Concerned About Unconventional Mental Health Interventions?

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

Thursday, January 27, 2011

Parole for an Adoptive Mother: Whose Fault Was the Child's Death?

The Utah Board of Pardons and Parole has decided to parole Jennete Killpack, who was convicted in 2006 of the child abuse homicide of her 4-year-old adopted daughter Cassandra several years previously. This disturbing case opens many questions about the responsibility of therapists whose advice to parents leads to tragedy.

Part of the Killpack story can be read at http://www.deseretnews.com/article/635174544/Killpack-receives-prison-sentence.html.
In 2002, four-year-old Cassandra Killpack died when her parents, who claim they were following the advice of therapists from the Cascade Center for Family Growth in Orem, Utah (who had been implicated in another child’s death), allegedly forced her to drink an excessive amount of water. Cassandra died at the home of her adoptive parents, Richard and Jennette Killpack, after the first week of a two week “intensive” holding therapy treatment regimen. In the six days prior to her death, Cassandra had been subjected to 15 or more hours of coercive procedures, including restraint and forced exercise.

Cassandra was first evaluated at the clinic by a former therapist whose license had been revoked in Oregon following his use of holding therapy and related practices . Oregon officials had described his behavior as “egregious and reprehensible” He was denied a license in Utah and claims to have been doing “pastoral counseling” after becoming an ordained minister through the Internet site http://www.ulc.org. This practitioner informed the Killpacks that Cassandra had severe Reactive Attachment Disorder and prescribed a two week “intensive”.

The Killpacks described the first five days of the “intensive” treatment as follows: Sessions were held daily, Monday through Friday, and were also scheduled for the following week. Each session lasted approximately three hours. Normally at least four adults were present, the two parents and two therapists or “support staff.”

Treatment in the “intensive” sessions alternated between holding therapy restraint methods and forced physical activity. Cassandra was restrained on the floor by the adults. The Killpacks say the therapists yelled at the child and told her to fight back, in an effort to purge her allegedly repressed feelings. When holding therapy was not being done, Cassandra was forced to perform repetitive physical activity such as kicking the wall, jumping jacks, running in place , and so forth. Cassandra’s older sister witnessed some of the sessions and described them to investigators, saying that the younger child was repeatedly yelled at during both the restraint and the physical activity .

The Killpacks say they were instructed to continue this manner of treatment toward Cassandra at home in order to facilitate a “breakthrough”. They say they were told by one therapist that if Cassandra did something wrong, like “stealing” food, they were to use a “paradoxical intervention”, forcing her to repeat the infraction over and over. They claim that one therapist said that Cassandra should be forced to drink water as a consequence for misbehavior.

The Killpacks apparently felt compelled to continue the harsh treatment during the two week “intensive” because they had been told that if they gave in to Cassandra’s “manipulation” she would not have the desired “breakthrough.” They claim they were told that if the two week “intensive” did not work, Cassandra would grow up to be a prostitute, drug addict, or school shooter and possibly murder her parents or family members. Furthermore, according to the Killpacks, they were told that if they followed through with the recommended course of treatment they were assured a “one hundred percent success rate.”

The Killpacks claim they were taught to force Cassandra to be completely dependent upon her adopted mother, Jennette, in order to bond with her. Cassandra was required to obtain permission from her mother for virtually everything, including food, drink, and use of the bathroom.

However, Cassandra took some of her sister’s drink without permission from her mother. As a “consequence” (punishment), Jennette forced Cassandra to sit on a bar stool and drink a large amount of water. When Cassandra became weak and semi-responsive, her parents interpreted this as manipulation and defiance. Believing Cassandra to be on the verge of the supposed “breakthrough” predicted by the therapists, the parents persisted in their treatment. With Cassandra’s hands tied behind her back, they restrained Cassandra, tilting her head back, and forcing more water down her throat, using sufficient force that the autopsy showed cutting and bruising of her lips. Mrs. Killpack was apparently the primary actor in this, but she had one of her older children help her.

Cassandra vomited a foamy substance and collapsed on the floor. The Killpacks told her to get a towel to clean up her mess. When she did not get up, they again interpreted her behavior as defiance and persisted in their demands. When the Killpacks finally realized that Cassandra was unconscious, they attempted to revive her and called 911. In the recorded 911 call, Richard Killpack explained to the dispatcher that Cassandra had a lot of “emotional problems”. He said, “she’s very, very sneaky … we gave her a lot of water.” He told the emergency room physician that they “forced the girl to drink lots of water as therapy.”

Cassandra died hours later at the hospital. The cause of death was determined to be hyponatremia, also known as water intoxication.

Mrs. Killpack was convicted in 2006 and sentenced to between one and 15 years imprisonment. At her sentencing, it was noted that she took no responsibility for what she had done. However, the parole decision, and her planned release in January 2012 , are to some extent based on her statement that she understands better what are her triggers that might lead her to lose control in dealing with a child.

Was Cassandra’s death Mrs. Killpack’s fault? Yes, of course it was, in ways both subtle and obvious. Her agreement to adopt Cassandra appears to have been made without common sense judgment about her ability to care successfully for more young children than she already had. In addition, she was unable to consider the nature of the advice she was receiving and to realize that the recommended actions were cruel and potentially dangerous. She may have had little insight into her own anger and frustration and the fact that these could lead her to go too far in doing what she had been told to do. She surely lacked reflection on her actions when she engaged her older daughter, then seven years old, in torturing Cassandra.

But was anyone else at fault here? The reasons that Mr. Killpack was not convicted in Cassandra’s death most probably had to do with the four living Killpack children and the consequences for them if both parents went to prison. He must bear a burden of responsibility for failing to consider and deal with what was being done to Cassandra, but imprisonment may not have been necessary.

There are, however, some responsible parties whose involvement in Cssandra’s death have gone unpunished. Among these are the staff of the Cascade Center for Family Growth, whose dire warnings about the need to treat Cassandra brutally were a direct cause of Mrs.Killpack’s lethal actions. As we have seen in other cases, the therapists, who were not present at child deaths or injuries, watch from a position of comfort while the parents who took their advice are imprisoned. In the Cascade case, an action to revoke the professional license of a leading therapist, Lawrence van Bloem, was in preparation, but he was killed in a car accident before this took place. Other staff members have left Utah and then come back to work in various guises such as massage therapy, in which their activities are not carefully monitored.

Somewhere, too, there are one or two responsible individuals who made a decision in 1990 to invite to Utah some Colorado holding therapists who offered training to state employees and essentially made this approach officially acceptable.

It is hardly practical to pass and enforce laws about specific types of therapy. There have been some efforts to do this, but the results have been weak; in any case, if the issue is how parents treat their children at home, there has been little success in monitoring any aspect of this.

But where, I ask, are the licensing boards and state professional organizations in these situations? National organizations like the National Association of Social Workers have made some attempts at adopting policies rejecting methods like holding therapy, and that is much appreciated by concerned persons. However, it is at the state level that decisions are made to reprimand professionals whose behavior is wrong. Licensing actions have a power that is found nowhere else, but it is not being used. It is time to change all this and protect the public by monitoring psychotherapists and “consultants” who give dangerous advice.

Friday, January 21, 2011

Measure for Measure: Rival Ways of Knowing

In recent months, I seem to have been embroiled in a number of arguments that basically turn on issues about knowing--- how we know, and how we know that we know. A recent one of these is at http://marginalperspectives.com/2011/01/silence-no-harm-seriously.html.
Contributors to that blog took me to task for having said that there had been no reported harm as a result of unusual childhood experiences like those of the much-discussed “practice babies” of the ‘50s and that this was a meaningful fact. They attributed to me the belief that if something cannot be measured, it must not exist. (This is, by the way, a point often discussed by proponents of complementary-and-alternative therapies; see M. Kane [2002], Research made easy in complementary and alternative medicine. London: Elsevier).

Actually, my position, like that of most scientifically-trained psychologists, is that if something cannot be measured, it may or may not exist. We may simply not have developed the right measurement techniques yet. Similarly, if something is said to have been measured, it also may , or may not exist; mistakes may have occurred in the measurement process.

So why would we measure, if neither measurement or the absence of measurement gives us a clear answer? The reason is simple: measurement by agreed-on methods is the only way we can share experience with other people and ask them to confirm our impressions. The whole point of scientific method is that it allows information to be made public, and for each person’s report to be checked by many other people who use the same measurement techniques as the initial observer.

When information is checked against other reports, there are many cases in which later observers fail to confirm the first observations. A famous example is the “Piagetian reach”. This was a phenomenon described by the famous developmentalist Jean Piaget. He reported that when a baby first started reaching for objects, she would look at the object, then at her hand, then at the object, and so on, as she brought her hand closer to the goal. Makes sense, of course-- but it turns out that no one else has ever seen such a thing. It took a while for anyone to realize that the Piagetian reach doesn’t seem to exist, because at first people were embarrassed that they were not as good observers as M. Piaget. Today, improved measurement and recording devices have shown a very different pattern in early reaching than the one Piaget thought he had seen.

Measurement lets us check and re-check what we think we know, and allows scientific evidence to be self-correcting-- although that process of self-correction is admittedly slow and clumsy at times, it can work well.

What’s the rival way of knowing? It’s an approach shared by Oprah, Ralph Waldo Emerson, and many of today’s bloggers. We might call it “personal truth”. Emerson spoke of it as Reason-- defined as knowledge shared with God or the “World-Soul” and present in all souls-- as opposed to Understanding based on systematic observation. (“Personal truths” may be claimed to be based on unsystematic observation, of course.) In this approach, what one person experiences as being true IS true, because it comes from Reason, and there is no need to check and re-check against the observations of others, or to use measurements that can be shared by others. No observation or argument from another person can shake commitment to a “personal truth”, and here we have yet another reason why Jenny McCarthy will not be convinced by the Wakefield scandal.

I support the approach to knowledge that uses measurement and public scrutiny to support or fail to support an idea. Having given some thought to the complexities of measurement and public communication, I find these issues too humbling and challenging for me to ignore. I do not put my “personal truths” (and of course I have some) forward and insist that others should agree to them, but neither am I willing to accept others’ “personal truths” without question.

Neither of these ways of knowing is any guarantee of being right. The emphasis on repeated measurement has a great advantage in the face of challenges, however: it contains ways to figure out what is wrong and to strive for correction. “Personal truth”, on the other hand, simply becomes more definite when challenged. If a matter affected me alone,I might venture to follow "personal truth", but when more people may be affected, I think it's only fair to invite others to check my claims.

Thursday, January 20, 2011

Attachment, the New Imperialistic Schema?

Several decades ago, Sandra Bem, a social psychologist interested in gender issues, referred to gender as an “imperialistic schema”. By this term, she meant that gender had become a concept that was strongly linked to other concepts, and that dominated them. For example, a person thinking about gender would automatically also think about how other characteristics of a person-- even of the world-- would line up as either “like males” or “like females”. Stereotypically, people would think of aggressiveness as “male”, peacefulness as “female”; of strength as “male” and weakness as “female”; of angularity as “male” and “curviness” as female; even of the sun as “male” and the moon as “female”. Other concepts that really had nothing to do with gender were somehow (probably because of repetition) hitched on to the gender schema and could hardly be separated from its “empire”.

Stereotyping of ethnic or class differences also gives examples of imperialistic schemas at work. Schema imperialism can cause us to make mistakes, but it also saves us a lot of cognitive effort, and we lazy humans tend to prefer not to have to think too hard.

I’d like to nominate another concept as a rising imperialistic schema. It has come to imply many more related factors than it was ever intended to mean, and as a result, like gender, it conveys much different information than a dictionary definition might suggest.

The new imperialistic schema candidate is, of course, attachment. This term, in its original formulation by John Bowlby and a few of his colleagues, referred to a young child’s strong preference for familiar caregivers and distress when separated from them at times of perceived threat. But when we read how the term attachment is popularly used today, we see it aligned with and almost inextricably connected with other concepts. Here are some common ideas that connect attachment to other concepts and can lead to confused thinking about family relationships:

1. Attachment is a concept that includes all early mother-child interactions, possibly including those occurring before birth; attachment does not really involve fathers.

2. Attachment includes all positive responses to another person, including recognition of voice or face, or interest in prolonging an interaction.

3. Attachment is connected with all positive aspects of personality development from infancy through adulthood, including obedience, respect, and affection for other people.

4. Separation from familiar caregivers is associated with all negative aspects of personality development, including psychopathy, with any displeasing behavior such as disobedience or sexual promiscuity, and with adult depression or prolonged unhappiness. (A few die-hards would still include autism in this list.)

5. Because adoption usually involves separation from the first mother (see #1, above), the concept of adoption can also be brought into the “empire” of attachment, making all these concepts connected to adoption as well as to attachment.

Allowing attachment to become an imperialistic schema (and to associate it with the gender schema!) means that we lose track of the most basic meaning of the term, and that is what’s happened as the list I’ve just given came into being. When Bowlby formulated his attachment theory, he was talking about specific events in development and their probable outcomes, not about everything that happens in the course of development or about every aspect of interpersonal relations. He was concerned that children who had poor early care would become antisocial, but his work on this involved juvenile thieves, not murderers. Reading about attachment as it is discussed in the blogosphere today, it appears that the specifics of Bowlby’s work have melted away, leaving nothing but a general view that bad developmental outcomes of all kinds are the result of the separation of children from their mothers. The imperialistic schema has taken over a wide range of factors that should be considered independently.

Can we ever fight our way back to the original definition of attachment, or make ourselves use other words to describe other aspects of the interaction between infants and adults? Of course we can-- if we want to. But wanting to change will mean being transparent about the agenda that has driven the attachment schema imperialism. That will be the hard part for many.

[Incidentally, next month’s issue of the journal Theory & Psychology will include an article in which I discuss ways in which attachment theory has been supported by the evidence and ways in which it has not.]

Monday, January 17, 2011

Practice Babies, Wet Nurses, Kibbutzim,and Boarder Babies: Are Humans "Omnicarous"?

A lot of concern is being expressed on various blogs about the history of “practice babies”, as described in Lisa Grunwald’s novel The Irresistible Henry House. Those babies, as probably everyone knows by now, were orphans who were cared for by “domestic science” students in colleges and who had many caregivers, in most cases before going to an adoptive family. The “practice babies” usually experienced multiple caregivers during the second half of their first year, a period of time that is associated with the development of attachment behaviors and which might be a time of vulnerability for emotional development.

However, there seems to be no obvious evidence that these children, who had also had multiple caregivers in their orphanages, were emotionally disturbed later in their lives. (Of course, it may well be that there is no such evidence because no one has looked for it, but it seems to me rather likely that adoptive parents would have complained if the babies they received were troubled, and that attention would have been called to the situation. Maybe not, though.)

On the basis of what’s usually said about attachment, we would expect those “practice babies” to be in a lot of trouble because of the absence of a small number of consistent attachment figures from their lives. But… could it be that our present emphasis on attachment is typical of Western culture in this period of history, and not a human universal as John Bowlby suggested it was? Humans are well known to be omnivorous and to thrive on a wide range of different diets, some of them pretty disgusting to those who are not familiar with them. Could they also be “omnicarous”? Forgive this made-up word, but I’m using it to mean capable of thriving on a variety of different infant care “diets”. Of course, human diets do have to contain certain essential components for survival and good health, and infant care “diets” may also have to contain certain essentials. But it may be that those essentials could be embedded in a wide variety of experiences-- not just the ones that we in industrialized Western countries regard as important.

A 1988 book by Valerie Fildes, Wet Nursing, describes a historically-common care method which is disturbing to many modern readers. Fildes traces the history of wet nursing, the practice of having a baby breast-fed by a woman other then the biological mother. Wet nurses received a salary for their services, those services being possible over a long period because human lactation does not have to be “freshened” by repeated pregnancy as is the case for cows, for example. Wet nurses have been used in many ways, sometimes living-in with wealthy families, and in the early 20th century being employed in hospitals to feed babies. Fildes also tells the fascinating and relevant story of the French bureaucracy associated with wet nursing in the 19th century. The demand for wet nurses was high in parts of France where women had skilled jobs in the textile industry and their husbands and families did not want to lose their income for a nursing period of perhaps two years. These families hired a wet nurse who was certified by the government; the wet nurse came to town, picked up the baby, and went back to her own village, where she might have 4 or 5 other infants and toddlers to care for, most of them being at least partially breast-fed. The babies’ families might or might not visit from time to time. Quite a few of these babies died while with the nurse, but the survivors would be brought home at about two years of age. Various sources record that they were frightened of the biological parents, treated them as if they were strangers, and strove to stay near the nurse. One feels terribly sorry for these terrified little people, forced into this abrupt separation-- but again, there seems to be no particular evidence that the thousands of children who went through this experience later showed unusual emotional or personality characteristics.

Much as I hate to quote Bruno Bettelheim, his book about kibbutz children, Children of the Dream, gives a relevant description of the lack of one-to-one child-to-adult social interaction in the original kibbutz culture. Although things are done differently today, one of the goals of the early kibbutzim was to break the emotional connection between children and parents and to make the children feel a primary loyalty to the group. The small number of overworked adult caregivers could not provide individual comfort or play, and children were expected to and did form their major emotional ties to others in their age group. But, again, no unusual number of mental health problems seems to have resulted from a situation which was far from ideal in terms of Bowlby’s theory of attachment.

One group of babies who may give us some insight into the essentials of the infant care “diet” is the “boarder babies”. These infants may be cared for for months in the hospital where they were born because legal tangles make their placement impossible. Informal observations suggest that these babies, at a time in their lives when they might be expected to have strong preferences for familiar people and maintain interactions with them, are instead friendly in a shallow way to everyone. They smile responsively but are not good at carrying on a longer interaction, and this is thought to be because everyone passing the room has stopped to smile and say hello, but then has left very quickly. The long-term effect of this are not yet known, but it’s possible that the boarder baby infant care “diet” does not contain all the essential emotional “nutrients”.

Our impulse to try to protect babies from unhappiness in every way is probably healthy and calculated to assure optimal development. But it’s possible that we have overdone the idea that good emotional development must follow a single pattern and involve the kinds of mother-child experience that we imagine to be “traditional” or even “natural”. To achieve a real understanding of the essential infant care emotional “diet”, we need to consider the whole range of ways in which humans have successfully reared children who grew to be good-enough humans.

Sunday, January 16, 2011

Prenatal Listening: It's Complicated

A New Yorker “Annals of Psychology” article by the columnist-pundit David Brooks, entitled “Social Animal”, appeared in the Jan. 17, 2011 issue of that magazine. I have to say that it was a fairly feeble article, apparently drawn largely from a Psych 101 textbook of several years ago. However, Brooks” article contained a little discussion of a topic that deserves careful consideration-- whether unborn babies learn from the voices that penetrate the uterus and come to their ears. Brooks stated: “Even when he was in the womb, [the infant] was listening for his mother’s voice, and being molded by it. French babies cry differently from babies who’ve heard German in the womb, because they’ve absorbed French intonations before birth. Fetuses who have been read “The Cat in the Hat” while in the womb suck rhythmically when they hear it again after birth, because they recognize the rhythm of the poetry.”

I certainly do not want to say that none of this is true, but I believe that the important implications of such early learning make it essential for us to examine with care the research behind the claims Brooks is making. The research report stating that French and German babies cry differently is by B. Mampe, A.D. Friederici, A. Christophe, and K. Wermke (“Newborns’ cry melody is shaped by their native language”),and was published in Current Biology in 2009 (Vol.19, pp. 1994-1997). Mampe and her colleagues recorded cries from 60 babies 2-5 days of age (half born of French-speaking mothers, half born of German-speaking mothers) while they were interacting with their own mothers-- having their diapers changed, preparing for feeding, or being soothed when spontaneously fussing. The cries were not the characteristic high-pitched pain cry of the young infant and were not recorded at times when there was a clear reason for pain like a heel-stick for a blood sample.

Mampe and her colleagues analyzed the ways the sound frequencies of these cries changed over the brief period involved in one exhalation of breath. Like adults, infants change their sound production rapidly in ways that can produce a rising tone or a falling one. The researchers were able to analyze each cry and create a graph indicating its pattern, and later to statistically compare all the babies of French mothers and all the babies of German mothers on their cry “shapes”, whether rising or falling. This was of interest because sound production by French speakers involves more rising tones than do the sounds produced by German speakers.

Because there is no reason to suppose that French people have different vocal anatomy than German people, it appears that those different sound patterns must be learned through experience. But when does that experience begin to have an effect? Mampe and her colleagues suggest that the babies must have learned prenatally to use the sound pattern of their mother’s language.

Of course this is a possibility. However, there are some details about this study that need to be examined before rushing to a conclusion. Mampe’s group reported statistical comparisons between the French-background group and the German-background group’s cries, but it’s not quite clear how they did all the steps in their analysis. When there is more than one cry from each baby, and not necessarily the same number of cries from each, there are particular ways to do a statistical analysis; most statistical tests are designed to work on one score or reading from each participant. The Mampe paper does not make it clear how this problem was solved. In addition, the graphic display of the results shows a very considerable overlap between the sound patterns produced by the two groups, with some “German-listening” babies crying with the French-like rising tones. Whatever was happening here, it would seem that whether or not hearing experience made a difference, there were some unidentified factors at work too.

There is a more obvious issue as well, having to do with the basic research design. When the babies’ cries were recorded, they were interacting in some way with their own mothers. Each French-experienced baby was with a French-speaking mother, and each German-experienced baby was with a German-speaking mother. Whether the baby continued to cry or stopped depended in part on the mother’s response. It’s also possible that how the baby managed its rising or falling tone also depended on the mother’s response. Possibly (but of course we can’t tell on the basis of Mampe’s research), a French-speaking mother responded to “French-like” cries, with their rising tone, as if she recognized the sound as language, and to “German-like” cries, with their falling tone, as if this was a vocalization but not related to speech. German-speaking mothers would reverse this, but in both cases the mothers might become more attentive, change facial expression, and speak when they heard the sounds that resembled their own speech, thus rewarding and prolonging a particular sound pattern. To really know about this we would need to switch German-speaking mothers to briefly caring for French babies, and French-speaking mothers to briefly caring for German babies. We might find out that because of her interest in understanding a baby’s intentions, a mother does things that shape even very early sound production.

Let me switch back for a minute to Brooks’ New Yorker article and that final claim that babies suck rhythmically because they recognize the rhythm of the poetry. This statement is presumably based on the well-known study by DeCaspar and Spence in which unborn babies were allowed to hear either readings of the Dr. Seuss classic “The Cat in the Hat” or an alternative with simple but different rhymes. After they were born, the babies were given a nipple device, like a pacifier. If they sucked in one way (long rests between sucks) they would hear one of the readings; if they sucked another way (short rests between sucks), they would hear the other. The babies tended to suck in the way that would let them hear the familiar verse. But… it did not matter whether the person reading the verses was the baby’s mother or someone else. They sucked in a particular pattern in order to hear the familiar verse, not to hear their mother’s voice. And, contrary to what Brooks implies, the babies did not imitate the rhythm of the verse with their sucking rhythms; they just used sucking as a way to choose what they listened to.

The moral of this story, I suppose, is that year by year we learn more about how young humans develop. It’s not easy to find this out-- we have to discover clever ways to get babies to tell us about themselves. A study that seems very definite in its results can suddenly be seen to need substantial follow-up. Regrettably, much of what’s written about children (like Brooks’ New Yorker article) does not include the essential thinking that’s needed before conclusions are drawn. Caveat lector!

Friday, January 14, 2011

Autism, Vaccines, and the Wakefield Study: III: Why Jenny McCarthy Still Believes

Over the last ten days, two articles by the investigative reporter Brian Deer, published in the British Medical Journal, have shown that the research purported to connect vaccination of children with development of autism was not only incorrectly done, but fraudulent in its conclusions. Are you thinking that True Believers will not be convinced by this information, but will go on believing that vaccination causes autism? Yes, you’re perfectly right.

According to the New York Daily News of Jan. 12, Jenny McCarthy, the Joan of Arc of the anti-vax forces, stated that “this hoopla made us a little stronger, and even more determined to fight for the truth”, by which she meant a connection between vaccination and autism, not Brian Deer’s investigation. (And by the way, thanks to Jane Sarwin of Gateway Maternal Child Health for passing this on to me!)

Why does Jenny say this? How can it be that she’s MORE convinced than ever when she receives information that says Wakefield was wrong? In fact, this is exactly what often happens when the facts contradict strongly-held beliefs. The first real demonstration of this phenomenon was described in a 1956 book, When Prophecy Fails, by the social psychologists Leon Festinger, Henry Riecken, and Stanley Schachter. Festinger and his co-authors studied a cult of UFO believers who were convinced that a flood would destroy the world and they alone would be rescued by a ship from another planet. The psychologists had to infiltrate the group, whose members were secretly preparing for their rescue by giving away their property. Of course, the predicted time arrived, and the world did not end. Most of us would have guessed that the cult members would go home in disgust, after telling the leaders in no uncertain terms what they thought of them and feeling thoroughly embarrassed at having been fooled this way. But no, the opposite was true. The believers became more thoroughly committed than ever and began to publicize their beliefs, to seek converts, and to provide flattering explanations for the failure of the prophecy. Similarly, we can expect Jenny McCarthy and her followers to become more active than ever in their support of Andrew Wakefield’s claims.

Sometimes, thank goodness, people do change their minds when new information shows they have been mistaken. Intensified belief seems to occur only under particular circumstances--- and those circumstances are present for Jenny McCarthy and other Wakefield supporters

The first necessary circumstance is that the belief is deeply held and that it is associated with some real-world behavior; the believer acts in ways dictated by the belief. (This is certainly true of the beliefs about vaccination and autism. Like most beliefs about our children, they involve serious commitment. This belief also dictates not only decisions about vaccination, but spoken and written opinions expressed in public ways.)

Second, the believer must have committed himself by an action that would be difficult to undo. (Public statements of support for the anti-vax cause, leadership in the cause, the collection or donation of money to support that cause-- all these are commitments that are so public and well-known that they can hardly be recanted. At least one person in this group even made death threats against the noted vaccine researcher Paul Offit. )

Third, the belief must be specific and related to real world events, so it’s possible for those events clearly to contradict the believer’s expectations. (This condition is present in the vaccination-autism case, but not in such a clear form as occurred for the UFO group. Understanding the evidence for cause and effect in the present case requires more sophisticated thought than simply noticing whether the earth has been destroyed by a flood.)

Contradictory evidence must occur and be noticed by the believer. (Publicity about Brian Deer’s investigation must be making it almost impossible for anti-vax believers to be unaware of the report.)

Finally, the believer must have the social support of other believers-- if social support is missing, an isolated believer is more likely to yield to the evidence. (Organizations and groups of committed individuals have provided social support to anti-vax believers for a decade and a half.)

As we see, then, the circumstances are nearly perfect for an intensification of anti-vax belief on the part of Jenny McCarthy and others who believe that vaccination causes autism. Paradoxically, the overwhelming case put together by Brian Deer makes McCarthy’s group more strongly biased against vaccination at the same time that it convinces those of us who were neutral or opposed to Wakefield’s claims.
If this seems hard to understand, consider what it would mean to Wakefield believers, what they would need to accept about themselves, if they were to accept the investigative report -- that they have essentially made fools of themselves in public, and that they must therefore be foolish people as well as mistaken; that they have been defrauded by someone they sincerely admired and trusted, and that therefore their judgment is poor; that they have risked their children’s health by mistaken choices and are therefore bad parents. Adopting the belief that the report is a tissue of lies or a fraud perpetrated by the pharmaceutical companies is a far more attractive position for believers to take, and it appears to be the position that Jenny McCarthy will espouse.

Thursday, January 13, 2011

Autism, Vaccines, and the Wakefield Study: II. The Apparent Motives

In my last post, I described some important reasons for the rejection of Andrew Wakefield’s 1998 paper that claimed a causal link between the MMR vaccine, the development of autism in young children, and gastrointestinal disease. Information about those reasons came from a remarkable investigation by the British reporter Brian Deer and was published on Jan. 5, 2011, in the British Medical Journal.

Deer also looked into the motives that seem to have been behind Wakefield’s publication of distorted data, and published a discussion of these in the British Medical Journal on Jan 12 (“How the vaccine crisis was meant to make money”). I’ll summarize some of the points Deer described, but this is a long story, and I would strongly recommend that interested readers read the BMJ article for all the disturbing details.

Before the study even began, Wakefield had patented a test for measles virus in bowel tissue and products. Claiming that certain bowel diseases could be diagnosed by detection of measles virus, Wakefield proposed starting a company that would manufacture testing materials and calculated that such materials would bring in over 70 million pounds a year from Britain and America. This income would depend in part on government health administrations and on governmental legal aid funds for patients suffering from bowel diseases. This business proposal was followed by a patent for a single measles vaccine (rather than the usual combination of measles, mumps,and rubella) and the suggestion that there was a connection between measles vaccine, bowel disease, and autism-- a posited syndrome Wakefield called “autistic enterocolitis”. Among the participants in the ensuing business plan were Wakefield, a venture capitalist, and the father of one of the children in the 1998 Lancet study. Also involved was an entity called Freemedic, the commercial section of the merged Royal Free Hospital and the University College (London) Medical School, which later resisted strongly Brian Deer’s attempts to untangle these matters.

Wakefield’s plan thus appears to have been that he and a few others would reap enormous financial benefits from his patented tests and vaccines, and that much of their income would be derived from litigation by parents of sick children. This did not happen, and in fact neither the test nor the measles vaccine had their efficacy demonstrated by later research. (Although Wakefield was directed by his superior to do a controlled study to replicate his research claims, he did not do so.)

What did happen, instead, was that parents became frightened of vaccination and began to resist conventional medical advice about protection from contagious disease. Immunization rates in Britain and other countries dropped and there was an increase in the occurrence of diseases like measles, mumps, rubella, and pertussis, which had been almost non-existent in industrialized countries for some years.

In addition, we have seen the growth of an anti-vaccination community devoted to Wakefield’s cause, and so determined that they must oppose vaccination that they have made serious threats and filed lawsuits against respected vaccine researchers like Paul Offit. My crystal ball tells me that these people will consider Brian Deer’s meticulous investigation to be a pack of lies, like all the other “lies” told about vaccination. In that, they will be very little different from the people who opposed smallpox vaccination over a hundred years ago and suggested that since the smallpox vaccine was derived from cows (vaca, that is), vaccinated individuals would take on cow-like characteristics.

So, those were the real results of Wakefield’s efforts. Wakefield and his friends are disgraced in the eyes of all but the anti-vax crowd, who undoubtedly regard them as martyrs. Children got sick, and sometimes very sick, when they did not need to. And what was it all about? Money, folks, lots of money--- money out of your pocket and mine.

And what about autism? Well, here’s how it is. If your child is vaccinated against common childhood diseases, he or she may become autistic. If your child is not vaccinated, he or she may still become autistic , and he or she may also catch a contagious disease, and as a result of that disease there will be a small but real chance that he or she may die, lose hearing, become mentally retarded, or suffer a number of other lifelong handicaps.

With stakes like that, will you let your decision be dictated by an offshoot of venture capitalism?

Autism,Vaccines, and the Wakefield Study: I. Reasons to Reject Wakefield's Report

Early in 2010, there was an excited reaction to the retraction by the British journal Lancet of an article published by Andrew Wakefield and a number of colleagues in 1998. That article had claimed that research evidence supported the hypothesis that vaccination for some childhood diseases played a causal role in the development of autism. Wakefield’s paper has been a major focus of the anti-vaccine movement and has encouraged parents to refuse vaccination of their children-- with some predictable results in terms of disease and even death of children.

Now in the early weeks of 2011, the British Medical Journal has published two articles by Brian Deer, the Times reporter whose investigation has done so much to clarify the errors in Wakefield’s work. The first of these articles, “How the case against the MMR vaccine was fixed”, appeared on Jan. 5. A second piece, “How the vaccine crisis was meant to make money”, was published Jan. 12.

Lancet's retraction of the Wakefield 1998 paper received attention from bloggers, journalists, scientists, and concerned parents, as we might expect. I’ll summarize some of the criticisms, as they are discussed by Brian Deer in the Jan. 5 article and elsewhere.

The majority of the critiques focus on the ethical errors in Wakefield’s work. Indeed, there were ethical errors by the carload. Wakefield failed to disclose his financial interests in vaccine protocols or in a relevant lawsuit where he was acting as a consultant; he procured blood samples from children whom he knew personally, thus making it awkward for the children or their parents to hesitate to consent to the procedure; he ordered unnecessary and intrusive tests for some children. All these ethical errors would be reasons for reprimands, for the withdrawal of job opportunities, for ordering Wakefield to attend an ethical training program. His withholding of financial disclosure would be good reason for a journal to refuse publication, to print a correction if the article was already published, or in some cases to retract the published material.

However, repellant as Wakefield’s ethical conduct may be, it is not in itself sufficient to support the decision that an article’s conclusion is wrong. A researcher might fail to document informed consent, might intimidate parents and children to get them to participate, and might secretly be on the salaried staff of a corporation with strong related business interests, but if his or her conduct of research, collection of data, and analysis of data were beyond criticism, the research itself could still be of value. Another researcher might follow all rules about informed consent and financial disclosure, but if he or she failed to do a good job in designing and carrying out a study, the conclusions drawn from that study would be worthless. Ethical errors raise questions about the researcher’s integrity in collecting and handling data, but are not necessarily evidence that the basic work has been done incorrectly. Compliance with ethical rules suggests that the researcher approaches his or her tasks with integrity, but adds no credibility to data or conclusions when it’s clear that these do not follow design guidelines. Journals refuse or retract papers when ethical errors are evident, but this is not because their action assures the publication of good material only; it’s because success or failure in publication are the major carrots and sticks available to enforce compliance with ethical rules.

I have seen very few comments about the design flaws of Wakefield’s retracted paper, so I will briefly list some. A major problem with the paper is the small number of children studied. Errors due to chance are much more likely to occur when a study involves twelve children than when it includes 120 children. Such errors might give the impression that an effect is much larger than it really is, but they could also make it appear that it is much smaller than it would appear to be with more data to consider. This is an especially important point in the light of other studies looking at many thousands of children and failing to reach the conclusions reported by Wakefield.

A second major problem has to do with Wakefield’s method of ascertaining what symptoms children showed, and at what times in their lives. Rather than using objective records like notes or videotapes dating from the children’s early years, Wakefield asked parents to recall events that had occurred eight years or more earlier. In taking this approach, he ignored the fact that human memory reconstructs past events rather than plucking them intact from some sort of bookcase of internal recordings. Previous and subsequent events help to determine how, or even if, reconstruction takes place. Memory research dating back almost a hundred years has shown that memories are influenced by expectation and motivation, and that repeated recall, rehearsal, discussion, and consideration of events change the way memories are experienced. These problems are real reasons why Wakefield’s study cannot be considered to provide evidence genuinely supportive of the conclusion drawn and much promulgated.

According to Deer’s investigation, however, there were far more serious problems than flaws in research design. Interviews Deer carried out with parents of children who participated in Wakefield’s study indicated that details reported about their children were not correct. (Because the number of children was so small, parents were able to recognize which case numbers actually represented their own children.) In one case, an American father stated that the child’s autistic symptoms occurred months earlier than the report stated, and in fact began before he received the vaccine. In other cases, there appeared to be no child in the report whose background as described by interviewed parents matched the reported histories. Several of the children had developmental delays and physical problems that were apparent before vaccination occurred. Of nine children described as having “regressive autism” (rather than autistic symptoms existing from early in life), three had in fact not even been diagnosed as autistic.

Deer’s investigation has made it clear that Wakefield’s work was not only sloppy, but involved apparently intentional distortions of the data. Why would Wakefield “fudge” his work? In a second post, I’ll discuss the reasons that Deer has shown.

Tuesday, January 11, 2011

Mothers Superior: Does Amy Chua Have the Secret to Child-Rearing Success?

“Why Chinese Mothers Are Superior”: this is the startlingly confident title of a piece by Amy Chua in the Jan.8 Wall Street Journal. And, in case you think there’s no cultural conflict at work here, the subheading: “Can a regimen of no playdates, no TV, no computer games, and hours of music practice create happy kids? And what happens when they fight back?” In this article, Ms. Chua explains all the things she doesn’t allow her daughters to do, and the fact that she doesn’t allow them to complain about not doing them. She rejects common Western concerns about self-esteem and individuality, and states instead what she considers to be the Chinese philosophy of child-rearing. Here are some important parts of that philosophy:

1. Success comes from hard work. If a child is doing poorly at a task, it is because he or she has not practiced often enough or intensely enough.

2.If someone is doing poorly at an activity, it is not because he or she lacks talent, but because of laziness, and it’s advisable to tell a lazy child he or she is lazy.

3.Activities become “fun” when you master them. Nothing will really be fun until you’ve worked at it enough to experience success.

4.Children owe their parents obedience and behavior that will make the parents proud. The child has to repay the parent for birth and care.

(You'll notice that the "happy children" of the subheading are not mentioned here.)

Chua recounts a knock-down, drag-out fight with one of her daughters about a difficult piano piece, a fight that got somewhat physical and that involved threats that the girl would get nothing to eat, nothing to drink, no Christmas, no Chanukkah, etc., until she got back to work. She did go back, she worked hard, she mastered the piece and was thrilled with her success and later snuggled and giggled in bed with her mother. She was, it seemed, a happy child at that point,and with a kind of happiness that Chua felt would give her a foundation for life-long accomplishment and satisfaction.

So what about all this? Is Chua right and Western parents wrong about how to treat children? I have to say that there are a lot of things that are right in her article!

For one thing, it’s true that the Western preoccupation with unearned self-esteem is useless at best and may even be harmful. There’s a myth that claims that high self-esteem causes high academic achievement, and as a result of this belief both parents and teachers have for some years concentrated on making kids “feel good about themselves” rather than on facilitating learning. The problem, as so often occurs, is that there is a correlation between high grades and high self-esteem, but this does not necessarily mean that the second causes the first. It makes just as much sense, if not more, that getting good grades could improve a child’s self-esteem. It can also be the case that other factors, like good health and good family functioning, can make for both good schoolwork and high self-esteem, especially for elementary school children. We should also keep in mind that there is in the United States a whole “self-esteem industry” providing toys, workbooks, and exercises that are supposed to increase you-know-what (see Humphrey,N. [2004]. The death of the feel-good factor? Self-esteem in the educational context. School Psychology International, 25, pp.347-360), and that industry makes it harder for parents or teachers to step back and take a common-sense look at the self-esteem concept. (It’s hard for people even to remember that 50 or 60 years ago, to say someone had high self-esteem was NO compliment .) I don’t want to suggest that we insult our children at regular intervals, but constructive criticism or instructions are not to be feared as detrimental to personality development. They may not be nearly as detrimental as constant cries of “good job!” and stickers for every accomplishment right down to breathing.

Chua is also right about the Western attitude that “talent” rather than hard work is responsible for success. We easily buy into the argument that someone “just can’t do math” or “just can’t learn languages”, rather than considering whether better instruction or more serious practice might be helpful. Of course it’s true that at the highest levels of performance there are gifted individuals who can do things no one else could do even if they did nothing but practice. Most of us will never win the Putnam Prize, sing at the Met, translate “The Tale of Genji”, or dance with the Bolshoi. But this does not mean that we can’t master the multiplication tables, learn to sing with the children’s choir, memorize French verb forms, or do anything else we have the general intelligence and physical capacity to manage. It’s hardly fair to any child to let her grow to adulthood unable to make change because we think she, a normal primary school pupil, “can’t do math”. Chua, in fact, says that if parents really care about their child they won’t let anything like that happen.

What’s wrong with Chua’s approach, if anything? I’d say that I do have questions about the article itself. Does it really represent family life in Chua’s household? What’s actually the proportion of time spent in hand-to-hand combat, and the proportion of ordinary cheerful family time? Chua writes such a vivid account of the fight over the piano lesson that it distracts us from anything else, but I can only think that if the conflict weren’t pretty unusual Chua would not have made it the centerpiece of her article. There has to be a lot more going on-- the parents’ marriage, the father’s relationship to the girls, Chua’s work, the sisters’ play together, meals, laundry, and all the rest of life. And did Chua really mean the girl couldn't eat or drink until she practiced and learned?

Beyond that issue, I see a couple of concerns. One is simply that brute force and threats are not the only way to encourage a child to do a frustrating task. Dividing the task into parts-- something children are not good at doing for themselves-- can be a great help that parents and teachers can easily provide. The child wails, “oh, I have to write such a long essay about our class trip-- it will take forever-- I don’t know how to do it!”. Rather than yelling at the frustrated child, a parent can suggest one of the steps needed for a beginning-- maybe “can you write a list of five things that you saw?”. Often the real problem with frustration is the child’s developmentally-based trouble with formulating a series of smaller tasks and attacking them one by one. With guided practice, he or she learns that there are ways to do this and develops strategies for cutting a job into manageable pieces.

As for excluding all the social events and school plays that Chua lists, I think that approach deprives children of chances to learn some important social skills, ways of thinking about others, and ways of thinking about themselves. One of the developmental tasks of childhood is to begin the mastery of the social rules that help us work as well as play with others, and although this achievement begins in the home, it can’t end there. Adult life requires us to deal with people other than our nuclear families and to figure out what they think and what they want. We don’t have time to learn how to do this when we grow up and embark on our careers and our own families, and we need a chance for this kind of learning in childhood.

I can’t imagine applying Chua’s whole program as she describes it-- but I’m not so sure that she applies it either. Perhaps the better approach (and maybe what Chua and her husband actually do) is what we might call conscious parenting with plenty of reflection on what we choose to do, and why, and where we and our children are trying to go.

Sunday, January 9, 2011

The Urban Legend About the Russian Orphans

I thought I would have a peaceful breakfast this snowy morning, January 9, 2011, with the Times Sunday Styles section. What could be in there to bother me, except maybe pictures of people in high-fashion camouflage clothing, an oxymoron to my mind?

But there was something bothersome, and it was on the first page. One Nicole Hardy had written a piece called “Single, Female, Mormon, Alone”, and although what she had to say was interesting, insightful, and well-written, and I wish her all the best, it took only a few paragraphs before my myth alarm went off loudly. Ms. Hardy wanted to find a good metaphor to convey how isolated she felt as a celibate adult, and how she felt she hadn’t been able to really grow up as an “old” virgin, so here’s what she compared herself to: “like the Russian orphans I’d read about whose lack of physical contact altered their neurobiology and prevented them from forming emotional bonds.”

It would seem that everybody now knows these things: Russian orphans can’t form emotional bonds . It’s because they didn’t get much physical contact when they were babies. That changed their neurobiology. They’re not like you and me or other human beings any more.

As is the case with other urban legends, the only trouble with this one is that it isn’t true. None of the parts we can unpack from Ms. Hardy’s statement is a demonstrable fact. I’ve discussed recent research on these issues at www.childmyths.blogspot.com/2010/12/when-romanian-orphans-grow-up-recent.html. Michael Rutter and other researchers of the English and Romanian Adoptees study have been following over 300 children adopted from Romanian orphanages in the early 1990s. These orphanages had appalling conditions, probably for many of these children the worst that could be experienced and still have the child survive; they were certainly worse than present Russian orphanages, so if there are many bad outcomes from poor early care, we would expect those outcomes from the Romanian adoptees.

Here are some points from Rutter’s research that are relevant to the urban legend Ms. Hardy chooses as her metaphor:

1. “Orphans from Eastern Europe can’t form emotional bonds”
In fact, in the Rutter research, most of the children had normal relationships with their adoptive families. Those who seemed unusual in their relationships (and there were more in the adopted group than in a non-adopted comparison group) were overly friendly and more likely than is usual to approach strangers or wander away. The developmental scientist Megan Gunnar, commenting on this in the Society for research in Child Development monograph “Deprivation-Specific Psychological Patterns: Effects of Institutional Deprivation” (Rutter et al, 2010), pointed out: “we should not be focused on garden variety attachment problems but ones that fit within the ‘disinhibited’ framework [excessive friendliness—JM]. There are still plenty of questions about whether [disinhibited attachment] is primarily a disorder of the attachment relationship… Though some [disinhibited attachment] behaviors do deal with failure to check back with the parent in anxiety-provoking situations, most deal with disinhibited behavior or lack of social reserve with strangers… it is not just that these children are really overly friendly with strangers; rather, they seem to have problems with social boundaries” (p. 243). Gunnar’s comments suggest that a failure to form emotional bonds is not the issue.

2. “The reason they have problems is a lack of physical contact.”

Although it is undoubtedly true that few, if any, of the Romanian group were cuddled or kissed the way we expect family babies to be, there is no reason to choose that deprivation as the cause of any problems that may occur. They were also both underfed and malnourished in terms of receiving appropriate nutriments. Some were confined to their cribs almost indefinitely, and were cleaned by being squirted with garden hoses. To choose a lack of physical contact as the major problem out of this menu of deprivations is arbitrary and misleading.

3. “Their experiences changed their neurobiology”.

While this is an important issue, too little evidence presently exists about brain-behavior connections to be able to make this statement. For discussion, see www.santiagodeclaration.org.

Poor Ms. Hardy. She was just looking for a good metaphor to use in communicating some of the peculiarities of her life, and she stumbled into a major controversy. I can’t really blame her for picking up this urban legend--- that’s almost what urban legends are, things people pick up unquestioningly-- but I would have liked it if she hadn’t added this one more brick to the wall that keeps people from seeing through a legend that has caused a lot of trouble to a lot of children and their adoptive parents.

Saturday, January 8, 2011

To http://etfamilies.websitetoolbox.com: A message

Dear etfamilies administrators:

A number of readers have come to my blog from yours over the last several days, so I went to have a look at your blog, where I see I have been the subject of discussion. I would like to comment on an inaccurate statement having to do with my Psychology Today blog, but I find that I can't register. My user name doesn't meet standards, I'm told, but there is no description of the standards and no way to communicate with anyone without being registered. I am hoping that you or one of your readers will see this and let me know what to do to register.

As it is, a completely inaccurate statement about me can be read by all, and I have no way to correct it.

By the way, I am wondering whether you check on the identities of your contributors.I would hazard the guess that one of the contributors to that thread is in fact one of the people the thread discusses.

Best regards,
Jean Mercer

Saturday, January 1, 2011

When Restraint Should Be "Prescription Only"

Those of us who from time to time speak out against the use of inappropriate physical restraint of children can expect certain criticisms in response. We are told that we are na├»ve, inexperienced, professionally untrained, and that physical restraint is essential to protect adults from wild children, children from each other, and children from themselves. We even hear from a very small proportion of clinical psychologists and social workers that when children are upset and out of control, physical restraint has a beneficial therapeutic effect. Some therapists recommend to parents that they use “take-downs” and physical restraint in order to ensure the obedience of their children.

There is a tiny grain of truth in these criticisms. It is, of course, correct to say that there may be times with any child when physical restraint is the best and quickest way to prevent some sort of disaster, and no one has said otherwise. (The same is true for adults--- what if you see that your friend is about to walk into an unmarked glass door?) But the criticisms also contain many grains of falsehood, especially with respect to a speculated therapeutic effect of restraint, an outcome which is unsupported by any systematic evidence, in spite of the publication of several papers that make related claims.

So, why do people so easily accept the idea that physical restraint is a method of dealing with children that should be left unregulated? It’s possible that part of the thinking about this comes from the experiences most of us have had as parents or caregivers for infants and toddlers. Almost anyone who has cared for a toddler will have on one or more occasions picked up that resistant little person and carried her away for a diaper change (whoever said babies cry to have their diapers changed?!), a bath, a nap-- whatever needs to be done and is unwanted by little Ms. or Mr. Autonomy Stage. When we think about an older child who is resistant or aggressive, it’s easy for us to imagine the situation as parallel to what we’ve done ourselves, with physical restraint or coercion definitely being done for the child’s own good.

But, regrettably, this is often not the case. In too many situations, physical restraint left to the judgment of institutional caregivers results in tragedy. Although I am not given to sensational or “journalistic” language, I cannot find more descriptive words for some of these events than “torture” and “murder”.

I am going to describe a case of this kind, the death of Angellika Arndt in Wisconsin in 2006. Her death and its subsequent investigation have been described by Disability Rights Wisconsin at http://caica.org/Angie%20-%20Seclusion%20Paper.pdf. (Disability Rights Wisconsin has not copyrighted this paper and invites interested people to distribute parts or all of it.)

Angellika Arndt was 7 years old when she died following chest compression asphyxia at a facility of the Northwest Counseling and Guidance Clinic. She had been removed from the home of her biological parents at age 3 because of abuse and had been in foster care and later in the residential treatment center. She was diagnosed with a number of cognitive and emotional disabilities, including an attention deficit disorder and an oppositional disorder. It was reported that she could not remember the day of the week five minutes after it was told to her.

Angellika’s caregivers at the residential treatment center employed two notable approaches to her. The first was for the child to be placed in a “cool down” room where she was expected to sit straight in her chair with her feet on the floor and her hands in her lap for 15 minutes. Timing did not begin until she was in the required position, and if she fidgeted, the time started over. If she continued to fidget, she was placed in prone restraint for a period of time. According to the Disability Rights Wisconsin report, Angellika in the few weeks before her death spent 20 hours in “cool down” and 14 hours in prone restraint-- a face-down restraint on the floor that lasted as long as an hour and a half.

Here is a description of Angellika’s first day at the residential treatment center, from the DRWI report: “…less than two hours into the program, Angie was placed in the time-out room for hitting her own chin with her hand. No self-injury was noted in the record and she stopped this behavior within five minutes. When she continued to fidget in her chair she was threatened with a physical control hold if she didn’t stop. This was the standard admonition given by … staff in response to the occurrence of any behavior to be discouraged, along with the admonition ‘you know what the expectations are’. When Angie didn’t stop, eventually kicking off her right shoe, she was immediately placed in a prone restraint for 85 minutes. By the end of her first day…, Angie had spent 5 hours either isolated in time-out or being restrained, and less than 2 hours engaged in actual activities.” Over the next several weeks, she was to experience similar treatment for “disruptive” activities like having her hood on, talking baby talk, and gargling milk.

During some of her many prone restraints, Angellika vomited or appeared to fall asleep. On the final occasion, she was thought to have fallen asleep while restrained, but eventually a staff member noticed that her lips were blue and she was not breathing. She had died while pressed against the floor by several staff members, kept there despite her complaints of pain and nausea.

Deaths like Angellika’s are a rare but very possible result of the use of physical restraint by professional caregivers whose actions are poorly supervised and regulated, and whose training has been superficial. Given a powerful weapon to control children who are annoying them, they deploy it at once rather keeping it as a safety measure. Indeed, their constant resorting to restraint serves to exacerbate children’s mood problems, to increase resistance, and to limit the cognitive ability the child can bring to bear on a problem. Torturing the child by repeated threats and demands for impossible levels of compliance, they pave the way for a response that ends in death.

The people who killed Angellika Arndt were professionally trained caregivers, but still appear to have been incapable of making appropriate judgments about restraint of this child, whose attention deficits and emotional history made her less capable of compliance than many children. When medications have the potential for causing painful and tragic outcomes, they are legally available only on prescription. We need to awaken to the fact that serious physical harm can result from methods that adults are taught or advised to use, and that rather than letting caregivers decide how to use dangerous techniques, those techniques also need to be “prescribed” in schools or treatment centers as they are in hospital settings.

We need to give similar consideration to situations where parents are given brief training or reading material, and advised by certain therapists to use physical restraint in their daily interactions with their children. Those parents and their children are put in a potentially dangerous position and should question the advice they receive, as any resulting tragedy will harm the family and leave the advising therapist without legal responsibility. As for the therapists who give this kind of advice, I challenge them to show the public systematic evidence that these practices are effective and safe-- or to change their ways.