicate alienation, where they exist, are in fact simply characteristic of children and adolescents at certain stages in their development, especially those wh
o are experiencing stress..

Let’s look at some of the claimed symptoms and see how they compare to developmentally-expectable characteristics of cognition and behavior.

1.      1. PA proponents state that affected children not only resist or refuse contact with a non-preferred parent, but give weak, frivolous rationalizations about their refusal. For example, a child or adolescent may cite the eating habits or other personal characteristics of a parent as a reason to avoid contact. There are a number of explanations for these apparently inadequate reasons for refusal. Some may have to do with other people in the parent’s household or with poor parenting skills on the part of the rejected parent, both currently and in the child’s past experience. In addition, when personal characteristics or behaviors of the adult are referred to, the problem may have to do with the appearance of misophonia, a sensory processing and emotional disorder, in adolescence (see www.psychatrist.com/PCC/articles/Pages/2017/v19n05/17102106.aspx). Both school-age children and young adolescents may have a great deal of trouble identifying and communicating factors that lead to refusal of contact, as their cognitive development makes it difficult for them to frame complex communications in ways that are easily understood by others; this would be particularly true when children are confronted by hostile adults bent on denigrating their statements.

2.    2.  PA proponents state that alienation is shown when children and adolescents show a lack of ambivalence or “black and white thinking” about their preferred and non-preferred parents. But this unsubtle view of life is characteristic of children whose thinking is at the concrete operational stage (which may last in some ways until the late teens). Concrete operational thinkers have many cognitive skills but do not think abstractly or create hypotheses that can be tested against reality. Thinking about multiple factors that operate simultaneously is most difficult for them, as is seen when they are asked to solve problems about pendulums or levers; they tend to focus on a single factor and ignore other possibilities. Thus, concrete operational thinkers, of school age or in early adolescence, are not likely to be able to consider multiple characteristics of parents and to compare multiple causes of parental behavior, or to accept that a person can be both bad and good at the same time. Even adults, whose tolerance for ambiguity is much better than that of children, have a strong tendency to categorize people as all good or all bad—in fact, we might say that concepts suggested by PA proponents are a good example of this tendency to demonize one member of a pair of people. Young adolescents, as they begin to develop the formal operational thought that will allow them to consider several factors at the same time, tend to thinking idealistically and are quick to reject any person whose bad qualities seem to outweigh their good ones.

3.    3..   PA proponents state that children who have been “alienated” from one parent display the “independent thinker” phenomenon—that is, they deny that anyone has influenced them and maintain that they have come to their positions entirely on their own. However, it is characteristic of school-age children to be unable to explain how they came to a belief, because their concrete operational patterns of thought prevent them from examining a range of factors that determined their ideas. As adolescents shift their loyalties from parents to peers, they typically deny parental influences on their ideas and are likely to assert their mental independence from any adult (as in “not trusting anyone over thirty”). Children and young adolescents generally have difficulty thinking about why they assume something is true, and like adults may resent the idea that they have been manipulated or persuaded by others.

4.   4.   PA proponents claim that children who resist or refuse contact with a parent are marked as “alienated” because they do not feel guilty about their treatment of that parent. This point is easily explained by comments already made in this post; if a child or adolescent actually believes that a parent is bad enough to reject, he or she will assume that it is the parent who should be feeling guilty. In addition, although even quite young children experience some kinds of empathy with others (and may try to get adults to help a person who seems to be in trouble), human beings of any age tend to empathize best with those who seem like themselves and are in need of protection. To expect a child or adolescent to feel guilt toward or empathize with a parent – to empathize with a person who neither resembles them nor needs help—seems equivalent to parentalizing the child. When guilt and empathy are felt toward a preferred parent, PA proponents speak critically of parentalization, but they are equally concerned when a child does not empathize with or feel guilty toward the non-preferred parent. Looking at this matter developmentally requires us to go beyond cognitive characteristics of childhood and to look at moral development, which has a less predictable sequence than cognition does. Higher degrees of empathy are displayed when individuals are at the level Kohlberg called “conventional morality”, with emphasis on rules associated with group membership and shared relationships. Many people do not achieve this stage until adulthood and even then tend to be limited in their capacity for empathy.

This examination of PA claims and common characteristics of children and adolescents suggests that the PA symptoms described may well indicate nothing more than a child’s age and developmental stage.
 

Friday, May 18, 2018

Persuasion, Attitude Change, and Parental Alienation



Persuasion-- attempts to change other people’s attitudes – is a common human activity, for good or ill. We see it at work in evangelism and religious conversion, political campaigns, war propaganda, advertising, and Jane Austen’s wonderful novel. Persuasion is an important part of the work of parents and teachers, whose efforts to get children to share their beliefs and attitudes are usually quite successful. By school age, most children have adopted adult attitudes about toilet use, using words rather than grabbing and hitting, physical modesty, politeness, and so on, although their behaviors do not always reflect those attitudes.

Persuasion uses various means to cause changes in attitude, with the further intention of behavior changes that can result from new attitudes. Persuasion can involve simple repetition of ideas, modeling of attitudes on those of loved or feared persons, and the provision of new information that supports new attitudes. Cognitive dissonance due to new information or experience may be at work in attitude change; when a person has two contradictory beliefs, one may change in a direction that decreases contradiction. Changes due to cognitive dissonance can seem paradoxical, as for example a person who is paid a small amount to make a statement he does not believe is more likely to change to greater belief than is be the case for a person paid a large amount. It is notable that attitude changes in children and adolescents can also occur in the absence of any persuasive attempts, as a result of maturation of cognitive abilities and of unrelated experience. Attitude changes are thus potentially the results of both persuasion and other factors in an individual.

Attitude change may or may not be the deciding factor in behavior change. Under the right circumstances, a person may behave in changed ways determined by new attitudes. However, circumstances may work against changed behavior, as when a newly-convinced vegan will starve unless he or she eats meat. Behavior changes can also occur in the absence of actual attitude change, because of the effects of bribes, threats, punishment, reward, physical or social circumstances, and, for children and adolescents, the occurrence of maturational changes like puberty.

Proponents of the idea of “parental alienation” (PA) argue that when children of divorced couples refuse or resist contact with one of the parents, this occurs because the other parent has used persuasive techniques to change the attitudes of the child toward the avoided parent. PA proponents claim that they have programs that will reverse this attitude change and create positive attitudes and behavior toward the previously-avoided parent. (It is notable, however, that PA discussions do not present objective evidence that the avoiding child had a positive attitude toward the avoided parent before the divorce; this is taken as given.)

In this post, I will discuss three ways in which PA is related to persuasion and attitude change. The first is the view of PA proponents that one parent can persuade a child to alter his or her attitude toward the other parent in a negative direction, and that this single factor is the cause of resistance or refusal of contact, unless physical abuse has been present. The second connection between PA and persuasion has to do with the methods PA advocates use to persuade courts to accept their views, to change custody arrangements, and to order children into PA treatments at the expense of the parent accused of persuading the child to dislike the other parent. Third, the counter-persuasive techniques used in treatment programs like Family Bridges will be examined.

1.     1.  Can a parent persuade a child to dislike and avoid the other parent?  It would be foolish to claim that this could not happen, although equally foolish to claim that such parental behavior can be detected simply on the basis of child attitudes, or that such persuasion is the sole factor determining resistance or refusal of contact.

 Shifting alliances between parents and children are characteristic of intact families as well as divorced families. A parent may express an attitude toward the other parent as a part of communication with a child or as a way of smoothing family functioning (“ Let’s wait until after dinner to talk to your Dad about the bicycle—he’s tired when he comes home from work”). Individual differences may be expressed as communicated attitudes about the other parent (“I really can’t stand to watch that boring show! See if Mom will watch with you, she likes that stuff”). Maturational changes can affect attitudes and alliances, as for example when a 13-year-old girl begs her mother not to tell the father that she has her first period, or when a mother presses her husband to have the “sex talk” with their son. 

Persuasion and efforts at child attitude change are very much a part of the post-divorce family functioning. Though some are happy to escape family conflict, children generally object to the fact and consequences of divorce, with its frequent multiple changes of house, school, neighborhood, income, parental mood, and often in residents of the household (a new partner for a parent; stepsiblings; sometimes a shared household with a grandparent or parent’s sibling). Divorced parents usually make more or less effective efforts to persuade children to more positive attitudes about their new circumstances. Attitude changes and establishment of new family alliances and roles are the work of the first couple of years after divorce.

Given that parents spend time trying to influence child attitudes about family members, roles, and circumstances in both intact and divorced families, it is almost certainly the case that  some divorced parents successfully create negative attitudes in children toward former spouses. However, a child’s resistance to or refusal of contact is not sufficient evidence to claim that this has happened, and only circular reasoning can suggest that the influence of one parent has created the attitude toward the other. Not only would support for this argument require evidence that the preferred parent had made unusual efforts to persuade the child against the avoided parent; it would also be necessary to show that before the divorce, the child’s attitude toward and relationship with the now-avoided parent had been good, and this demonstration would require more than the claims of the avoided parent.

 PA advocates argue that children and adolescents who avoid contact have no “rational” explanation that is acceptable, unless there is substantiated evidence of physical abuse.  They also privilege the mother and father over any other actors in the scenario, sometimes including new spouses, but often ignoring the roles played by grandparents, stepsiblings, and other involved persons. Like adults, children and adolescents may avoid contact with a person because of other involved individuals—an intimidating or overly manipulative grandparent, a stepsibling who is living in the house and with whom the child is expected to be friendly, a parent’s new partner who has decided to take a strong family role and acts out rivalry with the child’s preferred parent. Adolescents, in particular, may resent the choices forced on them by a visiting schedule, the teams they cannot be on because they frequently miss games, the parties they cannot attend, the weekend get-togethers for homework. These are all reasonable explanations for avoiding visits to a parent, although they may be difficult for the adolescent to explain and certainly do not fit the physical abuse category insisted on by PA advocates.

In considering adolescents’ resistance or refusal of contact, it is important to remember the influence of puberty and burgeoning sexuality. Girls may want to avoid dealing with menstruation at a father’s house; boys may feel that for a mother to see evidence of a nocturnal emission would be deeply humiliating. For both sexes, increased awareness of parents’ sexuality, especially if new partners are present, may be deeply disturbing, and a very different experience than that of teenagers living with “old married” parents. These examples and the ones above do not deny the possibility that a parent has tried to create negative attitudes toward the other parent, but they provide alternative or co-causal explanations that need attention.

2.    2.   How do PA advocates use persuasion to win court approval for custody changes and orders for PA-related treatments?

In the absence of any acceptable empirical evidence basis, PA advocates have used common persuasive devices like repetition and appeals to authority to bring PA concepts into the courtroom. In addition, they have depended on rhetorical devices like the use of analogies to create positive legal and judicial attitudes toward their claims. Some frightening metaphors have played strong roles in cases where courts were persuaded of the PA position. Here are some examples:

Alienation.
 The term alienation originally referred to a transfer of ownership or property rights. In the 18th and 19th centuries, the concept of “alienation of affection” was used in lawsuits against third parties who were claimed to have caused ruptures in marriages or engagements by their behavior toward one of the partners (usually the wife). Alienation of affection remains the foundation of suits in some states of the United States. Property rights in a wife or child were legal arguments, and provided the framework of early adoption laws. However, parents’ rights are no longer seen as property rights, so the use of the term “parental alienation”  depends on a questionable metaphor in which the two entities in the analogy do not share most characteristics.

The word “estrangement”, or a reference to the child’s resistance or refusal of contact, would avoid this metaphor, but would be undesirable from the point of view of PA advocates, as it would weaken their persuasive rhetoric.

Toxic.

A toxic substance causes physical damage to an affected person, potentially resulting in injury or death. Referring to behavior of divorced persons as “toxic” is a metaphorical practice used to suggest that possible persuasion, claimed to cause changes in a child’s attitude toward one parent, is in fact damaging to the child. Although this has become a common analogy (e.g. “toxic stress”), in fact the effects of toxins and of the posited parent behavior toward children have little in common. To make this analogy a useful one, rather than just a rhetorical device, PA proponents would need to show that children who resist or refuse contact with one parent display damage in the form signs of personality disorders or mental illness in adulthood, and that these problems have not been caused by genetic or other factors. No such evidence has been presented, so the “toxic” analogy remains a persuasive device rather than an appropriate way of reasoning.

Pathogen.

A pathogen is properly defined as a microorganism that can cause disease. This term is used metaphorically when PA advocates refer to the posited parenting behavior that causes resistance or refusal of contact as “pathogenic”.  A child’s resistance or refusal is not in itself a disease, and unless it can be demonstrated that such behavior is followed predictably by mental disorders in later life, the metaphor is a mistaken one. Nevertheless, the pathogen metaphor can be a powerfully persuasive one when legal and judicial audiences do not examine rhetorical devices with care.

Disruption of attachment.

Some PA advocates use the term “attachment” to refer to any positive aspect  of a child’s relationship with a parent. As clearcut attachment behavior is characteristic of toddlers and not of older children or adolescents, and as even preschoolers do not display this behavior much unless distressed, the attachment metaphor is not appropriately applied here. It is particularly the case that adolescent social and emotional development shifts positive feeling toward peers and away from parents, so the analogy of adolescent attitudes toward parents and toddler attachment behavior is a mistaken one. The idea of “disruption of attachment”—that toddlers had both short- and long-term ill effects of separation from familiar people—was a part of John Bowlby’s early conceptualization of attachment, later much diminished in importance, but certainly never applied to children of school age or adolescents. This misleading metaphor has considerable rhetorical power, however, because the idea of attachment is highly fashionable and generally though erroneously accepted outside the field of child development as a complete explanation of emotional development and especially of mental illness.

Brainwashing.

The “brainwashing” metaphor, suggesting that mental processes, information, and attitudes can be stripped away from an individual just as dirt can be washed from a surface, and can be replaced in the same way, was a popular one in the 1950s  and was used to explain why a small number of American soldiers refused repatriation after a period of captivity in North Korea. Subsequently, this metaphor has been used to explain adherence to Scientology and similar belief systems, as well as commitment to terrorism. PA advocates use the metaphor to suggest that children and adolescents can be made subjects of “mind control” by a parent who intentionally alters their beliefs and attitudes toward the other parent. Again, this is a powerfully rhetorical device in the courtroom, but the analogy is mistaken because there is little evidence that persuasion of any kind resembles “washing”. ( Recently, this metaphor has been partially replaced by the metaphors of “programming” and “deprogramming”, but these do not carry the persuasive punch of “brainwashing”, with its imlicatons of defecting soldiers.)

3.     3.  Can children be persuaded to drop their resistance and refusal and behave affectionately and positively toward avoided parents?

PA proponents describe treatment programs like Family Bridges as “psychoeducational” and argue that the information about persuasion offered to children in treatment can indeed persuade them and change negative to positive attitudes. Assuming that one parent has persuaded the child to take up negative attitudes toward the other parent, practitioners of these programs claim to counter the parental persuasion and reverse the attitude change.

Published reports of outcomes of PA treatments have not met standards required for outcome research, and cannot be used to argue that the treatments are effective. For example, the published reports do not show how outcomes of PA treatment programs compare with outcomes when children are either not treated or treated by some conventional psychotherapeutic approach. Given that school-age children and adolescents change in many ways because of maturation, PA proponents need to show that the outcomes they report would not have happened over time simply because of maturation and ordinary experiences.

Be that as it may, however, it is questionable whether the effects of the treatment are actually attitude changes subsequent to persuasive efforts and new information through videos and discussion. Reports of adolescents who have experienced these programs suggest that behavior change (with or without attitude change) may have resulted from threats to send the child to wilderness camp or a residential treatment center, to send the preferred parent to prison, or to charge the preferred parent additional fees because the child was not cooperative. This seems more probable than the claim that an entrenched attitude, created by months of intentional persuasion by one parent, could be altered in a few days by watching videos. Whether observed behavior changes are or not due to persuasion and attitude change is one of many unanswered questions about PA, all of which should be given careful consideration by courts.

Thursday, May 17, 2018

A Rose By Any Other Name May Be More Difficult to Treat: Mistaking Other Disorders for Attachment Disorders


Over the last couple of years, a number of psychologists, both British and American, have called attention to the excessive current emphasis on attachment and trauma as causes of mental and behavioral problems. The emphasis has generally been on diagnosis and treatment of adopted children, for whom any behavioral problems are so often attributed to their histories of separation and possible abuse and neglect. Matt Woolgar and Stephen Scott  (Woolgar, M. & Scott, S. [2013]  The importance of comprehensive formulations The negative consequences of over-diagnosing attachment disorders in adopted children. Clinical Child Psychology and Psychiatry. : DOI: 10.1177/1359104513478545)  gave examples of British cases where children were evaluated as having problems caused by attachment disorders when in fact their major difficulties stemmed from treatable issues like learning disabilities. The American psychologist Brian Allen, whom I mentioned in a recent post, has argued strongly against the view that conduct disorders and callous-unemotional traits should be considered to result from difficult attachment histories or from the posited “developmental trauma”.

There are certainly childhood disorders that seem to stem from problematic experiences with early care, and because such problematic experiences are likely to lead to termination of parental rights and subsequent adoption, it is true that adopted children are more likely than others to have these difficulties. However, it is a great mistake to assume that all problems of adopted children (or of nonadopted children, for that matter) are caused by experiences of separation, abuse, or neglect. The evidence at this point is that attachment problems in children involve either Reactive Attachment Disorder, a matter of sadness, social withdrawal, and difficulty in seeking comfort from familiar adults, or Disinhibited Social Engagement Disorder, a matter of unusually easy rapport with strange adults and failure to prefer familiar adults over strangers (in contrast, with most young children, who seek familiar people and are wary of strangers). Aggressive behavior, callous-unemotional traits, precocious sexuality, unusual tantrums, and learning difficulties—all serious problems-- are not included here.

Adoption has been called the most effective treatment for attachment disorders, and most children who have been adopted and stayed with a family for some years will begin to show more normal social behaviors. Adoptive families may benefit from therapeutic support, but treatment is likely to focus on the adults and their parenting behavior rather than directly on the children.

But like nonadopted children, adopted children may have a range of psychological issues in addition to or instead of attachment disorders. All human beings are subject to psychological disorders that are influenced by biological factors like genetic influences. Although there are many rare and serious problems that are genetically determined, the most commonly-diagnosed genetically-caused psychological difficulty is autism, now known to exist in a wide range of  severities (the “autistic spectrum”).

The British psychologist Joshua Carritt-Baker has recently commented on the frequency of autistic disorders among adopted children and the mistaken assumption that these children are suffering from attachment disorders. This assumption has led to the treatment of numbers of adopted children with non-evidence-based methods that claim to treat attachment problems (for example, Dyadic Developmental Psychotherapy as practiced by Daniel Hughes and Kim Golding). Carritt-Baker has created a video explaining the problems that have not been solved by the activities of the British Adoption Support Fund, which can be seen at



Carrit-Baker notes, by the way, the fact that the United Nations has warned France that its approaches to treatment of autistic children are violating those children’s human rights, and points out that the same warning is due to British organizations. The over-diagnosis of attachment disorders in the United States may deserve a similar caution.

What has brought about this difficult situation in which autism as well as other problems gets confused with attachment disorders?

 One source may be the historical one, whose “trailing edge” still influences thinking about children’s mental health. At the time when autism was first clearly identified as different from speech pathologies or mental retardation, psychology and psychiatry put an enormous emphasis on experience and learning as sources of mental illness. That autism was caused by aloof, overly-intellectual “refrigerator mothers”, and was related to a lack of attachment, was taken for granted in the 1940s. Genetic factors were unknown  (even the chromosomal causes of Down syndrome were not identified until the 1950s), and it was not until much later that it was demonstrated that autistic children had ordinary attachment behavior. The same stress on experience (as opposed to biology) created an emphasis on early childhood attachment experiences as the most important—even the only—factor in determining personality and mental health. This view has lingered with us and is especially obvious in non-evidence-based alternative therapies.

No one would deny that attachment is important. But other factors are also important. Children’s development is determined in complicated ways; biological and experiential factors interact with each other and have different influences at different ages. We have learned a lot about this in the last 60 years and should be able to do better than seems to be the case right now. Choosing the right kinds of treatments requires us to consider more than one possible problem and more than one possible treatment. Otherwise we waste public and family resources and do many children a distinct disservice.



A Rose By Any Other Name May Be More Difficult to Treat: Mistaking Other Disorders for Attachment Disorders


Over the last couple of years, a number of psychologists, both British and American, have called attention to the excessive current emphasis on attachment and trauma as causes of mental and behavioral problems. The emphasis has generally been on diagnosis and treatment of adopted children, for whom any behavioral problems are so often attributed to their histories of separation and possible abuse and neglect. Matt Woolgar and Stephen Scott  (Woolgar, M. & Scott, S. [2013]  The importance of comprehensive formulations The negative consequences of over-diagnosing attachment disorders in adopted children. Clinical Child Psychology and Psychiatry. : DOI: 10.1177/1359104513478545)  gave examples of British cases where children were evaluated as having problems caused by attachment disorders when in fact their major difficulties stemmed from treatable issues like learning disabilities. The American psychologist Brian Allen, whom I mentioned in a recent post, has argued strongly against the view that conduct disorders and callous-unemotional traits should be considered to result from difficult attachment histories or from the posited “developmental trauma”.

There are certainly childhood disorders that seem to stem from problematic experiences with early care, and because such problematic experiences are likely to lead to termination of parental rights and subsequent adoption, it is true that adopted children are more likely than others to have these difficulties. However, it is a great mistake to assume that all problems of adopted children (or of nonadopted children, for that matter) are caused by experiences of separation, abuse, or neglect. The evidence at this point is that attachment problems in children involve either Reactive Attachment Disorder, a matter of sadness, social withdrawal, and difficulty in seeking comfort from familiar adults, or Disinhibited Social Engagement Disorder, a matter of unusually easy rapport with strange adults and failure to prefer familiar adults over strangers (in contrast, with most young children, who seek familiar people and are wary of strangers). Aggressive behavior, callous-unemotional traits, precocious sexuality, unusual tantrums, and learning difficulties—all serious problems-- are not included here.

Adoption has been called the most effective treatment for attachment disorders, and most children who have been adopted and stayed with a family for some years will begin to show more normal social behaviors. Adoptive families may benefit from therapeutic support, but treatment is likely to focus on the adults and their parenting behavior rather than directly on the children.

But like nonadopted children, adopted children may have a range of psychological issues in addition to or instead of attachment disorders. All human beings are subject to psychological disorders that are influenced by biological factors like genetic influences. Although there are many rare and serious problems that are genetically determined, the most commonly-diagnosed genetically-caused psychological difficulty is autism, now known to exist in a wide range of  severities (the “autistic spectrum”).

The British psychologist Joshua Carritt-Baker has recently commented on the frequency of autistic disorders among adopted children and the mistaken assumption that these children are suffering from attachment disorders. This assumption has led to the treatment of numbers of adopted children with non-evidence-based methods that claim to treat attachment problems (for example, Dyadic Developmental Psychotherapy as practiced by Daniel Hughes and Kim Golding). Carritt-Baker has created a video explaining the problems that have not been solved by the activities of the British Adoption Support Fund, which can be seen at



Carrit-Baker notes, by the way, the fact that the United Nations has warned France that its approaches to treatment of autistic children are violating those children’s human rights, and points out that the same warning is due to British organizations. The over-diagnosis of attachment disorders in the United States may deserve a similar caution.

What has brought about this difficult situation in which autism as well as other problems gets confused with attachment disorders?

 One source may be the historical one, whose “trailing edge” still influences thinking about children’s mental health. At the time when autism was first clearly identified as different from speech pathologies or mental retardation, psychology and psychiatry put an enormous emphasis on experience and learning as sources of mental illness. That autism was caused by aloof, overly-intellectual “refrigerator mothers”, and was related to a lack of attachment, was taken for granted in the 1940s. Genetic factors were unknown  (even the chromosomal causes of Down syndrome were not identified until the 1950s), and it was not until much later that it was demonstrated that autistic children had ordinary attachment behavior. The same stress on experience (as opposed to biology) created an emphasis on early childhood attachment experiences as the most important—even the only—factor in determining personality and mental health. This view has lingered with us and is especially obvious in non-evidence-based alternative therapies.

No one would deny that attachment is important. But other factors are also important. Children’s development is determined in complicated ways; biological and experiential factors interact with each other and have different influences at different ages. We have learned a lot about this in the last 60 years and should be able to do better than seems to be the case right now. Choosing the right kinds of treatments requires us to consider more than one possible problem and more than one possible treatment. Otherwise we waste public and family resources and do many children a distinct disservice.



Tuesday, May 15, 2018

When Peer Review Fails: With Special Relevance to RAD


The idea of peer-reviewed articles in professional journals is, or at least was, a helpful way of keeping nonsense and excessive speculation out of respected print publications. Authors submit articles to journals, and editors send them on to professionals who are knowledgeable in relevant fields. Those people, peers of the article authors in that they have similar training, review the submitted material and convey their conclusions to the editors. These conclusions may be to reject the article entirely or to accept it just as it stands, but most often peer reviewers suggest acceptance with some major or minor revisions. Good reviewers can assess the background of a submitted article, can understand whether information cited from other work is correct, can evaluate research methods that were used, and can advise on improving organization and writing.

This is a lot of work and may or may not be done as well as we’d like. Not all peer reviews catch problems—and when big problems remain, journal editors may sometimes have to retract an article that contains major errors or that is just a repetition of something the author has published elsewhere.
In addition to the occasionally failures of reviews, nowadays we have the problem of the ever-expanding number of journals. Some of these are “predatory” journals whose real purpose is to collect fees from authors (conventional professional journals do not charge except sometimes for publication of  illustrations). Some are “open access” journals that charge fees and provide quick publication for articles that might not be accepted otherwise, or whose publication might be delayed longer than is comfortable for an author who is afraid of perishing without a publication. These journals refer to themselves as “peer reviewed”, and no doubt someone does “peer” at the submissions, but little effective reviewing happens.

When predatory or open access journals make mistakes about accepting articles, those mistakes are rarely corrected. Journals that take seriously the job of reviewing are likely to retract wrong articles or publish corrections—or, they very quickly publish additional articles critiquing the problem material. For example, the journal Child Development, which is about as serious and respectable as a publication can get, recently published a piece claiming that exposure to wireless technologies has been shown to affect child development (Sage, C., & Burgio,E. [2018]. Electromagnetic fields, pulsed radiofrequency radiation, and epigenetics: How wireless technologies may affect childhood development. Child Development, 89, 129-136). Interestingly, when this article was published on line, it did not include a conflict of interest statement, which was added for the print version, as one of the authors is the owner of an environmental consulting firm and a consultant on relevant policy and decisions.

When the Sage and Burgio article appeared on line, it was seen by others than the original reviewers, and these people were able to recognize that the authors had “cherry-picked” and misrepresented material. Two authors submitted a commentary that the journal published in the same print edition as the Sage and Burgio article—the commentary stating that “these claims are devoid of merit, and… should not have been given a scientific veneer of legitimacy” (Grimes, D., & Bishop, D. [2018]. Distinguishing polemic from commentary in science: Some guidelines illustrated with the case of Sage and Burgio [2017].) Grimes and Bishop stated that it was their view “that this piece has potential to cause serious harm, and should never have been published.” They followed this statement with a suggested series of questions to be used by readers and reviewers in ascertaining whether an article deserves publication or should be regarded as credible. Among these questions, all of which deserve real attention, were four of particular interest: 1. Is there a plausible mechanism for a claimed effect? 2. Does evidence come from [genuinely] peer-reviewed sources? 3. Are all relevant studies considered? 4. Are results of specific studies misrepresented?  Applying their list of questions, Grimes and Bishop were able to show that the Sage and Burgio paper was completely unacceptable. However, because the paper was not actually retracted, Sage and Burgio may (unfortunately) continue to argue that their work was validated by its acceptance by a prestigious peer-reviewed journal.

In the title of this post I said we would get to Reactive Attachment Disorder, and I am about to do that, with a description of an article that probably should not have been accepted by a journal and of another article that critiqued the first one. The problematic article was an effort to argue that difficult and oppositional behavior, conduct disorder, and callous-unemotional traits are closely associated with RAD (Mayes, S., Calhoun, S., Waschenbusch, D., Breaux, R., & Baweja, R. [20i7]. Reactive attachment/disinhibited social engagement disorders: Callous-unemotional traits and comorbid disorders. Research in Developmental Disabilities, 63, 28-37).

A little history is needed to understand the background of the Mayes et al article. Definitions of RAD have changed over the years, beginning in 1980 with the idea that the disorder involved infant failure to thrive and gradually changing to comprise unusual behaviors of young children toward adult caregivers. Until recently, RAD was considered to exist in two forms, an inhibited form in which young children did not seek care or comfort from adults, and a disinhibited form in which young children were as likely to approach strange adults as to approach familiar people for care and social interaction. The 2013 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) separated the inhibited version, which kept the term RAD, from the disinhibited version, which now became Disinhibited Social Engagement Disorder (DSED).

Meanwhile, however, there had been as far back as the 1990s an effort to create an alternative view of a disorder attributed to early separations, abuse, and neglect. This putative disorder was often referred to as Reactive Attachment Disorder, but instead of involving unusual social behavior toward caregivers, it was said to include disturbing aggressive behaviors like cruelty, theft, lying, and “fascination with blood and gore”. Some alternative practitioners claimed that they had discovered a new form of the disorder, not Reactive Attachment Disorder at all, but something they called simply Attachment Disorder. This notional diagnosis was promulgated by practitioners of Holding Therrapy/Attachment Therapy, by a number of adoption groups, and by support groups for adoptive parents. The idea of violent Attachment Disorder behavior was taught by made-for-TV movies like “Child of Rage” and by various related websites. For a number of years, newspaper articles about child abuse have often proposed that abused children showed disturbing behaviors said to be characteristic of RAD or AD and in some sense had forced adults to mistreat them. These beliefs continue to be promulgated, as can be seen at https://blogs.psychcentral.com/childhood-behavioral/2018/05/why-parents-of-r-a-d-children-always-look-like-aholes/, a blog where commenters claim that adoptive parents of children  “diagnosed with RAD” and behaving aggressively must treat those children as coldly and mechanically as possible. In reply to criticism of this position, comments are focused on the idea that anyone who does not think RAD includes callous-unemotional or aggressive behavior has simply never lived with such a child—a rather inconsequential response, as no one has said that their children do not display the claimed behaviors, just that these are not evidence of RAD.

Conventional, evidence-based work on childhood mental illness has rejected the idea that externalizing behavior, conduct disorders, or callous-unemotional characteristics such as lack of empathy are related to attachment experiences or should be treated by methods that stress attachment. The article by Mayes et al argues against that conventional view and presents a small amount of data that are used to conclude that children diagnosed with RAD are also likely to be violent, cruel, callous, and unemotional. The study examined 20 children, ages 4-17, who had been diagnosed with RAD or DSED or both, and compared them with much larger groups of children diagnosed as autistic or as having ADHD. The authors suggested that the DSM discussion of RAD should include references to conduct disorders and callous-unemotional traits as associated with RAD.


A trenchant response by a competent critic of misused attachment concepts followed the Mayes et al paper (Allen, B. [2018]. Misperceptions of reactive attachment disorders persist: Poor methods and unsupported conclusions. Research in Developmental Disabilities, 77, 24-29). In keeping with our concern with failed peer review, Allen offered guidelines for reviewing articles that stress attachment issues. He used the Mayes paper as an example of a publication about which reviewers had not asked the right questions.

Here are the questions Allen suggested as review guidelines:

1.      How well is attachment research reviewed? This is an area where, Allen suggests, Mayes et al seem to have “cherry-picked”, stressing early writings of John Bowlby and omitting some of the contradictory conclusions of his later work.

I would like to add that Mayes et al used a 2003 paper by Hall and Geher to support the claim of aggressive externalizing behavior in children with RAD; the Hall and Geher paper in turn was dependent on what may be the ur-article on such behavior in children diagnosed with RAD, an obscure publication, probably not peer-reviewed in any real sense, that put forth the idea that RAD children can vomit or defecate at will and do so simply to antagonize their caregivers (Reber, K. [1996]. Children at risk for attachment disorder: Assessment, diagnosis, and treatment. Progress: Family Systems Research and Therapy, 5, 83-98 ; this publication of a freestanding California institute used to be available on the Internet but I have not been able to find it recently). (Reber’s claims may have been behind the Internet arguments that Candace Newmaker died intentionally in order to cause trouble for the therapists who asphyxiated her.) The influence of Reber on Hall and Geher and subsequently on Mayes et al demonstrates that reviewers need to be aware not only of the background publications being cited in an article, but also of the nature of the material cited in those publications.

2.      Are attachment constructs clearly defined? Unfortunately, attachment concepts seem to have achieved the position of obscenity, in that most people can’t define them but believe they know them when they see them. Nonetheless, as Allen suggests, it is crucial to know whether authors are concerned with attachment behavior, attachment representations, or attachment theory. The choice of constructs is directly related to understanding of how a diagnosis was made—a point left obscure in the Mayes et al paper.

3.      Are assessment measures and methods clearly specified? All too often, discussions of RAD have involved “validation” of assessment methods against the intuition or “practice wisdom” of one or two clinicians. Elizabeth Randolph’s Randolph Attachment Disorder Questionnaire (RADQ) is described by its author as substantiated in part by her ability to diagnose an attachment disorder when a child cannot crawl backward on command.

Unspecified and vague assessment measures in the Mayes et al paper are especially important because of the age range of children examined—from 4 to 17 years of age, with a mean age about 10. Although toddlers can be expected to reveal the quality of their attachment to caregivers by their behavior with strangers or when separated from familiar people, this can hardly be expected with school-age children or teenagers, whose cognitive and emotional development and daily experiences allow them to handle separation or contact with strangers as normal events that affect their behavior very little. Assessments of 4-year-olds, 10-year-olds, and 17-year-olds can hardly take the same forms, yet Mayes et al do not state differences in evaluation of children of different ages, and ignore the many discussions in the literature about the maximum age at which RAD could be a meaningful diagnosis.

4.      Do the authors use tautological reasoning? When clinicians believe that RAD involves aggressive or callous-unemotional traits, they may use such traits as a reason to diagnose RAD, even though RAD by definition does not include these traits. Allen queries whether this illogical approach is responsible for the conclusions drawn by Mayes et al.

Historically, proponents of the idea that externalizing problems were part of attachment disorders have also argued  that children with problematic attachment histories (separation, abuse, neglect) will of necessity have RAD and [therefore] externalizing problems, such a history being in the past a factor in the RAD diagnosis; this claim was even applied when children showed no behavioral disturbance, with convinced clinicians telling parents that the child’s normal behavior was simply an indication of the degree of disturbance, intended to lull the parent’s concerns until the child found a way to attack effectively. 

5.      Do the authors make remarkable conclusions, which may not be supported by their data? Allen suggests that mistaken conclusions are drawn by Mayes et al, for example that it is incorrect to claim that RAD is associated with internalizing problems and DSED with externalizing problems (e.g., cruelty, lack of empathy), even though this is what other  unemotional traits, the Mayes et al conclusions fail to recognize the limitations of their study  as stated above and discussed in the Allen paper.


It is clear that if reviewers had used the questions supplied by Allen in their reviews of the Mayes et al paper, the paper would never have appeared except in a considerably revised form.
Revisions would also have been required for publication if the guidelines proposed by Grimes and Bishop (2018), some of which were discussed earlier in this post, had been applied. The plausible mechanism demanded by Grimes and Bishop is certainly missing in the Mayes et al article—by what mechanism would a failure of attachment lead to cruel and callous-unemotional behavior posited by Mayes, or the disobedience, ingratitude, and lack of remorse claimed by Randolph and others? Attachment theory and the idea of attachment representations, with their stress on cognitive and social development, do not provide any explanation of the proposed mechanism.

A question about causal claims put by Grimes and Bishop would also require Mayes et al to revise their article and supply a much elaborated discussion of limitations. This nonrandomized study design does not allow for the stated conclusion that externalizing behaviors are caused by problematic attachment histories.

There is little question that guidance is needed by peer reviewers dealing with submitted papers involving the complexities of attachment concepts and the conflation of established views of attachment with alternative attachment theories. Given the approaches proposed by Allen and by Grimes and Bishop, we can hope, along with Allen, that “through this process of enhanced scrutiny of papers examining RAD/DSED that misperceptions and subsequent substandard clinical services can be significantly improved.”


Wednesday, April 18, 2018

How Do We Know Whether an Intervention Is Effective? (E.g., PA Treatments)


There’s a lot of discussion right now about whether psychological interventions are or are not evidence-based (or empirically-supported) treatments. Even when there is strong evidence that a treatment is efficacious—causes good outcomes under ideal circumstances—there are further demands for evidence that it is effective and causes good outcomes in the less-than-ideal settings of the real world.

The strongest evidence in either case depends on research that has used randomized controlled trials. RCTs (not to be confused with residential treatment centers!) are studies in which people who have received the treatment being tested are compared to a control group of people who have not received it (and may have had no treatment, or had a well-established different treatment, or have been placed on a wait-list for the treatment being tested). Because this kind of research is randomized, prospective patients do not get to choose which group they want to be in, but are assigned to one or the other in some objective way like the flip of a coin or the use of a list of random numbers. The point here is to eliminate the bias that might be present if people got to choose the treatment they want—just believing that something will be good for them, or expecting that a treatment will be effective, can be enough to change people’s moods and behavior. (If we’re talking about treatments for children and adolescents, parents may be affected by their expectations about a treatment so that they behave differently toward their children if they think they are getting that treatment, or see their children’s behavior differently if they think the children are getting a good treatment, or, of course, both of these things.)

Having a control or comparison group as part of the research design adds to what is called the internal validity of the study. Internal validity is also influenced by factors like having a blinded evaluation, or assessment of children by people who do not know them or know what treatment they have been receiving or will receive. When parents, who know both of these things to some extent (even if not told their children’s treatment, they may figure it out from things the child tells them), are involved in evaluation of the children’s response to treatment, other biases can creep in; parents are the ones to say whether they liked a treatment, but can not say objectively whether it helped their children. A number of alternative therapies, like Love & Logic training for parents, make the mistake of asking parents whether their children have improved and then acting as if it is known what changes have really occurred in the children.

Many studies that claim to give evidence supporting unconventional, alternative therapies are more than one step below RCTs. They look very simply at measures (often parent opinions) taken before and after treatment. Does this seem like a good idea? Well, only if you think that children and adolescents do not change unless they are made to change by an intervention!

I recently had pointed out to me the statement by a guardian ad litem that changes she heard about in a girl between ages 11 and 13 could only have been caused by a PA treatment method the girl had experienced. It would appear that the GAL thought that nothing happened in those two years other than the treatment and separation from the preferred parent. But in fact much had happened.

A small amount of the change reported was no doubt due to adjustment over a couple of post-divorce years, during which one parent had remarried. A much larger factor, causing changes of all kinds, physical and mental, was the occurrence of  puberty for this girl—just under 13years being the average age of menarche (first menstruation) in the Western world today. Puberty in both sexes is associated with dramatic social and cognitive changes and the redirection of “attachment” and positive social attitudes toward peers and away from parents. Height and weight increase, breasts develop, hair and skin change, all producing a mixture of delighted and anxious feelings about the self, and further reducing (though not eliminating) the adolescent’s concern about relationships with parents.

 Maturation, the series of developmental changes that is largely governed by genetic programs, is rapid and intense during this period when “nothing happened” except the PA intervention. Without good research design that takes maturation into account, studies of PA or other interventions for children and adolescents are wrong if they claim they show the influence of their intervention. Because children and adolescents are always changing—most rapidly around puberty, beginning about age 9 in girls—every study of a psychological treatment for them needs to have a control group, similar to the treated group but nor receiving the treatment, whose characteristics will show us the natural maturational changes that occur during an age period. The effect of the PA or other intervention is shown (roughly speaking) by subtracting:

Changes following intervention (maturation + intervention) - Changes with maturation alone  =
Changes attributable to intervention

There would be many other technical details to be considered in designing a good study of PA or other interventions, but the two mentioned here, blind evaluation and a control for maturational change, are absolutely critical.


Thursday, April 12, 2018

Interesting Times in the Parental Alienation World


The idea of “parental alienation” has been around for some decades—starting with Wilhelm Reich, the orgone man—but in recent years it has been adopted by lawyers and some judges as a way to get child custody transferred from one divorced or separated parent to the other. “Parental alienation” is a concept applied to situations where a child refuses or resists contact with one parent and where the child can give no reasons for this position or gives reasons that are deemed unacceptable by adult authorities. (Physical abuse is considered an adequate reason for avoidance of a parent, but practically the only one.) In these cases, proponents of the “parental alienation” (PA) idea argue that the child’s resistance or refusal is occurring only because the preferred parent has manipulated the child’s thoughts and emotions so that he or she dislikes or fears the non-preferred parent. In this scenario, the preferred parent is referred to as the “alienator” and the non-preferred parent as the “targeted parent”. The child’s mental condition is referred to by PA proponents as “parental alienation syndrome” or “disorder” (PAS or PAD), and this condition is said to involve “splitting” and black-and-white thinking in the present and to predict the development of a personality disorder like narcissism. Actions that bring about mental illness in an individual are considered abusive to that individual, so part of the PA argument is that the preferred parent is abusive and the child must for his or her own sake be removed from that abusive person’s custody. As I noted a few weeks ago on this blog, some PA proponents also argue that for a court to pay attention to a child’s preferences would have malignant effects on the child’s psychological development.

The solution offered by PA proponents for this notional syndrome or disorder is that a child who resists or refuses contact with one parent must be removed from his or her present living situation and placed in the custody of the non-preferred parent. In addition, the child needs to be treated in one or another of several similar residential programs that may last from 4 to 90 days, during which contact with the preferred parent is prohibited or used as a reward for affectionate behavior toward the non-preferred parent. (These programs are to be paid for by the preferred parent and court orders include this proviso.) The programs are referred to as “psychoeducational” and consist of videos and discussions, mixed, apparently, with threats to send the child to a wilderness camp or residential treatment center where they will not be able to communicate with anyone outside.  

Obviously, there really are children of divorce (or even of intact families) who avoid one parent and who cannot explain to the satisfaction of adults why they do this. It’s not unimaginable that the PA scenario of influence actually takes place in some of these cases. But the declaration that there is a related psychological syndrome or disorder, and particularly that such a syndrome is the forerunner of serious personality disorders, is a claim that requires empirical support. Such support has not been presented, and that is why the American Psychiatric Association did not include such a diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

The claim that PA-related residential programs, psychoeducational or otherwise, can repair disturbed parent-child relationships/incipient personality disorders—and do this so effectively that courts should order such treatment to be used against the will of older children and adolescents who would normally be allowed to decide to consent to treatment—also requires empirical support. No amount of speculation in terms of well- or ill-chosen theory can tell us whether a treatment will be effective, and in fact attempts to claim that analogies provide evidence is characteristic of pseudoscience.
None of these points has impressed proponents of PA, and they have been experiencing a good deal of success in influencing high-conflict custody cases and enrolling children in their residential treatment programs.  Some attorneys have been eager to run with the PA argument, and some judges have accepted it with little question. But an event and an observation this week seem to suggest that the PA concept as presented by some of its proponents may be on the way out.

The event is one with a history that needs explanation. In June, 2017, the PA proponents Craig Childress and Dorcy Pruter (a psychologist and a “life coach” respectively) gave a presentation on their views at a conference of the Association of Family and Conciliation Courts (AFCC). Psychologists who attended this presentation received professional continuing education credits (needed for maintaining licensure), as AFCC is an approved provider of continuing education for the American Psychological Association. Although the conference brochure carried a disclaimer to the effect that  including a presentation did not mean approval of its content, to my knowledge at least one attendee came back to his practice full of enthusiasm, declared to a client that the APA CE credit meant that APA approved of the treatment described in the presentation, and attempted to persuade the client to send her child to California for the Childress program.

Complaints about the Childress-Pruter presentation led the APA continuing education committee  to announce this week an agreement with AFCC that Childress and Pruter may never again make this kind of presentation at AFCC. AFCC also agreed to provide an alternative webinar by Michael Saini on evidence-based views of child resistance and refusal and have posted this at www.afccnet.org. Given that according to Childress’ blog he is planning a sort of “March on Washington” where he and his followers will deliver a petition to APA and will videotape its reception, this AFCC-APA agreement may appear as a considerable blow. No doubt the rejection of Childress’ PA claims by APA will only strengthen the cult-like belief of his followers, but the APA decision will prove a powerful argument in many cases where parents are under attack as “alienators”.

The observation I referred to earlier has to do with the CV of a PA proponent (not Childress this time, although his has a sticky problem in the omission of some years of activity). In connection with a current PA suit, I saw the CV of Demetrios Lorandos. Lorandos has been a powerful advocate for the PA position, bringing to the argument both a law degree and a doctorate in psychology. But wait… that doctorate seems to be rather open to question. It came from the Union Institute in 1978. The Union Institute is pretty problematic in itself, having been the alma matter of a number of alternative psychotherapists like Gregory Keck of holding therapy fame. Students there have written dissertations on the topics they chose, and then decided what discipline (e.g. psychology or criminology) they wanted their degrees in. (An Internet search will show you why I say this about what is not quite a diploma mill but more a “wannabe university”.) But on top of those problems, Lorandos’ degree in 1978 predated by seven years the accreditation of Union in 1985. In other words, he does not have a doctorate from an accredited university and therefore should not call himself “Doctor”. (See, for comparison, https://www.insidehighered.com/news/2011/10/12/top_two_leaders_at_community_college_earned_doctoral_degrees_from_diploma_mills.) He may, of course, call himself a psychologist, as he is licensed in that field because of a master’s degree from the New School for Social Research.  How is it that no one has noticed before that Lorandos’ CV shows that he does not have a doctorate from an accredited institution? Well, not everybody spends their time looking at fraud and deception in psychology the way I do.

Am I arguing that Lorandos’ lack of a genuine doctoral degree means that he can have nothing useful to say? No, of course not. There are plenty of expert witnesses who have excellent backgrounds outside academia. But when someone presents himself repeatedly as having a doctorate, and fools people who are not familiar with the Union Institute story, I must question his integrity as well as his training in assessment of research.

Between the Childress and the Lorandos events, I think we may be able to look forward to a day when attorneys and judges will be able to recognize the weaknesses of the PA concept and of the treatments proposed by PA advocates.