Concerned About Unconventional Mental Health Interventions?

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

Monday, December 24, 2012

No, Virginia, There Isn't Any Santa Claus


Dear Virginia—

No, of course there isn’t any Santa Claus! I’m surprised at you, a big girl like you asking such a question. How could you believe a story like that?

Oh, you say your parents told you about Santa Claus? And they say it’s wrong to lie, so you don’t think they’re lying? Even though sometimes it’s okay for grown-ups to do things that are not all right for kids?

Well, Virginia, this time they are definitely telling a whopper. It’s pretty shocking to realize it. But I think I can explain why they’re doing it, and if you could understand this, you would forgive them.

The thing is, your parents love you and want to protect you--  not just from disappointment and skinned knees, but from understanding how horrible the world can really be. Your parents and most other grown-ups have an ability called empathy, and when they learn about awful things they can imagine what it would be like for them--  and especially, for you—to have to experience them. Your parents have heard about Auschwitz, My Lai, Abu Ghraib, and the events in Aurora and Newtown. When they think of those things they are sometimes tormented by pity, terror, and helplessness. They don’t want you to be tormented like that ever--  but they know that’s not possible, so at least they want you to feel happy about the world until you’re a lot older. They try to protect and defend you against terrible knowledge, and to do this they often do their best to fill in the gaps with stories of magical beauty, goodness, and happiness. They want to keep you as long as they can without the knowledge of evil that intrudes into every adult’s holiday, the fear of death that attends the birthday party, the ghost of loss that dances at every wedding. They summon Santa Claus to ward off those threats, and for some years he may do the job for their special children.

But you’re moving past that stage of life, Virginia. You want to know more of the things that adults know, even though you’re far from ready to know it all. (Indeed, who is?) What can you learn from the discovery that Santa Claus is not real?

Let’s start with learning to question anecdotes and testimonials, whether they’re on the Internet, on NPR, or from Mom and Dad. Trust, but verify, right? That’s the best policy if you really want to know what’s going on. On the other hand don’t forget that people, even you, don’t always really want to know. You can learn from the Santa Claus story that sometimes we like to work our own magic, tell ourselves lovely tales, and keep away the bad fairies that hover around our pillows all our lives. There’s nothing wrong with that as long as we don’t tell ourselves stories that encourage us to hurt other people or take away things they need, stories that convince us that we’re more important than anybody else.

You can also learn from this discovery that human beings are often willing to do things that are wrong in order to protect those they care most about. Your parents say it’s wrong to lie, and they believe it, but they will do that and much worse if they think it’s good for you. I’m not saying not to trust them--  but from now on you may want to give some thought to everything anybody tells you, before you make it your own belief. If you can manage that, you will have learned a lot.

I’ll bet that your parents would forgive you a lie if they understood that you told it because you were scared. It may be hard for you to believe, but they sometimes lie about things because they’re scared too. Learn this, and you’ll know that the Santa Claus story was not just told to fool you.  It made you feel good for a while--- and that made your parents feel good too. Now that you’re older, you and your parents will need to find new ways to handle the fears that we all have.

Best love,
Jean

P.S. There’s no need to break this important news to your little brother. Besides, believers always get mad when you try to reason with them.


Tuesday, December 18, 2012

Professional Parent Alienation Syndrome: Heads I Win, Tails You Lose


More news about Eve Innocenti, whose Kafka-esque case was discussed on this blog a few days ago. Eve was present by telephone at a meeting with social workers to discuss her being allowed to have contact with her children, who are now with their father and stepmother except when they are in residential treatment or a therapeutic foster home supervised by the attachment therapist we referred to as Woodrow Thynne.

Here’s what Eve was told: she may not have contact with the children unless she states that she abused and neglected them when they were in her care. Her refusal to “take responsibility” by dropping her denials of these accusations is interpreted as symptomatic of an ongoing emotional disturbance. As long as she denies guilt, say the social workers, she cannot help her children “heal” from the impact of what she is said to have done.

What is she accused of doing? Here’s an interesting thing: in a further Kafka touch, no one will tell her. She has been told that what she must do is to make a written list of bad things she did to the children, and the social workers will check it against what the children say. However, the children’s guardian ad litem has told Eve that in fact the accusations are related to information in letters from the children’s schools a year after they went to live with father and stepmother--  and these were not the same schools they attended when living with Eve.

Did the unspecified allegations then come from the interpretations teachers placed on things the children said, spontaneously or perhaps not so spontaneously? Maybe--  but let’s not forget that one of the techniques of attachment therapy can be to have children repeat over and over words given to them by the therapist, stating their hatred for a past caregiver and describing the awful things she did. This is considered to be expressing emotion, but can easily be a matter of putting words in a child’s mouth. Statements by children that were clearly guided or suggested by a questioner are not admissible in court, and in fact court-related interviews with children about their experiences are videotaped to show whether suggestions were given. A therapist may not appear in court, and if he or she does appear, a videotape of the therapy session is not usually requested. Certainly the alleged letters from the schools did not include videotaped evidence of the children’s statements.

It’s understandable that decisions regarding children should be made in a more private manner and with fewer procedural constraints than are found in a criminal court. Either adult or child behaviors may not reach a criminal level, but may show the need for some type of protection of the child that will prevent worse from happening. But have we not seen enough abuses of this special kind of court proceeding? A year or two ago, we had  juvenile court judges of Luzerne County, PA  sending children to prison-like residential situations and receiving financial kickbacks from the operators. This morning’s New York Times discusses reform of the Shelby County, Tennessee system that has mistreated juveniles for many years.

The particular abuse that Eve is experiencing—refusal of information and treatment of her denial as if it were an especially serious form of confession—is one that has also been experienced by fathers falsely accused of sexual abuse of their children. It could not happen when adults are tried in a civil or criminal court, but it is far from unknown in juvenile proceedings, and is largely connected with one tradition in U.S. social work. This tradition goes back to the days of the “psychiatric social worker”, and follows an intensely psychodynamic pattern of interpretation in which either confession or denial can be taken to mean guilt and in which actions can be attributed to repressed impulses; it does not, however, seem to include the possibility of false confessions resulting from persuasion. The tradition also interprets denial of accusations as evidence that an emotional disturbance not only existed in the past, but still exists, and will have deleterious effects on the children if any contact is allowed.

This tradition has the capacity to wreck lives and to violate the civil rights of both parents and children. It is ironic but unsurprising that practitioners who believe that loss of attachment figures is a primary cause of mental illness feel that such a loss, when engineered by the therapists themselves, is to the benefit of the children. It is also unsurprising that the therapists interpret the distress of a mother who has effectively lost her children as evidence of mental illness and as a reason why she should be denied contact. When we mingle the psychodynamic social work tradition with attachment therapy, as well, we need not be surprised at the circularity of reasoning that states that children who have been diagnosed with a form of attachment disorder must by definition have been abused or neglected, and that the diagnosis itself is evidence that a caregiver has done wrong.

There has been a lot of discussion in recent years of the so-called “Parental Alienation Syndrome”, a behavior pattern in which one member of a divorcing couple accuses the other of abuse, both publicly and in direct communication with the children. The goal is to destroy the children’s regard for the accused parent and to maximize the accuser’s custodial power. This behavior does exist, of course, although it is probably a mistake to call it a “syndrome” and thus imply that it is a useful diagnostic category of mental illness. In Eve’s case, however, we seem to be seeing a new version of parental alienation, performed by professionals as they exercise what Oscar Wilde called “officialism”. The social workers, the therapist Woodrow Thynne, court functionaries, and others have dedicated themselves to alienation of a parent and destruction of her children’s regard for her. Strangely, it seems that efforts to work with and support a parent who had been genuinely abusive would be pursued with energy, while the opposite is being done in this case--  the energy is devoted to alienation.   


Thursday, December 13, 2012

The Attachment Therapist Wears Two Hats, or, Kafka in Colorado



In Franz Kafka’s novel The Trial, the central character, Josef K., is mysteriously accused, tried, convicted, and sentenced for a crime that is never named and by a court that is never seen. Agents of the court try to make the condemned Josef K. kill himself, he refuses—and they carry out the sentence.

Couldn’t happen at all? Couldn’t happen here? Couldn’t happen to anyone like you? I’d like to be able to agree with those statements, but I have a story to tell that has convinced me that Franz Kafka is writing scripts for Colorado courts.

Here is the basic story, with all names changed. (I have permission to use the central person’s name, but I think it may be more prudent not to do so.)

Eve Innocenti was a young Colorado woman with a rough family background who was trying to get on her feet. In her early 20s, she had a baby with a young man with a drug problem—call him Fred—and was awarded full custody of that baby. A second child  with a different father followed a few years later, and Eve also had full custody of that child.. Meanwhile, Fred married Wilma and had another baby with her. Eve’s children visited Fred and Wilma periodically and the co-parenting went well. When Eve needed to be away for a couple of weeks, she asked Fred and Wilma to care for her boys. On her return, however, she was not able to get the children back from Fred and Wilma.

Eve went to court to ask for the boys to be returned to her custody and continued to make this request, with occasional visits from the children, over several years. But Fred was given full custody of both boys, his own son and the second child to whom he was unrelated. Eve was denied contact with either child, and a legal staffer even suggested that a restraining order might be appropriate because Eve walked out of the hearing.

Eve then married a man in the military and the couple moved to a nearby state, from which Eve tried to continue her efforts. She was allowed to drive 8 hours from the neighboring state once each week, to see the children for one hour.  Soon, however, the visits are ordered stopped for a period of a year. Shortly after that time period, the Colorado county filed a Dependency and Neglect case that could ensure that Eve does not have visitation with the boys--- even though Fred and Wilma had separated and Wilma had custody of the children. (Fred later returned.)

This brings the story up to a few months before the present day (Dec. 13, 2012). At that point, some interesting and disturbing new facts began to emerge. Wilma, it seems, had sought the help of an attachment therapist, one Woodrow Thynne, I’ll call him, who conducts an “institute” and residential treatment center in the vicinity of Long Green, CO (which I’m naming for its financial advantages to therapists). Wilma complained that the boys had symptoms of Reactive Attachment Disorder and were difficult to handle. The boys were treated in Thynne’s therapy program and at least one stayed in a “therapeutic foster home” connected with the center.

County legal and social work staff told Eve that Thynne’s report to the court would determine the custody of the children. Thynne was continuing to act as a therapist for Fred and Wilma’s family. If Thynne had been a psychologist, he would have been prevented by a professional ethical code from wearing both hats--  as therapist and as evaluator. As a social worker, however, he was only required to clarify his position with all family members. This should have included Eve, but in fact he had neither seen or spoken to her at any time. Eve’s appointed public defender, who should have been dealing with the situation, did not return her calls; Eve and her husband could no longer afford to hire a private attorney.

In mid-December, 2012, Eve managed to have a conference call with Woodrow Thynne and the guardian ad litem whose job it is to represent the children’s interests. Several interesting and disturbing points were  revealed during this conference. One was the fact that it was Thynne’s intention to break the attachment that the boys had to Eve, and to re-attach them to Wilma, following what appears to be a Velcro theory of emotional development.. A second was that Thynne believed that the children had been removed from Eve’s custody because of her neglect or abuse, and declared that he was not aware of the actual history (but nevertheless he did not immediately bring the process to a halt, as might have been expected). Third, Thynne referred, apparently without disapproval, to Wilma’s attempts to discipline the younger boy by threatening to send him to visit Eve; such a threat of abandonment would ordinarily be considered highly inappropriate for a child suffering from the effects of a complicated separation history. Finally, Thynne denied that his report would be the basis of the court’s custody decision, leaving open the question of the evaluation that would be used. But because it is part of Thynne’s technique to have children state that they were abused and neglected, his report will provide misinformation that cannot be contradicted by Eve.

In response to statements during the conference call, Eve began seriously to consider relinquishing custody of the children rather than continuing to fight against unknown charges in a process that has no predictable outcome except bankruptcy and court records that may be used against her in the future. She e-mailed her attorney about this and got an immediate answer telling her how to begin.
The likely result of all this is that a stepmother will receive custody of children whose birth mother not only wants them but has shown every evidence of caring for them well. The father of one child will have also have custody of another man’s child. Both children will continue to receive a treatment that has no evidence basis, supervised by a therapist who has apparently not troubled himself to understand the children’s family history.

Like Josef K., Eve has been accused of unstated crimes for which there is no evidence. Those who were supposed to help her have avoided her. Those who claim to be helping her children ignore the facts of the children’s lives and persist in beliefs and practices that have been rejected by organizations like the American Professional Society on Child Abuse. The information she needs has been withheld from her. Now she is offered the knife to stab herself in the form of relinquishment of custody, a step that is not only repugnant to her but predictably harmful to her own professional and personal options, as well as easy for the children to interpret as a final abandonment.

Surely Kafka is alive and well in Colorado and has written Eve and the children into a novel.

Monday, December 10, 2012

Toilet Training Concerns and Older Adoptive Children



 When I read blogs and Internet chat by adoptive parents who believe their children have some form of attachment disorder, I often see the expression of concern—and disgust—over toileting problems (for instance, see attachment.china.parenting.html). It is assumed that children over some certain age are capable of controlling bladder and bowels, that lapses are usually intentional attacks against adult caregivers, and that the child’s efforts to “hide the evidence” only show what liars and sneaks they are.

This set of beliefs is fostered by the continued circulation of a 1996 paper by Keith Reber (referred to on many adoption and attachment therapy sites, but I can’t find a URL for it at the moment). Reber, who incidentally later had his professional license revoked , stated in that paper that various physical acts like vomiting and defecation were intentional actions of children with Reactive Attachment Disorder and were expressions of rage about abandonment by the birth mother.   Regarding physical processes as intentional, of course, leads to the assumption that if the child wanted not to vomit, or urinate, or defecate, he or she would be able to inhibit these impulses. What follows as the day the night is often a plan to give the child good reason to control bodily functions by providing punishments, or, to use the language associated with attachment therapy, consequences.

Given that even healthy adults may urinate or defecate involuntarily, or be unable to do either at will, why would it be assumed that older children are always in control of elimination? There are various “psychological” (i.e., non-physical, non-biological) explanations that can be deployed to support this assumption--  although, as I’ll point out, there are reasons to doubt the applicability of each of them.

The first “psychological” explanation comes from common observations and interpretations of the behavior of pet animals. When their environments are disrupted and they are made anxious, cats and dogs sometimes urinate and defecate at unusual times and places. Pet owners and even some veterinarians interpret this behavior as an expression of anger or resentment toward the owner--  even though the animal’s general behavior displays anxiety rather than any anger cues like growling, hissing, or direct attack. The animal’s actions may be an attempt to find a place for elimination that resembles the usual setting, so for instance a cat inadvertently shut in a bedroom may defecate on a pillow rather than in the preferred but unavailable litter box. At other times, the behavior may be a form of displacement--  performing a normal behavior in an unusual situation, as when birds preen or humans yawn in response to anxiety. In none of these cases is the eliminative lapse due to anger, although they are commonly interpreted in that way. Thus, these animal situations are not a good foundation for assuming that children’s toileting problems are due to their anger.

A second problematic “psychological” explanation, the psychoanalytic concept of repression, may also lead parents to assume that children’s toileting problems are in a sense intentional. Repression is a speculative mechanism which is said to place unpleasant memories outside the reach of consciousness, and which allows those memories to motivate behaviors that may be quite undesirable. Such behaviors cannot be brought under control until the repressed memories are made conscious, but this is an uncomfortable process which the child resists. The belief in repression lacks empirical evidence but has become completely accepted in popular psychology, so “everybody knows” that this is how the human mind works. Parents are easily convinced that behavior that is a problem, and that they do not seem to be able to change, must be a direct result of children’s past traumas and a way for them to “act out” emotional concerns. This remains a common way of thinking about problems of elimination, and especially about relating such problems to sexual abuse, even though there is good evidence that people do not usually repress even very horrible memories (although they may suppress or try not to think about them). The lack of evidence for repression argues against the use of this concept to explain why some children have unusual toileting problems.

A third “psychological” explanation is one that frequently occurs in discussions of “attachment therapy” for adopted children. Proponents of this way of thinking hold that children who have been deprived of emotionally warm, nurturing care become frightened of emotional closeness and attempt to withdrawn when they feel themselves moving toward attachment relationships. Their fear, it is said, leads them to “sabotage” such relationships by behaving hatefully or disgustingly toward adult caregivers—and inappropriate urination and defecation are certainly effective ways to do this. Caregivers may complain that a child soils underwear or fails to wipe properly, or wets underpants and then hides them, and so on--  even though the child is apparently quite old enough for bowel and bladder control. The explanation given for these actions is that the child is afraid of getting close to someone and being disappointed, as an adult might be after experiencing several failed marriages.

How do we argue for or against this explanation? Children’s histories can be so complicated that it is very difficult to figure out why a behavior occurs. But is it plausible to claim that a child shows the behaviors just described, or similar ones, because they are trying to avoid the fearsome experience of emotional intimacy? Maybe examining an analogy will help out here. What happens when young children are deprived of food or underfed for a period of time? Would we expect such children to be frightened of food or to avoid situations where there are plenty of appetizing goodies? This seems most unlikely, and it is much more probable that such children will be preoccupied with food, hoard it, even steal it. Why then assume that lack of emotional warmth will make children afraid of attachment? And if there is no reason to think they are afraid of attachment, how can we attribute their behavior to such fear? The “attachment therapy” explanation of toileting problems thus seems as unacceptable as the other “psychological” approaches.

So, what do we have left? The common psychological explanations seem unsupported. In addition, it’s a good idea to keep in mind the rule of parsimony--  that if several possible explanations are offered, and no reason exists to choose any particular one, it is safest to go with the simplest explanation. Without implying that psychological explanations are never correct, the principle of parsimony suggests that non-psychological, physiological explanations may be the best approach to some problems of behavior, especially those with strong biological components, like elimination.

I want to offer some possible physiological explanations for the toileting problems reported by some adoptive parents. (I’ll provide some sources for this information at the end of this post.) First, let me mention bedwetting. Unless a child is frightened to get up for some reason, bedwetting occurs during sleep, is not under conscious control, and is not very responsive to daytime training methods. About 75% of boys, and quite a few girls, are not reliably dry at night until age 5, and some individuals go on for years wetting at night in spite of their own and everyone else’s best efforts. The developmental  step of staying dry at night is largely under genetic control, whereas the steps in successful daytime control are much more responsive to the child’s experiences. However distressing and annoying it may be to have a large child wet the bed, the problem is not likely to be solved by punishments, rewards, or psychotherapy either conventional or unconventional.

Daytime bowel and bladder control is responsive to training. However, in the cases of adopted or foster children, the child and the caregiver may have to deal with the results of training efforts and experiences that occurred long before the present placement. For example, the child may have had to hold urine so long that the bladder muscles have become insensitive to the pressure of a full bladder. The child does not urinate often, and as a result may develop urinary tract infections or experience leaks that do not empty the bladder completely (hence, perhaps, those moist panties that are hidden somewhere until the smell reveals them). Having to wait to move the bowels--  or fear of a painful bowel movement--  can create a similar situation in the colon. In that case, softer stools may leak around the hard stool retained in the colon, staining underwear and creating confusing sensations which the child cannot trust as an indication that it’s time to go to the toilet.

If the adopted child has already developed these problems, it may be necessary to see a urologist and/or a gastroenterologist in order to understand and work with the physiological causes of the difficulty. This should be presented as help, not as punishment, because the child is in fact not intentionally behaving inappropriately. Drinking a lot of water (not carbonated beverages, fruit juices, or caffeinated drinks) and using a timer as a reminder of the time to urinate can help retrain a bladder that has become insensitive. Water is also helpful for constipation, and so are food with plenty of fiber and a lot of exercise (children with physical disabilities may need professional help in the area of exercise).

What if a child develops bowel and bladder problems after adoption? I would suggest thinking over carefully whether certain precepts of popular attachment therapy are being followed. For example, is the parent convinced that the child must go through a period of complete dependency in order to mature emotionally? Those who are advocates of this belief may require that the child ask for everything that is needed, whether a drink of water or the use of the toilet, and do nothing without permission from the adoptive parent. This is oftenenforced by placing an alarm on the child’s bedroom door or locking the door. Children may be severely punished by “paradoxical interventions” such as forced drinking if they have taken a drink without asking (one child died of hyponatremia as a result of this tactic). Children may also have “consequences” like limitation of food to peanut butter sandwiches. Limited water intake, limited and low-fiber food, and constraints on toilet use--  can you tell me a better way to cause eliminative dysfunctions? Where these practices are in use, I submit that there is no need to seek a “psychological” explanation of toileting difficulties.


Some sources:
Presentation by Dr.Christine Kodman-Jones for Delaware Valley Group of the World Association for Infant Mental Health, Dec. 7, 2012.

[By the way, if you came to this post looking for more general information about toilet-training, you might want to try http://dvgwaimh.blogspot.com/2012/12/a-relational-approach-to-toilet.html .]
.




Tuesday, November 27, 2012

Events Leading to the Death of Ashley Smith


Ashley Smith was a 19-year-old Canadian girl who died while incarcerated in 2007. She placed a ligature around her own neck, and it appears that guards, who were aware of her action, waited outside her cell until she was unconscious before entering. This story is told at http://www.canada.com/opinion/op-ed/mental+health+system+failed+smith/7549496/story.html
and at www.cbc.ca/news/canada/story/2012/10/31/ashley-smith-inquest-scope.html. Ashley had originally been incarcerated when in her early teens she apparently threw crab apples at a mailman who she believed was withholding mail deliveries. As she repeatedly rebelled against incarceration, her actions were judged to qualify her for further imprisonment in the adult system.

John Sainsbury’s op-ed piece, linked above, addresses some of the abusive treatment that sparked Ashley’s continuing resentment and refusal to capitulate. Most of her time was spent in solitary confinement, a device well-known to destabilize even the best-balanced personality, and one intentionally used in brainwashing and other efforts to “break” prisoners. Frequent transfers from one institution to another made it impossible for her to have any sense of familiarity or security, whether in her physical or her social environment. Had Ashley been the captive of kidnappers or hostage-takers, we would all be admiring her heroism and ability to maintain her integrity under pressure; as her experiences occurred at the decision of national authority, we see her named as a delinquent and criminal whose suicide was a result of mental illness and perhaps general contrariness.

There are all too many points that need consideration in this story. I am going to comment on only one of them--  the use  in Ashley’s treatment of the “wrap”, a blanket-like body restraint that is both uncomfortable and terrifying for its victims, but which continues to be used because of claims that its effects are “therapeutic”. “Wraps” or “cocoons” can be and often are used punitively under the mask of “treatment” for noncompliant behavior, as other forms of restraint can be. When restraint methods are used without documentation or later debriefing of staff, a possible pattern is for a staff member who is annoyed by a patient or prisoner to taunt the person until he or she responds violently, then to use restraint in retaliation.

Beliefs in the therapeutic value of restraint have been promulgated by a few psychotherapists, notably Ronald Federici and Dave Ziegler. In the form of the “Body Sock”, an all-over pressure garment, public schools, like one in Tampa, FL, have used “wrapping” to quiet children and have not considered it necessary to inform parents of this practice. In a post a few days ago, I mentioned the use of the “papoose board”, intended to restrain children during essential dental and medical procedures, but used “off-label” to treat/punish temper tantrums.

Those who claim that physical restraint is therapeutic sometimes cite the use of swaddling as an effective way to calm young infants, but in generalizing to older people they make the same error that would occur if they suggested a milk diet for adults. Proponents of restraint also often refer to the “squeeze machine” created for her own use by Temple Grandin, the well-known, high-functioning autistic professor of animal husbandry. Grandin noted that as a child she observed farm animals being held in a restraining device and found it calming when she was “squeezed” in the same way. Important point, though: Grandin could start or stop her experience of restraint absolutely at will. But no one offers children, patients, or prisoners the option of seeking or leaving restraint as they choose. They cannot avoid or stop the restraint until their captor makes a decision--  which may or may not be based on how the restrained person acts. It’s not inconceivable that a person feeling distressed might find it comforting to feel full-body pressure that can be adjusted or stopped as is desired. If there were good evidence that such pressure is therapeutic, we would need to consider that, no matter how implausible it may seem when we imagine the experience. However, without evidence, and going on empathy alone, most of us would agree that restraint we cannot control would be experienced only as a fearful punishment.     

Why would anybody claim that physical restraint and body pressure could have therapeutic benefits? I would suggest that there are historical reasons that go back to the use of the strait jacket and the “wet pack” (wrapping in wet sheets) to treat distraught patients. These were without a doubt more humane and therefore more therapeutic than keeping the mentally ill shackled in cells where the public could gawk at them--- or than the “brave bracelets strong, sweet whips, ding dong, and wholesome hunger plenty” described by Tom o' Bedlam.

At about the same time as the movement toward more humane treatment of the mentally ill in the late 18th century, there were also new suggestions about human development that emphasized sensory experience as the shaper of mental growth. On the one hand, this perspective led to effective methods of educating blind and deaf children. On the other, however, it established the belief that sensory stimulation could solve many mental problems. In the 20th century, this approach was formalized by the occupational therapist A. Jean Ayres, whose recommendations of touch and vestibular stimulation have never been well-supported by systematic evidence but have been adopted by educators and therapists. Ayres’ views on “sensory integration” became the basis of the “Body Sock” and other “wrap” methods, --  which unfortunately lent themselves all too readily to being used as punishments (certainly not the intention of Ayres).  

Horribly, it is possible for frustrated, possibly ill-trained teachers, mental health staff, or guards to take a technique intended to do good and to use it in the service of their wishes to retaliate against noncompliance. A case in point is the present use of solitary confinement, a technique introduced by Quaker prison reformers who felt it would give prisoners the opportunity to think through their attitudes and become penitent while in the penitentiary. This seems unlikely to us today only because we now know how solitary confinement can be used for harm.  When will we become aware that in spite of all claims of therapeutic benefit, restraint is used primarily as punishment, and used at the whim of those with secret power on those with no defense?

Whenever this occurs, it will be too late for Ashley Smith and many others.  



Monday, November 26, 2012

The New "Myths and Misunderstandings" Is Here


Just a brief announcement: the second edition of my book Child Development: Myths and Misunderstandings is now available from Sage Publishers and Amazon. Like other revised editions, this volume is changed by more than 25% from the previous edition, with 14 entirely new essays and revisions of some of the older ones.

Here are some of the claims (common beliefs and statements) that are examined in this edition:


Feral children are individuals who have been brought up from infancy by animals.

When parents divorce, it’s important for young children to have certain experiences with both parents, or they will form an attachment to only one of them.

Parents who were abused as children are likely to abuse their own children.

A young child can tell when someone is just teasing.

When a child is mentally ill, any psychological treatment is better than no treatment.

If a child is sexually molested, he or she will probably repress the memory.

Single-sex schools give better outcomes of academic achievement than do coeducational schools.

Children and adolescents learn bad behavior from their peers.


So,what can be said about these claims? True, or false, or a little of each, or “not proven”? For each of these and the other 51 claims that are examined, Myths and Misunderstandings looks at research evidence and at critical thinking about the topic, and shows the reasons for one of these conclusions. It also provides a list of readings and of critical thinking questions to help readers master the material.

This edition is longer and more thorough than the first. My only real regret--  there’s a new cover picture, and my favorite “naughty boy” in superhero costume has vanished!

Branding Cures and Attachment Therapy: A Little History and Discussion



Writing in the New York Times Magazine on Nov. 25, 2012, Lori Gottlieb, a professional psychotherapist, talked about a modern trend in her article “The Branding Cure: My So-Called Career as a Therapist.” Gottlieb’s comments about the behavior of psychotherapists in general have a remarkable relevance to the existence of psychologists, social workers, and others who call themselves “attachment therapists”--  and for the appeal that title has to many parents.

Gottlieb’s article addresses the response of psychologists to the fact that there are too many psychotherapists for the number of possible clients. For a lot of reasons, including the availability of psychotropic medications and limitations of insurance coverage for talk therapy, psychotherapists are finding that all their training may not put them in the position of making a living. What to do? One solution that has been suggested is to “brand” themselves by stating a narrow specialty on which they can be consulted--  weight loss, for example, or parenting discipline methods.

Here is what a “branding consultant” told Gottlieb on this point: “Nobody wants to buy therapy anymore… They want to buy a solution to a problem….[People come in] because they wanted someone else or something else to change” rather than seeking deep changes in themselves. Gottlieb reported, also, that people wanted to choose a therapist on the basis of personal characteristics of the practitioner, often emphasizing experiences or background shared by the client. This means that psychotherapists  who want enough clients to support themselves may need to provide some personal information about themselves, perhaps on a blog.

 People like me who are old enough for emeritus status notice a remarkable contrast between this advice to present-day therapists and ethical standards for professionals several decades ago. In the past, it was not only not customary for professionals to advertise in more than the most discreet way (“Dr. X has opened a new office at 999 Chestnut Street and is available by appointment”), but advertising was in fact prohibited by professional codes of ethics. In the 1970s, two cases decided by the Supreme Court re-defined advertising as a part of commercial speech that is protected under the First Amendment. One of these, Virginia State Pharmacy Board v. Virginia Citizens Consumer Council, 1976, permitted pharmacists to advertise drug prices for competitive purposes. The other, Bates v. State Bar of Arizona, 1977, decided that an attorney was permitted to advertise his services in spite of the ethical guidelines of his state professional organization which forbade such advertising.

After those two decisions, it was only a matter of time until law firms used billboards to attract people who had been in car accidents or had other legal problems; the traditional ambulance-chasing gave way to advertising that was seen daily by potential clients who might not yet be in any trouble. Psychologists and other professionals followed suit. Of course, with the advent of the Internet, both obvious advertising and “informational” blog or website presentations became ubiquitous. Ethical guidelines for psychologists (www.apa.org/ethic/code/index.aspx?item=8 ) do not forbid advertising, but require that public statements of any kind not be false or deceptive. (However, attempts to get the American Psychological Association to enforce this guideline are not likely to meet with cooperation, in my own experience.)

It was only at the point when information could be placed on the Internet that psychotherapists were in a position to “brand” themselves by announcing a specialty, and quite a few now do this. The public should know, however, that a licensed psychologist or social worker has almost invariably received a general training in psychotherapy at the accredited (we hope) university that granted the degree. Although there are continuing education classes that focus on specialties like weight loss or parenting, these were not the focus of the practitioner’s professional education, nor do they have anything like the rigor of a serious training program. A psychotherapist may have sought extensive training in the “brand” he or she presents--  or, possibly, not. There is no mechanism for preventing a person from saying that his or her specialty is birth trauma if that is the “brand” chosen, even if there is really no such thing as formal training in that specialty.

What does all this have to do with “attachment therapy”? This treatment is a “brand” selected and fostered by the organization Association for Treatment and Training of Attachment in Children (ATTACh; www.attach.org). Although there are many academic programs that focus on research into the development of emotional attachment and its consequences for later attitudes and behavior, few if any “attachment therapists” have studied at one of them. Although there are also many academic programs providing training in psychotherapy for children, and all of them consider the role of attachment in the development of personality, mood, and behavior, few if any teach a form of psychotherapy that aims specifically to alter attachment status. (They may, however, teach methods of work with parents that can alter the adults’ responses to children’s communication of attachment cues.)

In other words, there are no “attachment therapists” in the sense of persons trained in an accredited educational setting to  do treatment that alters a child’s attachment to specific adults. The idea that there are such people is purely a matter of “branding” by ATTACh, which offers certification for people who have been through its educational programs and maintains a list of “registered” therapists. I have to admire the chutzpah with which ATTACh has declared itself the source of training in a posited therapy and the final judge of what is or is not “attachment therapy”. This has been done in the face of a complete absence of evidence that the problems to be treated even exist in the declared form, or that the treatments used alter personality or behavior at all. A “brand” has been  invented by ATTACh, it’s out there on websites and blogs, and the market niche this brand requires has been opened. ATTACh built it, and they have come, but unfortunately their attendance at this baseball game is not necessarily therapeutic.

How was the “branding” of AT carried out? Looking at what’s on the Internet, we can see how beautifully the actions fit with the trends described by Gottlieb. First, there was a definition of a variety of real or potential difficulties as due to a single problem factor, attachment. This provided potential clients with a problem whose solution they could seek from practitioners whose name, ”attachment therapists”, gave the evidence that they were the right people to do this job. Second, AT practitioners stated that no deep change in the parents was required. It was, as Gottlieb quoted, a matter of wanting “someone else or something else to change”, and AT blogs and websites said that this could be done by correct treatment (while also warning against the dangers of pursuing conventional treatment outside the “brand”.) Third, ATTACh and its associates emphasized personal characteristics of practitioners and provided unusual amounts of personal information in various ways like blogs and self-published books; this permitted clients to choose a therapist on the basis of adoptive parenthood (for example) rather than on general training at a respectable institution or on breadth of experience with childhood mental health problems. AT clients found this appealing, especially in contrast with the professional reticence of most conventionally-trained psychotherapists--  which those who chose AT often perceived as aloofness or even disapproval.

Did the Supreme Court make the right decisions back in the ‘70s? I think not. Advertising and “branding” by professionals is good for the professionals’ bank accounts--  but surely those should not be the first consideration for the community.



  

They Don't Do That Any More: Attachment Therapy/Holding Therapy



Everybody knows the story of the tippler who declared that he didn’t drink any more. Caught with a bottle of beer in his hand, he explained: “I don’t drink any less, either!” That seems to be the possible position of the Association for Treatment and Training of Attachment in Children (ATTACh). Following the deaths of Candace Newmaker and other children in situations associated with holding therapy, ATTACh announced early in the 2000 decade that its members would no longer use coercive methods or physically restrain children in treatment.  By the present year, 2012, we would expect all practitioners who consider themselves to be doing “attachment therapy” to have gotten this message--  if indeed it is being sent. (The continuing presence at www.attach.org of misinformation about Reactive Attachment Disorder raises questions about exactly what is being communicated.)

Nevertheless, here we are seeing the same old same old story being told in the blog http://adoptingspecialneeds.wordpress.com. This blogger has apparently spent her adult life adopting extremely difficult children and now has, among others, a 6-year-old who bites and fights. With this child, the adoptive mother is following the advice of the attachment therapy guru-ess, Nancy Thomas, and also displays a table of “facts” about Reactive Attachment Disorder that looks quite official but is in fact not based on any genuine information about that disorder as it is described in DSM (see p. 17 of her blog). Adoptive Mother has also sought an “attachment therapist” who will do an intensive treatment, many hours a day, with a method that is only vaguely described but appears to involve coercive restraint and other “holding therapy” techniques.

Adoptive Mother identifies herself with the Trauma Mamas (other adoptive mothers of children from severely traumatic backgrounds)  and believes that she and they are a special breed whose experiences and qualities no one else can understand. One of the reasons Adoptive Mother and others seek out “attachment therapists” is that such practitioners encourage the view that only people with similar experiences can “get it”, and that conventional therapists are critical and rejecting of parents and simply “make the children worse”. These parents may also welcome a belief system that stresses escalation of intrusive parental control--  whether they welcome it or not, they buy into it when they choose a method that emphasizes coercion. Someone has said that “attachment therapy” is a way for parents to have children punished without doing it themselves, and this may be the reason we see Adoptive Mother writing “While Hope is clearly RAD, and I am committed to her without reservation, there are too many times when I simply do not like her” (but I quote this remark in full awareness of the genuine ambivalence that may cause some of the intensity of parental love).

How do I know that the treatment Adoptive Mother has sought is a coercive one? Not having been in the treatment room, of course, I don’t. Adoptive Mother mentioned wanting to find an AT (attachment therapist) trained by Daniel Hughes, and Hughes, in spite of his earlier admiration of holding therapy, has stated that he does not use coercion. However, Adoptive Mother does refer to children who have died in the course of holding, and states that she and her husband are present in the treatment room and would not permit anything abusive to happen, so it appears that she recognizes at least some element of coercion. In addition, the treatment she describes involves insistence on eye contact, and how this would be achieved without some degree of coercion or intimidation is not clear to me.

In addition to her choice of therapists, Adoptive Mother comments frequently on the use of physical force in dealing with the child. This ranges from the “strong sitting” demands advised by Nancy Thomas to a physical takedown and pindown to the use of a papoose board, a padded wooden restraint board used in painful or frightening medical and dental procedures, the use of which by professionals should receive documentation. (She notes 30 minutes of restraint of the child on the papoose board at one point.)

It appears that in spite of the claims of ATTACh that they "don't do it any more", “attachment therapy” in its “holding” form is alive and well and maintaining its position in the forefront of unconventional psychotherapies for children.

Not surprisingly, Adoptive Mother is also attracted to other alternative, unorthodox treatments. She is enthusiastic about having a chiropractor treat a child for bed-wetting. She employs a “tapping” technique (see http://childmyths.blogspot.com/2012/11/fun-with-thought-field-therapy-why-some.html) with one of her other children. She refers to the use of “sensory activities” and of “therapeutic holding”, both approaches with little or no evidence supporting them. She seems to be an easy sell for the AT practitioner who tells her that her child is in terrible shape, but that a tiny “spark” remains in spite of all. Wouldn’t it be nice if screening of adoptive parents looked into their ability to detect snake oil? But, until caseworkers can detect it themselves, I don’t suppose such screening is about to happen.


Wednesday, November 14, 2012

An Open Letter to Richard Dawkins: Butterflies, Herring Gulls, and Hurricanes in Child Mental Health


Dear Professor Dawkins:

About 30 years ago, you contributed inadvertently to a mistake whose repercussions are still being felt by vulnerable and innocent people. Without wishing to blame you for an action whose consequences are not your fault, I would like to ask you to speak up in support of those of us who are working toward correction of the error.

The flapping butterfly, or perhaps herring gull, wing I refer to was your contribution to the book Autistic children: New hope for a cure, published in 1983 by Nikolaas and Elisabeth Tinbergen, with appendices by Martha Welch and Michele Zappella. In the Preface, the Tinbergens thank you for reading and critiquing Chapter 7 (“Methodological comments”). Presumably you had some idea what claims were made in the book; if you did not, I will point out now that the Tinbergens’ intention was to advocate for the use of “holding therapy” in the treatment of autistic children. Many of the book’s illustrations show children screaming and fighting against the physical restraint that is the core of “holding therapy”. In the appendices, Welch advised this form of restraint for every child every day, as well as for autistic children. Zappella claimed that  he used “holding therapy” to cure not only  autism but the problems of a child who had been exposed to rubella prenatally.

Today, it is clear that “holding therapy” is not only ineffective but dangerous to children, and a number of professional organizations have stated this in public resolutions. But such statements have not stopped the use of the treatment. Martha Welch, who has often referenced the Tinbergens, continues to practice in the United States. At least one British practitioner has used the method in residential treatment of foster children. The Czech practitioner Jirina Prekopova, whom the Tinbergens mention with approval, has recently returned to the Czech Republic to practice “holding therapy” after many years in Germany. Prekopova too refers to the Tinbergens’ book as the scientific basis for her methods, which apparently receive strong support from the church. If you want to hear the sound of the hurricane that has resulted from that butterfly or gull wing, go to www.youtu.be/uzQmHq-7rKM  where you will hear the screams and pleas of a child being subjected to Prekovopa’s “holding therapy” methods. (I suggest that you do not play this where children or unsuspecting adults can hear it.)

The chapter on methodology that you critiqued is in no way supportive of “holding therapy”, but simply discusses the Tinbergens’ view of an appropriate, ethologically-based way of studying autism. If the book stopped at that point, there might be little need to ask you or anyone else to speak out--  but it does not stop, and the succeeding unevidentiated claims about “holding therapy” appear to the na├»ve reader to be logical consequences of the earlier material. This presentation has enabled practitioners of “holding therapy” like Prekopova  to argue that there is a scientific basis for what they do. In point of fact, the Tinbergens’ elaborate discussion of behavior patterns provides an interesting hypothesis for the exploration of autism, but no support whatsoever for the use of “holding”. Your public statement of that fact could help to counter the present use of what is simply a complementary and alternative treatment.

In April 2013,  there will be a meeting in London of what may be provisionally named an International Working Group on Abuses in Child Psychotherapy. It will be attended by interested American and British psychologists and social workers and by people from the Czech Republic who are particularly concerned about the popularity of Prekopova’s methods in several European and Latin American countries.  A statement from you, making clear that you reject any scientific foundation for “holding therapy”, including the arguments presented by the Tinbergens, would be much appreciated by the members of the group and could help reduce the use of the method.

Thank you for your attention.

Yours sincerely,
Jean Mercer, Ph.D.

Friday, November 9, 2012

Fun With Thought Field Therapy: Why Some Randomized Controlled Trials Are More Controlled Than Others



Elsevier Publishers kindly send me links to articles in their CAM journal Explore:The Journal of Science and Healing. Today I actually read a couple of the articles, and although one is about a technique that is usually used with adults rather than children, I thought they might serve as good object lessons in why research design is every bit as important as statistical analysis done with packaged programs, and why basic statistical concepts are needed for interpretation of data.

The first of these papers is by Irgens, Dammen, Nysatter, and Hoffart (“Thought Field Therapy (TFT) as a treatment for anxiety symptoms: A randomized controlled trial”, 2012, Vol.8, pp. 331-338).

Let me start by describing TFT for those who are not familiar with this CAM treatment. TFT assumes that mood and emotional disturbances are caused by disruptions in energy flow within the mind-body totality, and that these can be corrected by tapping (physically) on points associated with meridians or lines along the body that are thought to correspond with a spiritual energy similar to the Chinese qi  concept.  

A second aspect of this study that I should mention is the idea of a randomized controlled design. The point of any experimental design is to discriminate between the effects of the factor being investigated--  such as a psychotherapy-- and the effects of the many other factors that can influence an outcome--  such as patients’ and therapists’ expectations or communications. Controlled studies employ various ways to make sure that those other factors are not mistaken for the important factors in the study--  the effects of the treatment, and how they compare with the outcome when that treatment is not present. Randomizing, or choosing by a random method which people will receive the treatment and which will not, is a way to control factors like choices made by patients or by therapists. For instance, if the patients choose their own  treatments, their expectations and beliefs about the treatments can affect the outcomes. Similarly, if therapists choose which patients will receive which treatment (this includes no treatment), they may inadvertently put people in each group according to their expectations or their wishes about what will “work”. (This is not an attack on their integrity, just acknowledgement of human errors.) But randomization is no panacea in itself, and if other aspects of the design are not appropriate, a randomized trial may not control for all factors that can confuse our interpretation of the results.

Here’s what the Irgens group did in their randomized controlled trial of TFT. They randomly assigned people who had anxiety symptoms to one of two groups, those who would receive TFT right away and those who would be placed on a waiting list and told they would receive TFT 2 ½ months later. This meant that one group received treatment that included social interaction and physical contact with the therapist, and the other did not. In other words, the study did not control for the effects of simply talking to and being touched by the therapist, and the effects of those factors were mixed with the possible effects of TFT itself, with its methods of tapping on meridian lines. The treatment group experienced all three of these things, and the non-treatment group experienced none of them--  but the researchers nevertheless concluded that TFT was responsible for an improvement in anxiety symptoms following treatment. They had randomized, yes, but they had not controlled, and therefore their conclusion was an invalid one.

The Irgens group did not show that anxious people feel better because of TFT. What they showed was congruent with the common-sense expectation that anxious people feel better when they have more experiences with caring social contact, and possibly that touch is an important part of those experiences. In order to show that TFT itself caused improvement in symptoms, they would have needed to control for these confounding factors by creating a sham treatment group in which patients would have received social contact, touch, and tapping as well--  but the tapping would not have used the meridians that are the focus of TFT. Without an approach like that one, we have to say that the researchers’ randomized design did not successfully control for powerful factors that could bring about their reported results.

In addition, I should point out that the longer-term improvement reported can easily be explained by considering regression to the mean--  that is, if you feel pretty bad today (and are not suffering from a progressing physical illness), chances are that you will feel better tomorrow. In addition, chances are that you seek treatment for emotional distress when you feel your worst, and therefore it is likely that you will feel better later on, with or without treatment.  Without wishing to suggest that serious mental illness be left untreated, I would point out that both unpleasant moods and pleasant ones will generally alter over time without any changes in circumstance.

There’s one more paper in this issue of Explore that I’d like to mention. By Jensen and Parker, it’s called “Entangled in the womb? A pilot study on the possible physiological connectedness between identical twins with different embryonic backgrounds” (2012, Vol. 8, pp. 339-347). The different embryonic backgrounds part had to do with whether they had shared a placenta and an amniotic sac, although it was not clear how that was known. “Connectedness” was the term used in describing posited events in which one twin was subjected to a mild shock or surprise, and the other responded by changes in blood pressure and other measures. Jensen and Parker concluded that there was no significant association between the reactions of the co-twins. However, in the time-honored manner of parapsychologists, they selected events in one of the four pairs of twins tested and reported that there were significant numbers of “hits” because on three of the 10 events the non-stimulated twin showed some reaction. This form of cherry-picking completely ignores the fact that such physiological changes can occur by chance or because of some other event in the environment. (Actually, what surprises me is that these researchers did not conclude that a failure to show “hits” was due to a motivation to develop an autonomous identity in the face of constant experiences of “connectedness”.)

I should point out, by the way, that Jensen and Parker, who obviously could not randomize people into twin and non-twin pairs, did not attempt to provide a comparison group of non-twins. If this kind of idea is to be pursued at all, surely it would be of interest to see whether a similar number of “hits” occurred in one non-twin pair. But, I guess, for Jensen and Parker--- not so much!    

Thursday, November 8, 2012

Diagnosing Reactive Attachment Disorder with Scales and Questionnaires



I’ve recently been having a correspondence with a birth mother whose two school-age sons have been placed in treatment with an attachment therapist by their stepmother. One child is now being placed in residential treatment. The attachment therapist, who is also evaluating the children and recommending a custody arrangement (he’s a social worker; a psychologist would not be permitted to wear two hats like this), says he has diagnosed one boy with Reactive Attachment Disorder by means of an unidentified scale.

What scale might this be, I wonder? Can there be a scientifically validated test of this type? Psychological scales and tests are generally developed in one of two ways. The first, the one used with intelligence tests for adults, involves developing a large set of questions, throwing out all the ones that everyone or no one answers correctly, and then determining what proportion of the population gets specific scores on the remaining questions. An IQ score is a shorthand statement of how well the person did in comparison with a lot of other people. (Tests for children are a bit different and need to be done separately for each age group.)

In the second method, there is some known accurate way to detect or diagnose a personality characteristic (for example), but it takes a long time to do it or requires special training. The test developers seek information that is easier to get and that correlates highly with the known accurate diagnosis. When the test is developed, it allows less trained people to diagnose in a short time a condition that otherwise takes a lot of work on the part of an expert. This is a good outcome if there really is a reliably accurate way of diagnosing, and if the new test is strongly correlated with that way of diagnosing. If there is no reliable way to diagnose a condition, or if the proposed test does not correlate very well with the accurate method, it may not be useful to employ the new method.

Both of these methods of test development require meticulous work and data analysis. The second method also demands a good design in which people collecting information from the test do not know that diagnosis someone has previously given the tested individual, for example.

Although there has been a good deal of research on the proportions of young children who show different attachment statuses, there is little on that topic for school-age children, and even less on proportions of children diagnosed with Reactive Attachment Disorder. One of the reasons for this lack of research is that no one has put forward a valid technique of diagnosing Reactive Attachment Disorder. The lack of such a method obviously also makes it impossible to follow the second method and develop a scale or questionnaire that gives an accurate diagnosis.

So what scale could the attachment therapist mentioned above have used in his diagnostic efforts? There have in fact been some attempts to create such a test, but so far all present serious problems.

The Randolph Attachment Disorder Questionnaire (RADQ), published by Elizabeth Randolph in 2000, is one of the most questionable efforts along this line. For those who have heard of this or even used it, let me point out an awfully important point:
The RADQ is not intended by its developer to diagnose Reactive Attachment Disorder. It addresses a different set of problems, posited by some attachment therapists and called simply Attachment Disorder.
Calling the test the RADQ and the disorder RAD does suggest that the test is about Reactive Attachment Disorder as commonly defined, but no---  the R is for Randolph.

Whatever the RADQ is meant to diagnose, it does not really matter very much, because Randolph herself observed and diagnosed the children and supervised the parents who filled out the questionnaire, as well as doing the data analysis on information whose background she knew. To comment on this is not to attack Randoph’s integrity; no researcher should trust himself or herself to avoid biases about known information. That’s why everyone is expected to be “blind” to any information that could skew diagnoses or measurements or mathematical analysis. Randolph did not take care about this, and as a result her complicated calculations amount to “garbage in, garbage out”. In addition, she did not clarify what she was looking for when making her own diagnosis, and since in a 2001 publications she stated that she could diagnose RAD from the fact that a child could not crawl backward on command--  well, need I go on?

IN spite of the shortcomings of the RADQ, Sheperis and his colleagues (“The development of an assessment protocol for Reactive Attachment Disorder”, Journal of Mental Health Counseling, 2003, Vol. 25, pp. 291-310) used the test along with various others and proposed that this battery would assess RAD in school-age children. However, in 2005, Cappelletty, Brown, and Shumate examined correlations between the RADQ and other sources of information (“Correlates of the Randolph Attachment Disorder Questionnaire (RADQ) in a sample of children in foster placement”, Child and Adolescent Social Work, 2005, Vol. 22,pp.71-84) and found that the scores for children in foster care (who would presumably be most likely to be categorized as having RAD) were not significantly different from those of other children. These facts suggest that it would have been a mistake for the attachment therapist to have been using the RADQ to produce the diagnosis.

What about other scales? Thrall, Hall, Golden, and Sheaffer (“Screening measures for children and adolescents with Reactive Attachment Disorder”, Behavioral Development Bulletin, 2009, Vol. 15, pp. 4-10), who apparently can’t spell Cronbach, used two questionnaires which they said discriminated between individuals who had been diagnosed previously with Reactive Attachment Disorder and those who had not. They noted that for those children with a RAD diagnosis, “the diagnosis of RAD, disinhibited subtype, had been made by a mental health practitioner specializing in attachment disorders” and that the children were now in treatment. This raises a question about the original diagnosis, because although most child mental health  practitioners consider attachment issues to be of importance, very few of them would describe themselves as specialists in attachment disorders unless they were much involved with the whole attachment therapy belief system. Thus, it’s questionable whether the questionnaires used by Thrall and her colleagues would actually have discriminated between children diagnosed with RAD by conventional practitioners and those receiving other diagnoses.

One more approach to be considered here: Helen Minnis, a Scottish psychiatrist, has spent years in trying to develop scales to diagnose RAD. (The Thrall paper used one of her questionnaires.) In 2010, Follan and Minnis (“Forty-four juvenile thieves revisited: From Bowlby to Reactive Attachment Disorder”, Child: Care, Health, and Development, Vol. 36, pp. 639-645) proposed a battery of tests to identify RAD for  research purposes (in other words, with less accuracy required  than we would demand for individual evaluation). Very interestingly, Follan and Minnis argued that concerning behaviors were probably due to early maltreatment and genetic vulnerabilities rather than to separation, and that current secure attachments could exist side by side with the condition called Reactive Attachment Disorder. They also noted that “insecure attachment is likely to be very common in child psychiatric populations and although its measurement is useful to develop   a holistic understanding of the child, is not an indication of disorder in itself.”

To conclude, then, there are some points to be made with respect to the attachment therapist who is using a scale for diagnosis of RAD. The first is that there is no scale of this type that  provides the sort of reliable and valid assessment that should be required for use in legal decisions about custody of children. A second is that there may be no reason whatsoever to seek a specific diagnosis of this kind--  other than the fact that insurance claims demand one. As Follan and Minnis note, whatever the concerning behaviors displayed by a child, they may have little to do with attachment per se, and therefore, I would point out, do not require treatment that focuses on attachment. In addition, evidence-based treatments focus on specific characteristics of children and parents rather than assuming that they indicate attachment problems; treatments that make attachment issues the central concern are not at this time evidence-based, although some practitioners make this claim.  

Wednesday, November 7, 2012

They Only Do It to Annoy: Adoption and High-Control Parenting


"Speak roughly to your little boy
And beat him when he sneezes.
He only does it to annoy
Because he knows it teases.

Wow! Wow! Wow!"
        --- Lewis Carroll

Well over a hundred years ago, Lewis Carroll wrote this parody that inadvertently predicted the views of some of today’s adoptive parents and their coaches or therapists. In the belief system espoused by these present-day thinkers, whatever children do, they do intentionally, and if what they do is unwelcome to their caregivers, they do it to “get back” at the adults. Yes, they only do it to annoy, even if it’s as involuntary as sneezing.

A rather appalling 1996 paper by Keith Reber, still very much in circulation among “attachment therapists”, states that vomiting and defecation are under voluntary control and will be deployed by children in order to avoid yielding to adult control. When the adopted 10-year-old Candace Newmaker died at the hands of her therapists in 2000, at least one Internet comment declared that she had died “on purpose” in order to create trouble for her mother and the therapists. She apparently “only did it to annoy”, too. The therapists did get into trouble, spending some years in prison, so presumably Candace is thought to have died happy in the view that she was thoroughly annoying someone by seizing control where the adults should have had it.
In comments at http://childmyths.blogspot/2012/11/canned-punishments-apps-advice-and.html, Marianne Milton contributed material from an Internet group of adoptive mothers. A number of them were concerned about children whose behavior was interpreted as controlling, manipulative, and exploitative, although it was just as easily interpreted as motivated by hunger or by anxiety. The discussion seemed to center around techniques that would prevent the children from controlling aspects of their lives--  for example, an alarm that would sound if the child’s bedroom door was opened. Some materials for adoptive and foster parents, like those written by Nancy Thomas, advocate limiting the amounts and variety of foods children receive, and stress the idea that the child must give up all control and become dependent on the adult if he or she is to be “healed” of the emotional disturbance the adult posits.

In one of an apparently endless stream of adoption starvation stories (http://abcnews.go.com/US/wireStory/Minnesota-couple-accused-starving-adopted-son-17648677#.UJ13v4U0yGo), a Minnesota couple, Mona and Russell Hauer, are accused of limiting their adopted 8-year-old to a liquid diet and using a door alarm to make sure he did not “steal” food. They attributed the liquid diet to the advice of a chiropractor about the child’s vomiting; that practitioner apparently felt that liquid was less likely to be vomited.  The Hauers acknowledged that they had at least once withheld food as a punishment (they also beat him with a broom and made him sleep on a sled as punishment for bed-wetting). The child was about half the weight to be expected at his age, was short in stature, and had other physical problems associated with malnutrition.  

Disturbing as this story is so far, I consider two comments attributed to the parents to be even more concerning. Apparently, the Hauers were convinced that  he “only did it to annoy”. Mrs Hauer said that the child’s eating habits were attempts to control the home, that he had controlled the home, and that in her opinion the 35-pound 8-year-old was not too thin. Mr. Hauer added to this that when the emaciated child was taken to the hospital, that meant that he “had won or gotten his way”.  Presumably Mr. Hauer would think that if the boy had died, like Candace Newmaker, he, the child, would have scored an enormous triumph in the control contest.

Far be it from me to deny that school-age children, like teenagers and adults, can get a kick out of  “getting over”. Literal interpretations of instructions--  like not wiping their faces at all when told “Don’t wipe your dirty face on the clean towels”—are a source of glee and evidence of good understanding of language and the nature of social rules. But people who are starving or frightened do not have the sense of proportion that allows them to do a tiny, acceptable spot of defiance without causing too much trouble. Nor do they have the resources to think how they will “control” a household. Just as the expectation of being hanged in the morning is said to concentrate a man’s mind wonderfully, a serious need for food or safety interferes with any possible concerns about who is in charge.

There are some things that people don’t do just to annoy others. Vomiting and bedwetting are among them. As long as we allow adoption by people who don’t know this, but who believe all unwanted child behaviors are intended to gain control, we will have more cases like the Hauers. And as long as we allow caseworkers to be “trained” by control-obsessed thinkers, we will have those adoptions and those outcomes.