Concerned About Unconventional Mental Health Interventions?

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

Thursday, June 30, 2011

That Lawsuit Again: Ronald S. Federici vs. A Crowd of Critics

Some readers may remember a lawsuit for defamation filed against me and a number of other people, part of which I attempted to describe at http://childmyths.blogspot.com/2010/12/federici-v-mercer-story-behind-lawsuit.html. I have to acknowledge now that my guess about Ronald Federici’s complaint about me was quite incorrect. I assumed he was going to complain about my comments on his involvement in the Salvetti case, in which adoptive parents went to prison for withholding food from their son and keeping him locked in a room for months. When I appeared in Fairfax County, VA, Small Claims Court to answer his original suit, that was what I thought the issue was, and I never found out otherwise because the judge rather quickly found for me.

However, when, after several other legal moves, Federici brought suit again against me and others, I discovered that my comments about the Salvetti case were not even a point of concern--- and I presume that this was because the factual parts of my remarks were drawn from documents of the North Carolina Court of Appeals. (I would not have made the statements I did without that kind of evidence to back me up.) Instead, Federici had a number of complaints about things that had been said about him on the Internet, and as it happened not one of them had been said by me.

Now that sufficient time has passed from the dismissal of Federici’s suit in Virgina Eastern District Court (incidentally, the same court that dismissed a defamation suit against Paul Offit about a year ago), all the relevant documents are now posted at http://www.citmedialaw.org/threats/federici-v-pignotti-et-al. You can see in “Federici’s complaint” his attorney’s description of what was said about him, and you can look at the many copies of Internet material to see what actually was said. As I mentioned, there was nothing about the Salvetti case; presumably, it would have been too hard to argue that my remarks were inaccurate. By the way, if you look at the “update” on this case, please note that the recent granting of Federici’s motion was in response to his attorney’s request for a formal statement that the suit against the “John Does” was dismissed, as well as the suit against the named defendants. For anyone interested in this situation, a look at the Memorandum requesting that dismissal will be rewarding, as it reveals the attorney’s reasons for wanting to stop representing Federici.

The Dismissal Hearing Transcript posted at citmedialaw has some points that I found of particular interest. Federici’s lawyer made the following statement: “… they have even called and made complaints that Dr. Federici assisted in the--- in the killing of a child. And they have actually not only put this online, they have actually reached out to the Virginia Board [of Psychology] to actually make the same false complaints.”

I have several comments about this statement. The first is that nowhere in material quoted in the Complaint is any such claim made, by any of the defendants. One thing that is actually said is that some of the methods advocated by Federici are potentially dangerous and have been associated with deaths in a considerable number of well-documented cases. A second point made in that material is that Federici’s methods resemble those of a group of so-called Attachment Therapists some of whose members have been involved in child deaths.

No one among the defendants in this case has accused Federici of killing a child directly or of in any way assisting in such a killing. If any of us thought there was evidence of such a thing, we would not bother to tell his professional licensing board, but would go as quickly as possible to bring our evidence to the police. My own complaints to Federici’s licensing board, which I made some years ago, have to do with inaccurate representation of his professional credentials, which, interestingly, I see repeated by his attorney in the Dismissal Hearing Transcript.

The statement made by the attorney at the dismissal hearing seems to be based on faulty logic. If someone says I’m a clumsy parallel parker, is that the same as saying I’ve damaged other people’s cars and had my insurance rates put up? No, of course not, and to say that someone’s methods are dangerous is not the same as saying that he has directly or indirectly caused a death. Naturally I’m very pleased that the suit was dismissed, but there’s something in me that would have liked to see how an opposing attorney would have handled the claim that anyone had accused Federici of killing.

One question people have asked is who the John Does were. Of the ones I know anything about, most are people who commented online and used pseudonyms. Strangely, though, two were Mr. and Mrs. Salvetti, Federici’s clients who went to prison after their adopted son was found to have been denied a normal diet. Did someone think these people had commented on Federici’s methods? As far as I know, they have been completely silent about the advice they received from him. And, again as far as I know, they were not served with this complaint, any more than the Internet commentators were.

The fact is that this lawsuit was what is called a SLAPP suit: a strategic lawsuit against public participation. Its intention was to have a chilling effect on public discussion of the methods Federici advocates. Federici was asking for compensation of $300,000, plus treble damages under a Virginia law, plus various other odds and ends. I am sure that these amounts were not expected to materialize; the goal was, instead, to encourage mediation, and to demand, in exchange for dropping the suit, a promise not to mention Federici again. Some states have legislation that allows defendants to fight these SLAPP suits, but Virginia is unfortunately not among them.

I mentioned above that the documents are posted on http://www.citmedialaw.org/. Let me take a moment here to praise the Citizen Media Law Project. I’d put their badge up here if I could figure out how to do it! This group, which is hosted by Harvard’s Berkman Center for Internet and Society, provides services to people who run into difficulties when posting legitimate material on the Internet. I e-mailed them on a Sunday and first thing Monday morning had an answer. Within a day, I participated in a conference call with the group and told them what I most wanted, which was a contact with a Virginia lawyer knowledgeable about defamation and Internet issues. They quickly provided me with the name of Josh Heslinga of Richmond, with whom I arranged for an hour’s consultation at his regular fee-- and the work he actually did must have taken about 5 hours and was enormously helpful. Because Josh was at some distance from the court in question, he suggested several other attorneys, and I found excellent representation at Cochran & Owen of Vienna, VA. All of this went smoothly because of the input of the Citizen Media Law Project-- without them, I have no idea how I would have found an attorney I trusted in a state at some distance from my home.

Wednesday, June 22, 2011

Adoptive Parents Feeding Survey

The SPOON Foundation has asked me to invite any readers who are adoptive parents to take a quick survey about foods you used to help the transition from your child's past experience to your ordinary family diet. It's at http://www.surveymonkey.com/s/LZYBK9C.

Do give them a hand, and if you want to talk about it further I'd like to hear your comments.

Monday, June 20, 2011

Creepy Crawlies: Response to Jessica's Comment

On the comments for “Jean Talks!” post from several days ago, Jessica has asked an important question-- which I would answer right there if I could, but some glitch in this site seems to prevent me from doing that recently. (Help, blogspotters!). In brief, Jess is thinking about crawling because her baby is at about the age when it happens, and she wants to know what the story is, about advice that tells you you have to make your baby crawl-- even that you should move the furniture farther apart if a baby who hasn’t crawled yet wants to “cruise”.

As it happens, I was just looking up some material about this today. The first point I want to make about this is that nowadays most of the people who give this advice are chiropractors. See, for instance, http://unitedfamilychiropractic.com/pediatric-chiropractic/chiropractic-and-the-importance-of-crawling/. This chiropractor warns you that if your baby doesn’t crawl, he or she may not learn to read either.

This is pretty scary, but fortunately not true. If you doubt that, ask yourself if you’ve ever met a person with severe cerebral palsy who couldn’t have crawled, but who reads very well. Q.E.D.

The idea of the essential role of crawling in development seems to have been initiated by one Glenn Doman (not Dorman as the unitedfamily site says), a physical therapist who got his degree in 1940 and who in 1955 started the Institute for the Achievement of Human Potential, which still exists in the Philadelphia area. Doman opined, and he convinced many parents and teachers, that failure to crawl was problematic, and that many developmental disorders, from cerebral palsy to autism and severe brain injury, could be cured by a treatment he called “psychomotor patterning”. Patterning was a procedure in which five adults grasped a child’s head and limbs and moved them repeatedly in a pattern that imitated a reflexive movement of early infancy. (This procedure has twice been rejected as useless in position statements of the American Academy of Pediatrics.)

Why did Doman and his present-day chiropractic followers think this would work? As a first reason, they cite neuroplasticity-- the fact that the nervous system can continue to grow and develop long past infancy. Such a characteristic of the brain certainly exists, but it does not mean that any and all damage can be overcome, nor, certainly, does it mean that crawling movements would cause such recovery.

As a second reason, Doman and the gang repeated the mantra of the late 19th century, “Ontogeny recapitulates phylogeny”, or, the development of the individual repeats the development of the species. To a certain extent, this is true-- but it’s also irrelevant. What they really are saying is that they think ontogeny can recapitulate ontogeny, that a person whose development was interrupted or damaged can be made to go through the same developmental stages a second time and emerge healthy. That’s a lot different from anything about species development, and once again, what does it have to do with crawling?

The “cross-crawl” is an especially silly idea, because what true crawl would not be a cross-crawl, with right arm and left leg moving together and so on? It’s true that some animals “pace” by moving the two legs on the right together, and the two on the left together (I think tigers do this, and horses can be trained to do it). But imagine an infant doing a pace-crawl without falling over. As for some poorly-defined need to use the two sides of the body in “cross” fashion, we do this when we’re walking! One leg bears the weight while the other moves forward, and simultaneously older children and adults counter-rotate their shoulders to keep their balance, causing the left arm to swing forward with the right leg and so on.

There are a number of other issues about motor development, in addition to the Doman/chiropractor stuff. One is what Jessica said: babies will crawl or do whatever when they and the circumstances are ready for the action. If you have a very slippery floor, or a rough splintery one, they may skip the crawling part. In any case, they may only crawl briefly, then get themselves up (maybe because your furniture is a good size and shape to pull on), or for whatever reason they may figure crawling gets them where they want to go and stick with it for months.

However, if a baby gets to be 18 months old and shows no sign of standing, or if he or she crawls asymmetrically, using one leg much more than the other , or if only one hand is ever used in crawling or in reaching, those are all possible signs of developmental problems and should be carefully checked out (and in my opinion, not by a chiropractor).

Jessica also queried advice to put the baby on its stomach on a hard surface when he or she is awake. This is an interesting issue. If you are putting your baby to sleep on its back (and I’m afraid there is no really good reason to do that, no matter what you’re told-- but save that for another time), the order of motor development in the first months will be different than what it would be if the baby slept and spent most of its time on the tummy. Pushing up when in the prone position exercises neck and arm muscles and takes strong muscles to do well. If a baby doesn’t push up well because it hasn’t worked at doing it, getting up on all fours is not going to work too well either, and without all fours, crawling doesn’t happen. All those things will happen eventually, but unless the baby gets lots of tummy time, they won’t happen as early as they did before “Back to Sleep” came along. But… by age two years, no one will be able to tell the difference, so unless you’re worried when the baby doesn’t meet the milestones that are based on babies 20 years ago, there’s no real problem here.

Saturday, June 18, 2011

Book Review: "Selfish Reasons to Have More Kids"

I’m bemused. I’ve just been reading the anti-Amy-Chua, Bryan Caplan, whose “Selfish Reasons to Have More Kids” declares that parenting should not be hard or anxiety-provoking, because what parents do doesn’t have much long-term impact anyway. I must say it’s not so easy to make Caplan’s claims and citations congruent with much that’s known about child development. I wouldn’t want to say he’d been cherry-picking, but he seems to have used a peculiar pie recipe, and some of the fruit is hard to identify.

Let me begin my discussion of “Selfish Reasons” by saying that Caplan starts and ends with a surprising and ill-supported premise: that it’s better to have more people, better for the whole world and for you, too, even if they aren’t your children. If we don’t have lots of people, he says, much of the world will be like living in Hays, Kansas (Caplan’s example, not mine, and what he means is that it would be boring to him). This statement suggests some interesting ideas, because what if there were suddenly many fewer people? This has happened at times, for instance in the time of the Black Death in Europe, and the social consequences were enormous. But you can’t necessarily reason from one event’s results to the possible consequences of its opposite. Having no money is bad, and we can reason from that to the idea that lots of money is good. On the other hand, what about Vitamin A? A deficiency is a bad thing and can result in blindness-- a lot is also bad, as we see from the effects on Arctic explorers of eating polar bear livers.

Have we forgotten that much population growth would mean one of two things: either an increased and destructive demand for food and energy, or a great many starving and distressed people? To assert that it’s better to have more people, without providing a rationale that addresses these possibilities, is certainly to slide by an essential question.

However, I can accept with enthusiasm the idea that having more children [than you thought you’d want] would have a number of selfish benefits for the individual or couple. Yes, kids are a lot of fun, and in the words of Holly Near’s old song, “they remind us how to play”. Having a little crowd of people you know very well is a great idea in this age of high mobility, where the old gang of old friends may not be easy to reach. It’s great to see the grandchildren and watch the whole process of parenting from an intimate but safe distance.

Okay, so far we have two assertions by Caplan—first, that it’s good for the world to have more people (which I challenge), and second, it would be nice for me and others like me, and probably for my children and grandchildren too, to have a big family (which I accept).

But how about the assertion that it doesn’t really matter in the long run what parents do? Ah, here’s the crux, because now we run into matters of definition and of choices of information. Everyone is going to die, no matter what their parents did, so looking at occurrence of death would support the idea that parenting makes no difference, but naturally that’s not what Caplan or Judith Rich Harris mean when they make their claims.

I’m going to make a suggestion about what Caplan really does mean. I think he means that the small differences in childhood experiences for the families he knows don’t over-ride the effects of biological differences. Speaking about a highly restricted range of experiences, Caplan is saying that within that range experiences don’t have much long-term effect. Whether the child goes to a Montessori school or a Waldorf school doesn’t make much difference. Whether he’s given a time-out or a single smack on the behind doesn’t matter much in the long run. But Caplan knows that there are some things that do make a difference, because he points out (on p. 89 and elsewhere) that you ought to be kind to your children. He thinks, probably correctly, that unkindness is not inside that restricted range of circumstances where variations have little effect.

In warning against unkindness, Caplan stumbles into the area of parental attitudes and beliefs that help determine both parent and child behavior. Unkindness is not necessarily defined in the same way by people inside and outside Caplan’s circle. In Michael Pearl’s book, “To Train Up a Child”, Pearl and his wife propose that four-month-old infants who cry or resist a parent should be whipped with a willow switch, or, if no switch is available, a length of plumbing supply line is excellent for the purpose. The Pearls believe this is a kind thing to do, because a child who does not learn early to obey his parents will also defy God and be condemned to Hell. Naturally, if you take this view, you’ll consider it far kinder to save your child from Hell, at the expense of a few minutes of pain, rather than to let him roast for Eternity, just as some of us might think the pain of an immunization is kinder to cause than allowing the risk of death by tetanus.

Caplan’s advice to “be nice”, although undoubtedly valid, is in its vagueness a clue to the lack of real information and thought that went into this book. I can’t expect anyone to read on forever, so let me just address one example of incompleteness here: the discussion of behavior genetics. Caplan provides a handsome equation on pp. 73-74, describing the fraction of developmental variance explained by heredity, the fraction explained by shared family environment, and the fraction explained by aspects of family environment that are not shared by the family’s offspring. Very nice, but what is missing, and quite important, is the variety of interactions between heredity and environment. An example of such an interaction would be the custom in some parts of the world of giving available food to males in a family, and restricting females to whatever food is left over. This is particularly relevant to protein sources. The genetic factor, maleness or femaleness, determines how much food is consumed when resources are limited; the genetic factor thus causes an environmental effect that has a direct influence on development of both body and mind. In this type of interaction, the genetic characteristic actually evokes a response from the environment because of social attitudes.

Very well, you say, but I don’t feed my son more than I feed my daughter. What does this have to do with my parenting? What it has to do with the parenting of people who are likely to read this review is that discipline techniques, to work well, need to be matched to children’s biologically-determined temperaments, such as tendencies to explore or to withdraw from new things, or to have a generally positive or generally negative mood. (By the way, I expected Caplan’s interest in biological factors to lead him to temperament, but apparently it didn’t.) An example of research in this area is Kochanska, G., Aksan, N. & Carlson, J.J. (2005). Temperament, relationships, and young children’s receptive cooperation with their parents. Developmental Psychology, 41, 648-660.

Another important point about interactions between heredity and environment has to do with age. It’s so easy to assume that whatever is true about “nature” and “nurture” in infancy will be true in childhood, adolescence, and so on. But this is not the case, and statements about heredity and environment need to consider events across the developmental trajectory. Take for example Williams syndrome, a genetic disorder that has obvious effects but is not very debilitating. Adult Williams syndrome individuals have wonderful language abilities and are extremely sociable, although because they have little social anxiety they may make things awkward for others. So what would you think they were like as babies? Friendly, early talkers? No, they are not at all the way you would expect them to be. They have horrible colic, which lasts longer than with most babies and makes them extremely irritable. When they begin to recover from the colic, rather than laughing and smiling, they stare at people as if longing for eye contact. They don’t even begin to talk until about age two, rather than the typical 12 months or so.

These are just a few examples of the failings of Caplan’s book, which may have started as a desirable antidote to Amy Chua’s drag-them-by-the-hair philosophy, but which has ended up omitting too many details to provide useful arguments. I notice that the Wall Street Journal review admires the book for its omission of abstruse psychological concepts; that’s okay with me, but I do want to see evidence and reasoning that are relevant to claims, not just evidence that “shows the flag” but does not actually speak to the premises of the book.

[Disclosure: This review was written at the instigation of my son. Now may I play with the grandchildren?]

Thursday, June 16, 2011

Gotta Pass the Physical: Child Psychotherapy as a Contact Sport

A friend recently passed on to me some interesting information about some Ohio practitioners who employ holding therapy (HT), a physically-intrusive procedure, as a method of purportedly establishing a child’s emotional attachment to his or her parents. Like many proponents of the Attachment Therapy approach, these particular people attribute a great many childhood problems to a lack of attachment, believe that establishing attachment will solve the problems, and also believe that their HT methods create attachment.

There are quite a few proponents of this unconventional form of treatment, in spite of the fact that HT, a type of physical restraint, has been associated with injuries and even deaths of children, and is remembered with terror by adults who were formerly subjected to it. (For more information on this point, see Attachment Therapy on Trial [Mercer, Sarner, & Rosa; Praeger, 2003]). What makes the subjects of today’s post a bit different is that they require a physical examination before accepting a child into their treatment program. Children aren’t treated unless there’s medical evidence that they can stand the treatment.

I will bet a large amount of money-- even the amount an unconventional practitioner recently sued me for unsuccessfully-- that nobody can find me a conventional psychotherapist who has this requirement for treating a child. (Asking for a general medical exam, to make sure there is no physical reason for mood or behavior problems, is not the same thing.)

The HT practitioners in question are at an Ohio counseling center (www.lake-cc.com). Here is what they say about the need for a preliminary physical examination: “… some attachment and bonding interventions evoke anger or anxiety responses similar to those found after exercise. … at times during the treatment process elevated emotional states are expected. If at any time a participant’s behavior creates a risk of physical harm to themselves or others, brief periods of physical holding (i.e., several minutes) to ensure safety may be indicated. In order to further ensure the safety and wellbeing of all participants in attachment therapy using holding interventions, we require participants to pass a physical exam from their medical provider (similar to those given for sports activities) prior to participation.” (Incidentally, these practitioners also state that they abide by the safety standards of ATTACh, the Association for Treatment and Training of Attachment in Children (www.attach.org), a group that has been stating that its members use only mild holding since shortly after the 2000 death of 10-year-old Candace Newmaker at the hands of holding therapists.)

Let’s examine the claims of the Ohio therapists under a strong light. “Anger or anxiety responses similar to those found after exercise.” What anger or anxiety responses are found after exercise and actually caused by exercise, as opposed to anger at getting a red card or anxiety that your ankle injury will sideline you for the season? As an every-other-day gym attender, and mother or grandmother of four sports enthusiasts, one whom lifts 500 pounds, I have never seen or heard of exercise-caused anger or exercise-caused anxiety. On the contrary, exercise is usually thought of as having a calming effect. Why would we contribute to the YMCA swim team if it made kids unnecessarily upset? Wouldn’t there be a nation-wide anti-youth-sports movement if there were any truth to this idea?

So what’s the point of making this claim, equating exercise and sports activities with the experience of being restrained? It would appear that the goal here is to “normalize” the use of physical restraint in child psychotherapy, to make it appear to be common and acceptable, just like Little League-- when in fact it is not only unconventional but has been established as a potentially harmful treatment as defined by the Emory University psychologist Scott Lilienfeld. By introducing the exercise concept early in their discussion of HT, these practitioners pave the way for their later statement requiring a physical examination, and they close the persuasive bracket by another reference to sports. The "logic" then becomes the following: childhood sports are normal and acceptable; childhood sports require a physical examination; HT requires a physical examination; therefore HT is, like childhood sports, normal and acceptable…. so don’t be alarmed at the idea that there might be some potential for harm in HT; there’s some risk in everything, even being on the swim team.

This is really quite a beautiful and expert use of persuasive techniques, and one almost has to admire the author of the document. Almost--- until it’s remembered that HT is a method whose effectiveness is unsupported by research evidence and which is potentially harmful. It doesn’t work, it can do harm; doesn’t this tell us something important? Of course, the document doesn’t address either of these concerns.

One query: what about the physicians who do these physical exams? What do they think if and when they’re told that the exam is in preparation for psychotherapy? Pediatricians, if you’ve received such a request, did you think of discussing it with child protective services?

P.S.
A few additional points of interest: the Ohio therapists state that they may have parents hold their children for diagnostic purposes. Now, any behavior sample can contribute to a diagnosis, but it’s deceptive to suggest that observations of holding are in any way standardized, or that any systematic research has connected holding behaviors to one diagnostic category or another. This claim is not surprising, though, in light of the therapists’ use of the Randolph Attachment Disorder Questionnaire (RADQ), a poorly-developed and unstandardized test whose creator, Elizabeth Randolph (California psychology license revoked some years ago) states that it diagnoses “Attachment Disorder”, a disorder never described or used in any conventional work.

Tuesday, June 14, 2011

Jean Talks! Podcast for Center for Inquiry

If you want to hear a podcast discussing myths, mistakes, and misunderstandings of child development, go to

http://www.pointofinquiry.org/jean_mercer_child_development_myths_and_misunderstandings/

where you'll also see the adorable cover of my critical-thinking-oriented book Child development: Myths & Misunderstandings (Sage, 2009).

I had fun being interviewed by Karen Stollznow... now I have to buckle down and do the promised revised version of this book.

If anyone has a new myth to suggest, I'd be interested to hear about it....

Saturday, June 11, 2011

Eye Contact and Sign Language: A Comment from "Messy Mommy"

Blogger seems to be having difficulty in permitting me to respond to comments, so I'm going to use this method to call people's attention to a fascinating response I received to a recent post, http://childmyths.blogspot.com/2011/05/more-about-infants-and-eye-contact-gaze.html. "Messy Mommy" has written to describe issues that arose when her toddler was paying attention to gestures and not to faces.

Do read what she had to say if you're interested in this eye contact business.

If anyone has had other relevant experiences with their children, I would be very interested in hearing your stories.

Monday, June 6, 2011

When Child Therapists Promote Coercive Tactics: A Deadly Trickle-Down

The front page of the New York Times today (June 6, 2011) carries a most disturbing story headlined “A Disabled Boy’s Death, and a Troubled System” (http://www.nytimes.com/2011/06/06/nyregion/boys-death-highlights-crisis-in-homes-for-disabled.html?_r=1&ref=dannyhakim). The article reports that “on a February afternoon in 2007, Jonathan, a skinny, autistic 13-year-old, was asphyxiated, slowly crushed to death in the back seat of a van by a state employee who had worked nearly 200 hours without a day off over 15 days. The employee, a ninth-grade dropout with a criminal conviction for selling marijuana, had been on duty during at least one previous episode of alleged abuse involving Jonathan. “I could be a good king or a bad king,” he told the dying boy beneath him, according to court documents. In the front seat of the van, the driver, another state worker…, watched through the rear-view mirror but said little.” The boy was in the face-down restraint position well-known to carry a risk of asphyxiation. When Jonathan stopped responding, the two staff members spent an hour driving around, talking and shopping, with his body in the back of the van.

The article goes on to describe how Jonathan had been losing weight at the state school where he was a resident, and a logbook about his treatment revealed that “the school was withholding food from Jonathan to punish him for taking off his shirt at inappropriate times”. Bruising and other injuries had been part of Jonathan’s school life as well as that of other residents.

Obviously, there was no single cause for this horrible event. Overwork , undertraining, and lack of supervision of staff are important reasons, as is the hiring of individuals with criminal records. But I believe there is another factor: methods proposed by a small number of child psychologists, therapists, and parent educators, which suggest that coercive and potentially dangerous techniques are acceptable ways of dealing with noncompliant children. Those methods are directed toward family use, but I question whether such recommendations do not “trickle down” to use in so-called special education facilities.

Some readers will recall that I have mentioned in earlier posts situations in which parents were advised to withhold food from children in order to force compliance. (I described one case in which the parents who withheld food and kept a child locked up both received prison sentences, but the therapist who advised them suffered no consequences.) Others as well as I have repeatedly discussed the continuing problem of recommendations for restraint of individuals in the prone (face-down) position, and the possibility of asphyxia when this advice is taken.

I would contend that these suggestions do more than put specific home-reared children and their families in danger. The existence of this advice, without response by comment or consequences from professional licensing boards or from national professional organizations, is a signal to those who care for the developmentally disabled. The signal says: withholding food and using dangerous types of restraint are good techniques for families to use; therefore, they are appropriate and acceptable for residential school staff too.

Recently, I spent 90 minutes listening to an audio presentation available at http://www.consequences.com/aggression/audio.html. This presentation was essentially a lengthy advertisement for a $900 weekend training in which parents would be taught methods of restraint declared to be safe by one of the presenters, a person who in his self-published work has recommended face-down restraint as a means of establishing compliance in children.

The weekend was described as providing contact with people to talk to, who would not turn the parents in to child protective services. It was also to include advice about establishing relationships with the police and with protective services staff so they would not take complaints of abuse seriously. Declaring that he didn’t understand “fancy psychotherapeutic stuff”, one of the presenters stated that he was “FBI trained” and that he would personally train and certify parents in restraint methods. The certification would give them credibility with authorities who might otherwise object to their treatment of children. The presenter suggested that single parents needed to recruit outsiders to help them with restraint, and that living in northern Virginia he arranges for Marines from Quantico to do this.

This presenter, and others with similar messages, break no laws when they give this type of advice and suggest ways to evade the attention of authorities who deal with child abuse. Even parents who follow the advice are unlikely to meet legal consequences unless, and until, a child is injured by their actions. As the Times article shows, when that kind of advice trickles down to the residential treatment center level, even harm to a child may receive only the mildest punishment. (In Jonathan’s case, the driver who watched the child being killed “had been fired from four different private providers of services to the developmentally disabled before the state hired him to care for the same vulnerable population”.)

I don’t propose legislation that would prohibit giving bad advice about parenting. There are too many possibilities for any law to cover. I do ask, however, why professional licensing boards and professional groups like the American Psychological Association appear to be indifferent to advice that can mislead parents and harm families, and that may encourage public attitudes that foster ill-treatment of the developmentally disabled. I understand and cherish the First Amendment, but I don’t believe that professional privileges include the right to mislead.

Incidentally, in the audio presentation mentioned above, one of the presenters says that in some states continuing professional education credits may be available for the advertised workshop. If anyone comes across CE units given for such a class, I would very much appreciate hearing from you about it.

Saturday, June 4, 2011

Does Individualized Treatment Mean Systematic Research is Impossible?

In a recent e-mail discussion, someone mentioned to me her belief that it was not really relevant that some psychotherapies for children are not supported by clear research evidence and thus can’t properly be called “evidence-based”. She reasoned that because psychological treatments have to be tailored to individual cases, it is impossible to control how the treatment is done, and real experimental research like that done in physical medicine cannot be managed. Therefore, she argued, we should not demand that psychotherapies be supported by evidence from randomized trials.

That correspondent was talking about a treatment called Dyadic Developmental Psychotherapy, which has not earned the “evidence-based” category, but she was certainly not the only person to make that argument, nor is DDP the only treatment that has been discussed in this way. Several weeks ago, when I was present at a workshop on Sensory Integration treatment, I took the opportunity to ask the presenter privately where she stood on the idea that Sensory Integration lacks the support of research evidence. She cheerfully agreed that it had very little support, and followed up her statement with the argument that individualization of treatments means that it will never be possible to evaluate SI and provide clear research evidence supporting its effectiveness--- so, we should choose to use SI or similar methods simply on the basis of therapists’ judgments about what seems to “work”.

These are not irrational arguments, but I think they are wrong. Obviously, research on any treatment of human beings is going to involve many more complicated factors than, say, studying which kind of fertilizer gives the best crop for a particular kind of bean. With more factors, it becomes increasingly harder to define and interpret outcomes. Nevertheless, by following rules of research design, it’s possible to work out ways of deciding whether a treatment is more effective than another choice (whether it’s a different treatment, no treatment at all, being on a waiting list for the desired treatment, or whatever it may be). Applying those rules gives a better assessment of the treatment than can be given by the judgment of a therapist who is very much involved in the therapy, or the judgment of parents who may have their own reasons for enthusiasm or hostility toward a particular psychotherapy for their children, or for that matter the judgment of the treated children themselves.

Here’s the thing: in most situations where either a child or and adult is going to receive psychological treatment, somebody is going to make a decision about what the treatment will be. That “somebody” may be a parent or a teacher or a judge or a psychologist or a social worker. Without research evidence, none of those people have anything but their own experience or other people’s opinions to go on, and even very experienced therapists can hardly have treated more than a few hundred of certain kinds of problems in their professional lifetimes. Their opinions may be better ways of making choices than flipping a coin, but they can’t be nearly as good decision guides as systematic research, and I’ll tell you why.

1. Individual teachers or therapists can only have a limited number of past observations to go on, but systematic research approaches can bring together information about hundreds of similar cases. The great advantage of having all those cases is that the individual differences between children and their situations are likely to average out and “disappear” arithmetically from measurements of the children’s conditions. In addition, when you work with small numbers of children, it’s much more likely that individual differences will affect the results, and even that the children you are looking at are by accident a different sort of people than the rest of the population. (This is like the old sock drawer problem: if you have a drawer full of socks, half of them white and half black, and you pull out only three, it could easily happen that all three are the same color. But when you pull out a dozen socks, chances are that you will get something closer to half black and half white, and with two dozen that’s even more likely. Similarly, if half of the children will get “better” with a treatment, and the other half will get ”worse”, it could easily happen that a small number of children could by accident all be of the “getting better” type.)

2. Individual therapists or parents may not be in a good position to compare children in treatment to children with similar problems who are not being treated. Without that kind of comparison, it’s impossible to know whether changes in the treated children are caused by the treatment, or whether they change just because they are getting older, or whether their problems are of a temporary kind to begin with. The rules of systematic research direct us to begin a study by establishing a comparison group of people who are similar in age, sex, socioeconomic status, etc., etc. to the people who will be treated, but who will receive a different treatment, or possibly no treatment at all. Simply comparing the children’s conditions before and after treatment is just not good enough, because it gives us no idea whatever why any improvement has occurred, and improvement can take place for a thousand reasons-- even the parents’ changed behavior because they have confidence in a therapist.

3. Individual therapists, parents, or teachers, however careful they may try to be, can find it impossible to be objective about the effects of a treatment. This is not an insult, or even a criticism, but just the statement that all of us human beings easily think or remember things the way that makes most sense to us or that suggests that we’re right about something. Well-designed research does not let this kind of subjectivity get in the way, because it makes sure that children are evaluated by people who do not know what kind of treatment they are getting, and that the data collected are also analyzed “blind” by people who don’t know the children.

4. Individuals may be very much tempted to make decisions about treatments on the basis of other individuals’ experiences-- testimonials, for example. But those individual experiences are very likely to be seriously biased in ways that systematic research is not. What testimonial ever said, “Oh, it was okay, I guess”, or for that matter, “It was ghastly-- what a waste of time and money”? Decisions based on individual experience are likely to pay close attention to positive statements and ignore neutral or negative experiences. On the contrary, the job of systematic research is to try hard to find negative information that will lead to the rejection of a treatment unless it is far more than balanced by positive findings.


All these are reasons why choices about treatment are better based on systematic research than on individual experiences. All choices are likely to be based on some information rather than by random decisions, so it only makes sense to choose treatments based on systematic research evidence when that is possible (and, by the way, it usually is possible, as there are well-supported psychotherapies for parents and children).

One other thought, however. I don’t mean to say that individual experiences are worthless, and in fact there is one situation where they may be enormously valuable in the assessment of a treatment. This is the case when a therapy is actually potentially harmful under some circumstances. We can assume that even potentially harmful therapies don’t hurt every client, because it would rapidly become obvious if they did. However, if they harmed only one person in a thousand, it would be important to know this. Chance factors might mean that no individual in a systematic study would be hurt. We would be likely to find out about problems only from family members or from a therapist who observed an adverse event. Let’s hope that if such discoveries are made, the observers will find some way to make their findings publicly known.