Concerned About Unconventional Mental Health Interventions?

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

Tuesday, November 29, 2011

Adoption Risk Factors and "Strong Idealization of Motherhood"

A recent publication discusses the emotional difficulties associated with adoption and takes a much more complex view than the Primal Wound approach advocated by Nancy Verrier. The paper (St.-Andre, M., & Keren, M. [2011]. Clinical challenges of adoption: Views from Montreal and Tel Aviv. Infant Mental Health Journal, 32, 694-706) examines a variety of risk factors and recognizes that no single problem determines a good or bad developmental outcome for the adopted child.

Among other issues, St.-Andre and Keren consider the effect of post-adoption depression (PAD), a problem that has received little study but that probably occurs at least as often as post-natal or post-partum depression (PND or PPD-- also called perinatal mood disorder, PMD). They point out a number of reasons why PAD may have received so little attention, including the view of adoption as a happy ending to a sad story of infertility, the fact that there are no obstetrical problems to deal with, and the apparent absence of the abrupt hormonal changes that follow childbirth. There may also be an assumption that an adopted older child will be less “trouble” to take care of than a newborn, and that the adoptive family can thus just go on with its life without missing a step. Whatever the actual causes of depression following birth or adoption, there is no question that maternal depression contributes to developmental problems.

St. Andre and Keren suggest that, just as birth mothers should be screened for PND, adoptive mothers should also be screened for factors that make PAD likely-- and that the factors contributing to the two forms of depression are quite similar. They list among the risk factors a past history of depression or anxiety, a family history of depression or bipolar disorder, low social support, and early relationship difficulties. To these, they add a risk factor that I find very interesting: “strong idealization of motherhood”.

To the best of my knowledge, there has been no systematic investigation of the role of “idealization of motherhood” in postpartum depression or in problems of adoptive families. It’s not even clear how such an attitude would be measured or detected. From a purely speculative viewpoint, though, I must say it rings a bell.

Idealization of motherhood has been mentioned in two popular books (Estela Welldon’s 1992 Mother, Madonna, whore: The idealization and denigration of motherhood, and Susan Douglas and Meredith Michaels’ 2003 The mommy myth: The idealization of motherhood and how it has undermined all women). As well as discussing other feminist issues, these two volumes touch on the idealization of motherhood in the sense that I think St-Andre and Keren intend-- the belief that being a mother is woman’s highest calling, the crowning achievement of life, and a state of nobility and virtue. This kind of idealization is also much to be met with on web sites that specialize in what we might call “motherhood porn”, sentimental descriptions of mothers’ love and sacrifice in the face of their children’s indifference or even hostility. These approaches are nothing new, going back to Victorian times and before; when seriously annoyed with me, my own mother once sent me a verse that described how a mother was the only person who refused to believe that her child had committed murder (and he actually had!).

Why would idealization of motherhood be a factor in the development of post-adoption depression? Motherhood (and fatherhood too) in reality involve a tangled skein of joys, pains, boredom, overexcitement, social isolation, financial terrors, and exhaustion. The adoptive family additionally experiences both praise and criticism from outsiders, fears about the nature of the “stranger child”, and the impact of being observed by agency staff. They have had a roller-coaster ride of timing, sometimes having to “hurry up and wait” for long periods and sometimes being told that the baby is here right now. To represent this life stage as a crowning achievement is about the same as suggesting that having your appendix out is a transcendental experience. (It’s much better than not having it out when you need the operation, of course.)

I don’t mean to downplay the wonderful things about having children. But parenthood is real, not ideal. It has all the gritty, dirty, discouraging aspects of any part of real life, and however well we manage it we cannot realistically consider later on that we did everything right. As a Massachusetts DMV worker once told me, “we’re doin’ the best we can”. If we’ve idealized what it means to be a mother, and can’t accept that all we can do is “the best we can”, the meeting with reality may trigger depression in people who are vulnerable to that emotional problem-- whether it’s labeled PND or PAD. On the other hand, if nobody idealized motherhood at all, how many people would adopt?

Of course we can’t completely prevent depression by reminding people of the realities of parenthood and arguing against idealization of motherhood. And there is more to the picture than parents’ mood disorders, wherever they come from. In thinking about the potential problems of adoption, St-Andre and Keren emphasize the importance of taking a transactional view-- looking not only at multiple factors, but considering how parents and children influence each other, and how those influences change over time. Although a mother’s vulnerability to depression is of great importance, characteristics of the adopted child also contribute to the risk of problems. For instance, difficulties are more likely if the child has experienced extreme deprivation of care in the first two years or when adoptions are later in the child’s life. Multiple simultaneous adoptions are problematic (and unfortunately appear to be encouraged by Russian orphanages).

Friday, November 25, 2011

The Nathaniel Craver Case: Many Dissatisfactions With Decisions

If you have been following the trial of the adoptive parents of Nathaniel Craver in York, PA, you know some of the details of the case. Nathaniel (Ivan Skorobogatov) was adopted from Russia in 2003 and died as the result of multiple injuries and malnutrition in 2009. The parents, Michael and Nanette Craver, were recently convicted of involuntary manslaughter and given a sentence which allowed them to be released for time served. Their defense had argued that Nathaniel’s injuries were self-inflicted.

Russian representatives have stated strong objections to this mild sentence, as has been reported by the New York Times (http://www.nytimes.com/2011/11/20/world/europe/russia-angry-at-penalty-against-dead-adopted-boys-parents.html) and also by the English-language version of Pravda (http://english.pravda.ru/russia/politics/22-11-2011/119704-cravers_russian_boy-0/). Pravda reported a statement addressed to Secretary of State Hillary Clinton and Attorney General Eric Holder by the Russian Ombudsman for Children’s Rights Pavel Astakhov. Astakhov remonstrated about the inappropriateness of the sentence and asked for an appeal to be filed. In addition, Vladimir Markin, spokesman of the Investigation Committee of the Russian Federation, stated that documents about the case have been forwarded to the National Central Bureau of Interpol, a step that according to Markin placed the Cravers’ names on an international wanted list with the goal of arresting them and bringing them to Russia for prosecution.

I too am dissatisfied with the results of this trial, but I acknowledge that without far more evidence a death penalty decision would have been profoundly questionable. My concern is directed to the failure of the state of Pennsylvania to discipline persons who were either active or passive accessories to the child’s death. This situation was a regrettable example of similar failures that have occurred in case after case of deaths and injuries of children in the last 15 years. Individuals who were mandatory reporters of child abuse (required by law as members of their professions to bring abusive situations to the attention of child protective services agencies) did not report and were apparently inattentive to indications of trouble. Others who were not mandatory reporters but observed problems failed to take the responsibility they should have taken.

Again and again, therapists and counselors have come forward to testify that children who have been harmed are themselves guilty of their injuries. The two-year-old Russian adoptee David Polreis, who died of injuries in 1996, was said to have beaten himself to death with a wooden spoon. An older Russian boy (State v. Salvetti, North Carolina Court of Appeals 2010) who was poorly nourished and had been kept in isolation was said by a therapist to have refused food offered by his adoptive parents. Staff of the Institute for Children and Families, who were involved with treatment of Nathaniel Craver, stated that Nathaniel knew how to push his mother to the breaking point. One staff member, a school psychologist with a degree from a sometimes-accredited institution, testified that the child’s condition might have been worsened by a period in foster care, apparently implying that his condition was the factor that led to his death.

Where were these people when the harm was being done? If they believed that the children self-injured or precipitated injury by other people, why did they not monitor what was happening more closely? Why not help the parents engage in training programs to help them deal with risk-taking or self-injuring children? If the parents were seen as potential threats to provocative children, why not guide them into counseling that would help them control their own impulses? If a child is refusing to eat or is known to have feeding difficulties, why not enlist the family physician and keep growth records to make sure that growth stays within normal limits? Although legal restraints come into the picture only after harm is done, good practice for mental health professionals includes anticipating problems and helping to prevent them by supplying appropriate interventions.

The First Amendment permits therapists and parent educators to state their opinions to parents, even when those opinions are not supported by systematic evidence. Making mistakes in their practice, advice, even testimony, does not make these professionals liable to prosecution. However, the state of Pennsylvania, like other states, has the option of disciplining mental health and other practitioners through state licensing boards. These boards can investigate professionals for ethical and practice errors and can discipline them in a variety of ways, including license revocation. But a look at the on-line records of state boards shows that investigation and discipline are rare except where there was an injury caused directly by the practitioner, or where there was sexual misconduct, or where drugs and alcohol were involved. Failure to follow up injury or malnutrition is rarely a disciplinary matter-- even when the practitioner later testifies that the child’s own behavior (the practitioner’s presumable focus) caused the problems. State licensing boards justify their disengagement by pointing to their low budgets-- but cases that culminate in physical injury or death of children surely deserve priorities even higher than cases of sexual contact with an adult patient.

It has become abundantly clear in recent years that Russian adoptees are especially likely to be injured, killed, or abandoned. Whether this is due to the problems the children have to start with, to the nature of the adoptive parents, or to both, is unclear. Anecdotes about Russian institutions suggest that there may be pressure for adoptive parents to “take” more children than they had planned for, and this may also be a risk factor. But whatever the causes or mechanism, everyone with an interest in adoption has already heard about the tragic outcomes for some of these arrangements. Doesn’t this suggest that therapists, counselors, caseworkers, teachers, and pediatricians should all be especially alert to signs of trouble in adoptions from Russia? Lark Eshleman, one of the Cravers’ therapists, notes on her website the many years in which she has worked with foreign adoptions; did it not occur to her that a Russian adoptee with unexplained or self-inflicted injuries should receive extra attention, and that his parents needed more careful guidance than most adoptive families? Did not the fact of a previous abuse investigation alert anyone to the need for an appropriate care plan that would not punish the parents but would guide them to safe and effective child-rearing approaches?

If professionals working with foreign adoptions can’t keep these issues in mind, and state licensing boards are indifferent-- well, perhaps the Russians are right in turning to Interpol, but they need to add some names other than the parents’.

Wednesday, November 23, 2011

Disrespect or Disobedience? A Matter of Perspective

This morning I received an e-mail from someone who writes about nannying. She very nicely sent along some of her work, and hoped I might mention it on this blog. I am going to talk about it, but I won’t cite my source, because I can’t agree with most of what she said.

The material I was sent discussed problematic child behavior that nannies might have to deal with and listed a number of issues like disobedience, tantrum-throwing, and lying. I certainly agree that these can be problems if they occur frequently (but breathes there a child who has never done any of these things?). My concern is not that my correspondent pointed out these problems, but that she classed them as matters of disrespect to the nanny.

From early life, children behave toward others with what would be appalling disrespect if it were done by an adult. (I don’t know about you, but if one of my friends stuck a finger up my nose, I would definitely take umbrage.) One of the jobs of adult caregivers is to guide children toward empathic responses that will lead them to be respectful of others’ feelings.

This is a job that is better done by adults who see it as the job it is, rather than focusing on whether they have personally been disrespected. One of my real concerns with the nanny material I was sent is that by using the term disrespect to categorize disobedience and other problematic behaviors, it encourages child care providers to perceive child behaviors as personally significant, rather than as goals in the task of child guidance. When we see ourselves as being disrespected, we are likely to be angry and resentful; when we are angry and resentful, we don’t think clearly; when we don’t think clearly, we can’t bring all our knowledge and ability to bear on what we want to accomplish.

Don’t misunderstand me. Although I know that disobedience and so on are common foibles of childhood, I would not for a moment say they are unimportant or suggest that they may all be ignored. On the contrary, it’s because I think child guidance is so important that I don’t want it to be confused with separate issues like a nanny’s sense that she gets the respect she deserves.

Disobedience and other problem behaviors are significant issues in several ways. One is that they are strongly related to health and safety concerns. Children who frequently disobey home rules (“don’t jump on the bed”) can’t be trusted to stop at the corner before crossing a street, or to keep their hands away from sharp knives in the kitchen. We owe it to children to train them in reasonable obedience to reasonable rules, for their safety as well as for our adult convenience (our needs do count in this equation sometimes, too). However, a sensible approach to obedience recognizes that young children may forget or misunderstand directions, and some older children may act on impulse or take risks when they need attention. Their disobedience, although it needs to be worked on, should be understood in terms of their developmental stage or individual characteristics, not in terms of their wish to annoy a particular adult, or their lack of esteem for that adult.

My correspondent included lying and tantrum-throwing among “disrespectful” behaviors, and of course if our adult friends do these things to us we rightly interpret their attitudes toward us as less than respectful. With reference to children’s lying, let me suggest several interpretations that may be more fruitful than assuming they are disrespectful. Depending on the child’s age and situation, here are some possibilities: the child may be frightened of some consequences of his own or other people’s actions; the child may have misunderstood events or information; the child may be telling a story about imagined events; the child may not remember events or understand the question. If the child has reasons to be frightened, those reasons need to be explored for the child’s own sake. If none of these possibilities seems to apply, but the child is persistently untruthful, it’s important to investigate whether the behavior is an aspect of emotional disturbance.

Interpreting tantrum behavior also needs to be done in the context of the child’s developmental age. Toddlers who do not yet talk well are likely to have tantrums as a result of frustration about unsuccessful communication. Punishing them for this behavior simply increases the frustration level and decreases their ability to handle problems in a more mature way (which will not be very mature in the best of circumstances). Older children may have learned to have tantrums to “get their own way” when adults have rushed to placate them when they make a scene-- but they may also behave in this way when overwhelmed by frustration. When older children have tantrums, it might be useful to explore whether marital problems are leading the parents to be less responsive or positive than usual; whether the child is overscheduled with school, lessons, and sports; whether divorced parents are scheduling visits that are too long or too unpredictable for the child’s comfort; whether the relationship with the nanny feels tenuous to the child (e.g., parent threatens to fire nanny, nanny mutters about quitting). In none of these cases is the tantrum an expression of personal disrespect for the nanny.

In high-quality child care settings, staff are provided with what is called “reflective supervision” to help them focus on problematic interactions with children as tasks to be done, rather than personal wars to be won. Ideally, nannies too would be provided with that kind of help, but very few of them, if any, are supported in this way. We certainly don’t need for nannies to be told that childhood problems are personal disrespect—potentially making matters worse rather than better.

Sunday, November 20, 2011

If It's Not RAD-- What Is It?

Again and again, parents and semi-professional therapists turn up on the Internet and in print, stating their claims that aggressive and difficult children have Reactive Attachment Disorder. They go on to say that the undesirable behavior can be cured only by correcting problems of attachment and causing the children to become emotionally attached to their parents. The same group used to press these ideas with respect to autistic children, too, until research showed that those children were normally attached to their parents and caregivers.

Also again and again, various authors (including me) have rejoined that the criteria for diagnosis with Reactive Attachment Disorder do not include aggression, firesetting, or any of the other frightening behavioral symptoms so often claimed for that disorder. At the same time, though, no one commenting on this issue has denied that there are children who display a range of disturbing behaviors. What, then, should be the diagnosis for those children, if it is not Reactive Attachment Disorder?

One possible diagnosis for children who display severe behavior problems early in life is early-onset schizophrenia. This has been said to be the difficulty of Malcolm Shabazz, the grandson of Malcolm X, who started the fire that killed his grandmother, Betty Shabazz. Malcolm Shabazz was reported to have fought with his mother (also apparently mentally ill) until they were both bloody, when he was only three years old. Now in his late teens or early twenties, he has continued to display violent, irrational behavior. Although it is certainly true that Malcolm Shabazz has poor relationships with others, there is evidently far more going on here than problems with attachment.

Early-onset schizophrenia is not frequent. A more likely, and far more common (between 2% and 6% of the population), diagnosis for children with extremely difficult and aggressive behavior is Conduct Disorder. An article by the eminent psychologist Alan E. Kazdin has recently discussed Conduct Disorder-related behavior and appropriate treatments (Evidence-based treatment research: Advances, limitations, and next steps. [2011]. American Psychologist, 66, 685-698). I am going to be quoting his comments directly and indirectly in this post, as well as adding my own remarks.

Here are some characteristic behaviors of the children Kazdin discusses: fighting, destroying property, lying, using a weapon, physical cruelty to people or animals, stealing, forcing someone into sexual activity, firesetting, truancy, and running away. According to Kazdin, “a typical outpatient case would be a 10-year-old boy who is constantly fighting at school and having frequent explosive tantrums at home. Siblings may have been harmed or may be in jeopardy of being harmed. He may be playing with matches in his bedroom at night, not coming home from school, occasionally not going to school even though the parents believe he is there, and making threats to harm others (peers, teachers).” (This child, by the way, might well be labeled a “psychopath” by those who use that term rather freely.)

Kazdin notes that Conduct Disorder is frequently followed by adult psychiatric disorders, and that it has harmful consequences for parents, siblings, and teachers, as well as the child himself or herself. Without commenting on the complex possibilities of cause-and-effect relationships, Kazdin goes on to say that “many children with [Conduct Disorder] are subject to moderate-to-heavy corporal punishment or live in very stressful environments”.

How can Conduct Disorder be treated? The interventions suggested by Kazdin are far removed from the various “attachment therapies” preferred by those who attribute difficult and aggressive behavior to Reactive Attachment Disorder. Kazdin focuses on parent management training (PMT), an intervention that examines parent-child interactions in the home and guides parents in altering interactions that make the child’s behavior more deviant. Randomized controlled trials have shown this method to be an effective one. When there is no parent involvement, for example because of substance abuse or simple refusal to participate, Kazdin recommends a cognitive approach, problem-solving skills training (PSST), which again has been shown to be effective and to significantly reduce undesirable behavior. In contrast to the “attachment therapy” approach, Kazdin’s program thus emphasizes altering parent behavior if possible, and follows up by using well-understood principles of learning rather than efforts at changing basic but poorly-understood attitudes and emotions.

A frequent comment of “attachment therapy” advocates is that conventional treatments make children’s disorders worse, that children must be capable of trust in order to benefit from psychotherapy; in addition, they state that parents who have “tried everything” will be happy with interventions approved by ATTACh and its admirers. Kazdin’s treatment program is of demonstrated effectiveness and does not require that children trust--- on the contrary, trust might be expected to result from behavior changes beneficial to both child and parent. I would hazard the guess that those who have “tried everything” have not tried serious interventions like PMT, but instead have spent a few hours with popular local counselors who have little more than their personal experiences to guide their work.

From the point of view of ATTACh and its members, PMT has one characteristic they would very much wish to avoid. This is the fact that parents are asked to examine their own behavior in detail and work to change it. “Attachment therapy”, although it may include some version of parent education, is attractive to parents because it does not ask them to change in any difficult way. Parents may be asked to make intense demands on their children, to watch them constantly, and to refuse to let them “get away with” anything, but all these are matters of investing time and energy-- not the more difficult matter of considering whether what one just did was part of the problem and not part of the solution. To admit that you are not an “awesome parent” is frightening, especially for families where the authority and rightness of the parents is a matter of religious belief. But it may be the most important step in helping children whose actual problem is Conduct Disorder.

Tuesday, November 15, 2011

For [Heaven's Sake] Never Amber [Necklaces]

Has anyone else stumbled across the recommendation to put necklaces of amber beads on teething babies, to act as a “natural analgesic”? I just came across this idea, on the Internet of course, but I’m not going to provide a link, because why encourage this stuff? If you want to see what they say, you can Google “amber” and “teething” and you’ll see plenty... including one or two expert debunkers at work.

When I first read about these necklaces, I was reminded of the “teething coral” necklaces of Victorian times-- but the amber necklaces are not meant to be chewed on and are not just to relieve the irritation of itchy gums. The basic claim appears to be that amber contains a substance called succinic acid, and this substance is absorbed by the skin, resulting in reduction of discomfort and increases in immunity, nervous function, etc. But there appears to be no evidence whatever that succinic acid has such an effect, or even that the small amounts contained in amber, if absorbed, would be sufficient to have any effect at all. One necklace website, by the way, claims that amber will help asthma and other disorders as well--- again, an unsupported claim.

The obvious concern is that an infant wearing a necklace could either catch it on something and strangle, or could break the necklace and choke on the beads. Websites advertising the necklaces advise against keeping the necklace on at night. Some necklaces are described as hand-knotted, with knots between each pair of beads, just like real pearls, so a break means that only one bead will come off the string. Others are said to have magnetic clasps that will break away under pressure.

So, what we have here is a situation where the sellers of the necklaces themselves recognize the potential danger of strangulation, resulting in death or (almost worse) near-death and severe, incurable brain damage. The necklaces are potentially harmful, and only anecdotes suggest that they are in any way helpful. Yes, the amber contains succinic acid as well as many other components, but there is no reason to think that succinic acid could possibly have the desired effects.

Why would anyone choose such a method, then? One reason seems to be the everlasting conviction that anything that is “natural” must also be beneficial. This belief perseveres in the face of the facts that illness, injury, and death are all natural events, and in spite of the clear evidence that naturally-occurring substances may have evolved ways of protecting themselves by harming creatures that consume them. What about a healthy, natural meal of oleander leaf salad, death cap mushrooms on toast, polar bear liver (get your Vitamin A, folks) and a pokeberry crumble (mmm, those scrumptious-looking, juicy purple berries)? The survivors, if any, might then enjoy a soothing massage with natural oils from poison sumac and poison ivy.

A second reason for the amber necklace idea is the lingering commitment to folk beliefs--- what you might call the trailing edge of medicine. Amber itself was an ingredient in pre-scientific medicine and could be consumed as a powder or used in other ways. But stones of all kinds were believed to have specific powers and connections with body parts and functions. These ideas were part of sympathetic magic and the belief that when two things resemble each other or “go together” in some way, they have some sort of cause-and-effect relationship. In modern life, we still see some of this focus on stones in the custom of “birthstones” and the characteristics associated with them; astrologers and alchemists associated not only the birth month, the stone, and the characteristics, but features of the heavens, body parts, and geographical areas. The attention paid to amber is only one facet of this (sorry, talking about gems made me think of that word!).

Be their reasons what they may, devotees of amber teething necklaces seem to have forgotten the caution common sense would advise for treatments that are potentially harmful AND that lack evidence of usefulness. And, regrettably, merchants of snake oil are also happy to supply amber necklaces to the naïve. They won’t be standing by to help a choking baby, though.

Sunday, November 13, 2011

Spanking Is Not Whipping (and Why It Matters)

Tempting though it is to take a simplified view, I don’t want to be the one to claim that once you’ve defined your terms you’ve found a way to understand any disagreement. However, I am quite willing to propose that clear definitions will help make constructive discussions of arguments about corporal punishment of children. Here is an effort to start the process:

Spanking is not whipping. Spanking is not paddling or beating. Spanking may or may not be the same as a smack. Spanking may or may not be equivalent to a whup, a whoop, or a tap. Spanking is not caning, belting, or flogging, or even slippering.

Spanking has been defined again and again, in the course of discussions about differences between corporal punishment of children and physical abuse of children. Spanking involves a small number of blows given with an adult’s open hand, usually to a child’s buttocks, legs, or hands. It does not include blows to the face or head or “boxing” the ears. Spanking does not employ kicking, giving blows with the closed fist, or using an object like a whip, switch, wooden spoon, belt, or razor strop to strike. Spanking does not cause bruising, bleeding, or welts, although it may leave a reddened mark for some minutes on pale skin.

This definition appears clear enough, and it is quite familiar to anyone who has read a little of the literature about child abuse and physical methods of punishment. Yet few people seem able to make the distinction. The Nov.7 Times article on children whose deaths were associated with the recommendations for corporal punishment of Michael and Debi Pearls (now at http://www.nytimes.com/2011/11/07/us/deaths-put-focus-on-pastors-advocacy-of-spanking.html?scp=1&sq=1&sq=Michael%20Pearls&st=cse) bore the following headline: “Preaching Virtue of Spanking, Even as Deaths Fuel Debate”. Yet the Pearls’ recommendation was not for spanking; it was for whipping with a narrow object like a willow switch or plastic plumbing supply line. Advocating for the opposite viewpoint, Project NoSpank (www.nospank.net) uses the word “spank” in its name, yet focuses primarily on corporal punishment involving blows with objects.

Why is it important to clarify whether corporal punishment involves actual spanking, as defined, or some other form of blows? To begin with, when we’re talking about important things, it’s wise to be sure exactly what’s under discussion. And, second, it really does not do to dismiss the differences on the grounds that “corporal punishment is corporal punishment” and that details like its intensity are irrelevant. Nobody would say that scolding is always the same thing, when it can range from a quiet request that a child think twice, to terrifying yelling and screaming coupled with threats of mayhem. We have every reason to think that, in corporal punishment as well as in other treatments, there is a dose-response relationship, and that more of a treatment should be expected to have a greater effect than a small amount does. We are not likely to be able to understand the influence of corporal punishment unless we are sure how intense and how lengthy the punishment is.

It’s obvious how a clear definition of spanking is necessary for understanding of ordinary claims about physical punishment. Is it also important for the understanding of research on outcomes of corporal punishment, or can we expect researchers and discussants to insist on definitions of terms? As it turns out, published research reports are not always cautious about definitions. For example, two papers by Elizabeth Gershoff conclude that corporal punishment may have short-term benefits, but may also cause long-term harm by increasing aggression and aggravating mental health problems (Gershoff, E.T. [2002]. Corporal punishment by parents and associated child behaviors and experiences: A meta-analytic and theoretical review. Psychological Bulletin, 128, 539-579; Gersgoff, E.T. [2010]. More harm than good: A summary of scientific research on the intended and unintended effects of corporal punishment on children. Law & Contemprary Problems, 73, 31-56). Criticizing these papers, however, other authors pointed out that Gershoff’s work had combined studies of spanking with studies of other forms of corporal punishment (Larzelere, R.E., & Baumrind, D. [2010]. Are spanking injunctions scientifically supported? Law & Contemporary Problems, 73, 57-87). Examining research on spanking alone, as defined above, did not show an association with long-term problems.

By the way, there’s a distinct possibility that neither spanking nor other forms of corporal punishment have long-term influences of their own. Instead, it might well be that the kinds of parents who choose to spank, and the other kinds who choose other corporal punishment, have other ways of influencing their children, through the behavior they model and through the specific instructions or messages they communicate. In addition, the kinds of children who do things that their parents believe require physical punishment (like taking dangerous risks or harming other people) may be different in personality to begin with, and retain their differences as they grow older-- rather than being “shaped” by their parents’ child-rearing methods.

If people want to claim that God wants children to be punished physically, it’s pointless to argue with their belief system, nor does it matter much whether they advocate spanking or blows with objects. Those people don’t need or want specific definitions. However, if the argument is about the outcome-- whether children who are spanked develop well or poorly, and whether the effects of other physical punishments are the same or different-- we need to avoid the Times' headline-writer’s blurring of distinctions and be sure we all know what we’re talking about.

Friday, November 11, 2011

RAD Foolishness at Huffington Post

The Huffington Post columnist Lisa Belkin deplores the deadly results of child abuse, and well she may. But in her remarks at www.huffingtonpost.com/lisa-belkin/adoption-spanking-childabuse_b_1081617.html , she falls heavily for an idea associated with an eccentric view of child mental health--- the belief that emotional disturbance can cause an inability to feel pain. Belkin says that Reactive Attachment Disorder is “essentially the inability not only to bond, but to feel… these children can have elevated levels of the hormone cortisol, which increases their tolerance for pain… Some speculate that … spanking can spiral out of control” because the children do not respond to normal levels of painful stimulation.

Let’s parse this remarkable statement.

Do “some” speculate on this idea and claim that children with Reactive Attachment Disorder (or adopted children-- the two are sometimes spoken of in the same breath) are not very responsive to pain? Yes, “some” certainly do. Here are a couple of examples. At www.attachmentdisorder.net?Letter_to_Teacher.htm, we are told that “RAD kids can walk around in significant physical pain from real injuries”. At www.adopting.org/DrArt/diagnosisrad.html, the social worker Arthur Becker-Weidman, the soi-disant “Dr. Art”, provides one of those do-it-yourself RAD checklists, including the item “My child ‘shakes off’ pain when hurt, refusing to let anyone provide comfort”.

These statements confuse the actual response to pain with the seeking of comfort from the “right” people, and ignore the possibility that the child does not find particular adults (or adults in general) to be very comforting people. Belkin, however, accepts the idea that children diagnosed with Reactive Attachment Disorder may have an increased tolerance for pain-- by which I assume she means a raised threshold, requiring a higher level of painful stimulation before the child experiences pain.

Is it possible for this to happen? Yes, as Belkin states, changes in stress hormone levels can make a difference to pain tolerance. Physical stimulation can result in changes in pain threshold called stimulus-induced analgesia. People with diseases of the peripheral or central nervous systems such as leprosy can lose skin sensitivity of all kinds in some parts of the body. Studies of soldiers during World War II showed that wounds treated at front-line dressing stations required much less morphine than similar injuries due to surgery. A very few people are congenitally insensitive to pain and are frequently injured as a result (for example, being unaware that a hand is on a hot stove until they smell charred flesh). A few others, afflicted by harmful genetic factors, mutilate themselves by chewing their lips and tongues and do not seem to find this painful-- but can learn not to do it when subjected to painful electric shocks.

Is there any documentation of the claim that children who have been given the RAD diagnosis are in fact less responsive to pain than other children? This could be ascertained through standard laboratory tests of pain thresholds, or by systematic observation of toleration of dental work or medical procedures like immunization. No one has done this, so in fact the idea of higher pain thresholds (better pain tolerance) remains entirely hypothetical. The DSM description of Reactive Attachment Disorder certainly mentions no such symptom.

Let’s look at Belkin’s suggestion in another way. Does ordinary child guidance depend on experiences of pain? If a child felt little or no pain, would he or she then be untrainable? Although many parents do use spanking (a few blows with the open hand, no weapon) as a disciplinary method for preschool children, it is also common and effective to use timeout, isolation in the child’s room, scolding, or deprivation of treats-- all useful methods without physical pain. An ordinary spanking itself, when applied through a layer or two of clothing, involves intimidation much more than pain. In fact, it is not necessary for punishment to be painful in order to be effective . (The use of aversive treatments like electric shock-- certainly a painful experience-- is ethically limited to situations when a child will put himself in danger of real harm if he does not comply with instructions. ) If indeed children with Reactive Attachment Disorder had high tolerance for pain, there is no reason to think that this would affect their response to ordinary discipline one iota.

This line of discussion leads to another claim, one not made by Belkin but common among the people whose work she seems to have been reading. This is the idea that children with Reactive Attachment Disorder are unable to learn cause and effect connections, as stated by the “Evergreen Consultants in Human Behavior” at http://attachmenttherapy.com/ad.htm and many others. This bizarre belief appears to have come from someone being frightened by Piaget at an early age. In fact, learning to associate cause and effect begins in the first months of life, and is shown in thousands of daily behaviors such as becoming toilet-trained and using a spoon to eat with. The belief that Reactive Attachment Disorder necessitates severe parenting methods and high levels of child discomfort appears to be based on this entirely hypothetical inability to associate cause and effect. Children who attend school, dress and feed themselves, and do household chores all are demonstrating evidence of cause and effect learning, but they may for quite other reasons fail to learn to display affection or gratitude to their caregivers, or to make the caregivers feel that they have achieved the family relations they wanted.

Belkin associates Reactive Attachment Disorder with an “inability to feel”-- perhaps deriving this idea from the claimed lack of responsiveness to pain. Yet even the attachment therapists from whom she seems to have adopted ideas would point to the children’s rage and grief about separation from their original caregivers, even in cases where there was not enough time for an attachment to have occurred. The real issue appears to be that the children do not feel what their adoptive families want them to feel, or if they do, they do not display their feelings as is expected of them.

Belkin’s suggestion that children are abused because they are insensitive to pain and do not “feel” emotions is simply not tenable. This is not a matter of parents who must escalate physical punishment because without pain the children will not learn; it’s clear that children, adopted or not, do learn without pain. There was something else going on in the child deaths associated with “To Train Up a Child”. What was it? There were undoubtedly different factors and combinations of factors in the three known cases, but here’s a short list of possibilities:

The belief that the child’s eternal damnation or salvation rests on present obedience.

The belief that physical punishment is traditional, Christian, or in some way linked to a set of “family” values.

The belief that it’s a child’s job to make a family happy.

The belief that isolation of the family from the surrounding community is desirable.

The belief that adopted children are different from others in essential ways (a belief, by the way, fostered by Belkin’s comments on this subject).

The belief that there is an undefined process called “bonding” that may be undertaken by children and which is different in its nature from emotional attachment.


These factors could all be part of the lives of fairly ordinary adoptive parents. When we add in the possibility of serious mental illness in parents or in children (sorry, RAD doesn’t count), we multiply enormously the possibility of child abuse, injury, even death. The hypothesis that adopted children have a high tolerance for pain is not only unsupported, but an unnecessary addition to the discussion. Stressing that hypothetical factor is just another way to say, “the child made me do it.”

Monday, November 7, 2011

Pearls or Swine? Another Death Possibly Related to "To Train Up a Child"

The New York Times this morning reported on the front page a third child death among apparent followers of the evangelical ministers Michael and Debi Pearl (http://www.nytimes.com/2011/11/07/us/deaths_put_focus_on_pastors_advocacy_of_spanking.html). Mr. and Mrs. Pearl are the authors of “To Train Up a Child” (posted in its entirety at www.achristianhome.org/to_train_up_a_child.htm), a document that advocates not what most of us would call spanking, but practices like whipping of 6-month-olds with plastic plumbing supply line. I have written about the Pearls in the past (Mercer, J. [2007]. Destructive trends in alternative infant mental health practices. Scientific Review of Mental Health Practice, 5(2), 44-58), but this third death report makes me feel that there is plenty more to say.

The Pearls are evangelicals living in Tennessee and associated with an organization called the Church at Cane Creek. According to the Times, there are 670,000 copies of their self-published book in circulation (an interesting fact when the book is readily available on line). The Pearls share an intensely Calvinistic belief system in which obedience to God is the essential correlate of salvation. Human beings are naturally “froward” or disobedient and rebellious, and those sins are the deeply serious ones that caused Lucifer to be hurled from heaven. Parents are responsible for their children’s salvation, and the first step they must take is to “break the spirit” and stamp out all rebelliousness expressed against the parents themselves. Without this step, children will not be meek and obedient before God, and therefore will be damned eternally. (There appears to be no room in this system for mercy or grace-- and Unitarians or Quakers need not apply!) The experience of pain is the natural tool for breaking a rebellious tendency, and although it may be uncomfortable for parents to cause this, it is their job to do so and rescue the child from an eternity in the torments of Hell.

In one anecdote in “To Train Up a Child”, the Pearls tell of a visit from a toddler who had never seen Mrs. Pearl before but was left with her for some hours. As he appeared unhappy, she offered him some roller skate wheels to play with-- but he “rebelliously” refused. Smiling at him, she whipped his leg with her plumbing supply line. This event was repeated ten times, at the end of which, according to the Pearls, the child played happily (I’m just reporting the news here, you know). Whipping was advised for a wide variety of early offenses like turning the head away when offered a spoonful of food or rolling off a blanket when placed there. The Pearls also approve of occasional withholding of food and of using a garden hose on a child who has had a toilet accident.

However appalling these practices may seem to many of us, it is unlikely though possible that they would ordinarily cause death or even serious injury. It is difficult to know whether the three child deaths-- all of adopted children, by the way-- can legitimately be attributed to the Pearls’ advice, although the parents in these cases are known to have been admirers of the Pearls’ practices. In each case, the parents’ behavior went far beyond the Pearls’ recommendations. To summarize from the Times article: The first death, that of Sean Paddock of Johnson County,NC, in 2006, involved suffocation of the 4-year-old child in a tight blanket wrap. The second, early in 2010, was that of Lydia Schatz, age 7, in California. She was whipped for hours, with pauses for prayer, and died from severe tissue damage, cut to ribbons by the lashing. The most recent death, last May, was that of 11-year-old Hana Williams in Washington State; according to the Times report, she “was found face down, naked and emaciated in the backyard; her death was caused by hypothermia and malnutrition… [she was] deprived of food for days at a time and [made to] sleep in a cold barn or a closet and shower outside with a garden hose.” The day she died, she was beaten with a link of plastic tubing as recommended by the Pearls.

Some questions come to mind, not so much about these pitiful children, who suffered unimaginably, but about the role of parenting advice and of religious belief in the United States . The First Amendment guarantees freedom of speech, but that freedom has its limits-- for example, it does not extend to yelling “fire!” in a crowded theater when there is no fire. Should there be limitations on advice that might be misused by parents whose mental health or intelligence limitations distort their understanding of appropriate parenting behavior? What should be the constraints placed on adoption caseworkers or other publicly-paid functionaries, whose instruction to parents may be out of line and lead to injury? Do parents’ religious beliefs allow authorities to waive the usual requirements about adherence to child abuse statutes? How do we, as a multicultural society, decide what laws to enforce for all families?

Simple and suitable though it may seem to just make the Pearls shut up and withdraw their book, and deplorable though the apparent results of their teachings may be, legislation may not be the answer here. However, the continuing silence of professional societies is of no help in this complex situation. The American Professional Society on Abuse of Children spoke out against attachment therapy in 2006. When will we see a task force addressing the intertwining of serious child abuse with religious and cultural beliefs? And when, particularly, will adoption organizations notice that it is dangerous to place older, foreign-adopted children with large families who concern themselves with “spirit-breaking”?

Sunday, November 6, 2011

Lark Eshleman's "Becoming A Family": Approach With Caution

A Pennsylvania school psychologist, Lark Eshleman, published in 2003 a book called “Becoming a Family: Promoting Healthy Attachments With Your Adopted Child”. Although Ms. Eshleman is eager to be helpful and has written an enthusiastic volume, looking through the book unfortunately reveals misunderstandings that could easily lead to inappropriate treatment of adopted children.

Ms . Eshleman quickly focuses on the idea that adopted children are likely to suffer from Reactive Attachment Disorder and presents two definitions of “what RAD looks like”. She does not appear to notice that these “clinical definitions” (as she puts it) have little to do with each other.

Looking at discussion of Reactive Attachment Disorder in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, Eshleman quotes the following description:

“Reactive Attachment Disorder (RAD) is a complex psychiatric condition that affects a small number of children. It is characterized by problems with the formation of emotional attachments to others that are present before age five. A parent or physician may first notice problems in attachment with the caregiver that ordinarily forms in the latter part of the first year of the child’s life. The child with RAD may appear detached, unresponsive, inhibited or reluctant to engage in age-appropriate social interactions. Alternatively, some children with RAD may be overly or inappropriately social or familiar, even with strangers. The social and emotional problems associated with RAD may persist, as the child grows older.” [I haven’t checked for the accuracy of this quotation. It seems a bit clumsy, but nobody ever said psychiatrists had to be engaging writers.]

Next, apparently with the intention of reinforcing the comments above, Eshleman proceeds to quote the Association for Treatment and Training of Attachment in Children (ATTACh, a hybrid parent-professional group that has in recent years offered credentialing to those trained in their perspective on attachment issues):

“ Attachment disorder is a treatable condition in which there is a significant dysfunction in an individual’s ability to trust or engage in reciprocal, loving, lasting relationships. An attachment disorder occurs due to traumatic disruption or other interferences with the caregiver-child bond during the first years of life. It can distort future stages of development and impact a person’s cognitive, neurological, social and emotional functioning. It may also increase the risk of other serious emotional and behavioral problems.”

Let’s examine these two statements point by point and see to what extent they are in agreement with each other.
The APA statement refers to a specific diagnosis, Reactive Attachment Disorder, which has been listed in DSM for a couple of decades and which originally referred to a type of feeding problem of infants. The ATTACh statement speaks instead of “attachment disorder”, a general term that could be applied to less-than-ideal attachment styles that are nevertheless well within the normal range.
The APA statement makes no comment about treatability of RAD, while ATTACh introduces the idea of treatment before even describing the problem.
The APA statement describes observable behaviors that are part of the disorder and which presumably could be noted by parents and teachers as well as by psychiatrists, psychologists, or social workers. The ATTACh statement refers to vaguely-described problems such as the “ability to trust” or to “engage in reciprocal, loving, lasting relationships” which are not observable, but can only be inferred from behavior that is not described.
The APA statement refers to problems that can be observed beginning in the latter part of the first year of life. The ATTACh statement points to causation by events that occur in the first years (not otherwise specified), but does not cite behavior that occurs early.
The APA description notes that the social and emotional problems of concern, such as detachment and reluctance for social interaction, may persist rather than be “outgrown” as the child gets older. ATTACh warns that attachment disorder can “distort future stages of development”, a different and more serious matter than persistence of early problematic behavior. In addition, ATTACH speaks of impacts on “cognitive, neurological, social and emotional functioning”. The APA description is entirely focused on the social and emotional eccentricities that are the basis for a diagnosis of Reactive Attachment Disorder and never refers to either cognitive or neurological effects.

Following her quotations from APA and ATTACh, Eshleman goes on to add a description of a girl who is said to have some type of attachment disorder. This girl, in her early teens, is described as aggressive, destructive, jealous, and controlling, and steal from the family as well as shoplifting. At this point in her narrative, Eshleman introduces the idea that the girl shows “many of the typical features of RAD”, and cites these as lying, inability to trust, oppositional, acting-out behavior, engaging in dangerous behavior, apparent desire to keep others at a distance, and hypervigilance. None of these, please note, were mentioned as characteristic of Reactive Attachment Disorder in the APA description.

Eshleman appears to disagree on almost every point with the APA concept of Reactive Attachment Disorder. Between her quotation from ATTACh and the conclusions drawn from her case description, Eshleman has provided a view of Reactive Attachment Disorder that thoroughly contradicts that of the APA description.

Why, then, did she include the APA description to begin with? I can only attribute this to a sort of “showing the flag” by citing a conventional professional organization’s views. Or perhaps we might call it “sweetening the well” as the opposite of the persuasive technique of “poisoning the well”. By quoting the American Psychiatric Association, Eshleman claims for herself a modicum of orthodox authority and thus prepares the reader to accept her later statements. As Eshleman and similar authors well know, naïve or careless readers are not likely to say, “Wait… what? That’s not what you said before”, but are likely to read straight on and conflate the two contradictory statements with each other.

When a book displays so many contradictions in a few pages, readers need to be cautious about accepting the content. Even though some material is correct, it would be silly to assume that all of it can be trusted.

Tuesday, November 1, 2011

Moral Panics and Reactive Attachment Disorder

Some sociologists have a useful term for a kind of change in public attitude: moral panic. Moral panics are periods of agitation and concern about an issue that is not realistically of much importance (and by the way, the term has nothing to do with sexual morality, but is an old-fashioned way of saying that the panic exists for psychological reasons). Discussing these periods in a 1994 article (Goode & Ben-Yehuda, Moral panics: Culture, politics, and social construction. Annual Review of Sociology, 20,149-171), two sociologists defined moral panics as “explosions of fear and concern … about a specific perceived threat. In each case, a specific agent was felt to be responsible for the threat; in each case, a sober assessment of the evidence… forces the observer to the conclusion that the fear and concern were, in all likelihood, exaggerated or misplaced.” During moral panics, much attention is focused on the agent that is thought to cause the feared events, which incidentally need not be common and may even be nonexistent. Actions taken against the perceived agent can in themselves be far more dangerous than the feared events.

Moral panics have been common enough throughout history. The pervasive fear of witches in Europe and in the Massachusetts Bay Colony, the “Red Scares” of the last century, and the more recent preoccupation with “Satanic ritual abuse” are examples. Such panics may run their courses relatively quickly, but often leave traces in folk beliefs or even in institutions like laws that were originally established to deal with them. It can be argued that moral panic is responsible for some prevailing but unrealistic concerns of modern life and for some unnecessary and potentially dangerous steps taken in the hope of escaping a perceived threat.

I would suggest that for some episodes of moral panic over the last 60 years’ the perceived threat has been the same, although the agents thought to cause the threat have been different. The perceived threat is this: our children will hurt us.

In the 1950s, the psychiatrist Frederic Wertham invoked a moral panic by claiming that comic books depicting violence caused young people to behave violently. His beliefs remain institutionalized in comic book publishers’ “codes”. Both jazz and rock-and-roll music were subjects of moral panic in episodes when these forms of music were declared to loosen inhibitions and weaken morality, including resistance to violent impulses. Presently, moral panic is visible in intense concerns about violent screen games and the impulses to aggression they are said to foster ( a connection that is not supported by research on violent behavior and screen game-playing). While moral panics focus on factors that are considered agents of the threat, in these cases the threat remains the same: our children will hurt us.

Although I am far from claiming that moral panic is the sole reason for confusion, I would like to suggest that the continual misinterpretation of the symptoms of Reactive Attachment Disorder by the media and by a small number of professional and quasi-professional authors is also facilitated by the fear that our children will hurt us. Those experiencing moral panic about this issue look for agents that they believe contribute to the perceived threat. They do not imagine that their children will hurt them because they have hurt their children, or because they have modeled aggressive behavior for their children, or because they have failed to provide their children with non-violent strategies for dealing with others. Instead, encouraged by the work of a few authors and lecturers, people look to aspects of modern life which they think are the agents that can cause their children to hurt them--- abuse by other caregivers, their mothers’ thoughts about terminating the pregnancy, experiences in the NICU, difficulties with attachment, and of course adoption. To control these “agents” is their goal, because these factors are seen as the causes of the threat that creates moral panic.

Misunderstandings and false claims about the nature of Reactive Attachment Disorder focus on the violent nature and dangerous behavior posited for affected children-- in other words, in the probability that such children will hurt someone, and the likelihood that it will be a foster or adopted parent who is hurt. This focus links Reactive Attachment Disorder with the subject of moral panic, the fear that our children will hurt us. From that moral panic and pervasive references to the fear, misinterpretation of Reactive Attachment Disorder draws the energy that maintains it in the face of all evidence and arguments to the contrary. Institutionalization of Reactive Attachment Disorder as a focus of moral panic has occurred in the form of publication of misstatements by major publishers like Wiley and Academic Press and in payment for training of social services workers in related beliefs by some states (for example, Georgia).

Why do I say fears about being hurt by our children are a matter of moral panic-- a completely disproportionate reaction to the actual occurrence of any such events? The reason is that in fact youth violence has decreased rather than increased over the years when the supposed agents encouraging aggression have stayed constant or increased. Like any form of panic, moral panic makes it difficult for us to think clearly or make reasoned decisions. Under the impetus of moral panic, we may choose actions that are in fact harmful, like accepting and promulgating mistaken views of Reactive Attachment Disorder, or using treatment methods that are assumed to be harmful by child abuse researchers. Difficult though it may be, all of us-- and the media above all—need to breathe deeply and count to 100 before we allow moral panic to work through us and cause us to do harm while trying to escape an unlikely threat. Let’s not hurt our children out of our unrealistic fear that our children will hurt us.