Concerned About Unconventional Mental Health Interventions?

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

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 naïve 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.
  

Sunday, November 4, 2012

Surrogates: Another Day at the Office--- A Guest Post

My thanks to Lili Miller, a social psychologist, for contributing the following intensely practical view of what happens when a woman agrees to be a surrogate mother and have a baby for a couple to rear as their own:




In most cases when the topic of surrogacy comes up, it is first put in terms of family, growing choices that couples have when trying to have a baby, questions about adoption, and more. These topics—and most others surrounding surrogacy—tend to focus on the emotional and philosophical implications of surrogacy as an option for the couple. What is often left out of the mix are underlying discussions about the financial implications of surrogacy for the surrogate mother, and what putting a price on this type of service actually means for her. Analyzed through this viewpoint, surrogacy is only a business, much like any other type of business. The surrogate therefore simply becomes a service provider. Her role inevitably changes when money comes into the equation.
Just in the United States, surrogacy continues to be a multi-million dollar business, and while some don’t like to look at it as a question of dollars and cents, it must be treated as such by surrogates, because there are a range of financial issues that must be understood and taken care of during the process.
Many of the financial implications of surrogacy have to do with taxes. In many cases, surrogates work as independent contractors, and as independent contractors, there are a number of tax breaks that they could be entitled to. Most surrogates have a range of business expenses they have to deal with—many of which can be used towards deductions when tax time comes around.
Before even delving into taxes, costs, potential earning, and financial planning for surrogates, it helps to take a look at the process that potential surrogates can follow to ensure that they are working in a safe, organized environment.
Surrogacy Agencies
Like a number of jobs on the market, surrogacy can be made much easier with the help of a professional organization or agency. While we don’t like to think of surrogacy agencies as being exactly the same as an agent that an actor or an athlete might have, the agency does serve some of the same types of functions for the surrogate, and they can be crucial allies every step of the way.
“Surrogacy agencies choreograph the entire process, from matching of the surrogate and intended parents to administration and enforcement of contractual matters.” (from When Your Body is Your Business)

When working with an agency, the surrogate is freed up to take care of herself and to deal with the physical aspects of the process without having to worry about the minutia of the business end of the process. Surrogacy agencies are also there to ensure that both parties are suited for the process and for each other.

Not everyone is qualified to be a surrogate. There is great risk involved, as well as physical and emotional strain. Surrogacy agencies take major steps to ensure that both the surrogates and “intended” parents are uniquely qualified for the process and that they are the right match for each other. This involves good old fashioned advertising (agencies conduct searches for both surrogates and potential parents) and serious screening.

Once a connection between a surrogate and intended parents has been made, the surrogacy agency starts to truly earn its keep. Extended contracts between surrogates and intended parents can be incredibly complex, with altering payment scales, multiple disbursements, and a range of caveats. They can also help define the manner in which business will be conducted between the intended parents and the surrogate. Contracts can include types of behavior that surrogates cannot engage in, as well as rate of communication between the parties, and much more. At the end of the day, the agency is there to ensure professional behavior on the part of both parties.

Once a birth takes place, the agency continues to manage the payment process and to make sure that the surrogate’s contract is honored in full. This is key for surrogates. If financial or legal issues arise, it’s crucial that the surrogate is not taking all of this on by herself.

Financial and Tax Options for Surrogates
While payment for surrogates varies, income can be considerable. However, costs for surrogates can be considerable, too. As was said earlier, there are a number of tax options and deductibles that surrogates can qualify for.

If a surrogate is working as an independent contractor, which many do, it’s important to keep thorough records of all job-related expenses. It’s also important to work with a professional in the field who can give you a clear picture of what types of products and services surrogates can legitimately “write off” on their taxes. Some surrogates can even qualify for the earned income tax credit.

Surrogates engage in single contracts that last a long time, and for health or just plain life reasons, contracts can be few and far between. A surrogate must explore all financial options and engage in a level of serious financial planning to make sure the money earned from surrogacy goes as far as it can.

Surrogates face health risks, physical strain, and a range of emotional elements that most people will never face on a job. For some surrogates, those risks and strains are worth it to help potential parents achieve their dream of having a family. In the end, surrogacy is still viewed as a business. Surrogacy is stripped of all its expressive motivations, and honed as another service for proactive consumerism.




Bio: SimplyLili is a PhD student in Social Psychology, and the eccentric author of Simply Lili Blog; created to disperse knowledge on a plethora of topics in a minimalist and humorous way. She is a self-proclaimed nerd and her 3 fave things are blogging, copywriting, and pugs.
 'Knowledge-Simply'
plus-badge.png Google+




Thursday, November 1, 2012

Canned Punishments: Apps, Advice, and Erroneous Assumptions


People are really committed to the idea that punishment is the best form of child guidance, aren’t they? Yesterday two interesting messages about this came across my virtual desk. One was the suggestion of a nanny website that phone apps will make punishment easy and effective. The other was the blog of an adoptive mother who recounted how her “attachment therapist” had advised methods like locking a teenage daughter in the bathroom for several days as ways to a) make her attached to the adoptive mother, and b) behave the way the mother wanted her to.

In both cases, the adult action was clearly a punishment, whether or not anyone wanted to use the term “consequence”. The child did something that the adult disliked; the adult responded with an action that was expected to be unpleasant for the child; the expectation was that the child would not do the disliked act again. If the child did do the disliked thing again, the plan was to escalate the punishment. I refer to this strategy as “canned punishment”, because it is not shaped particularly to the situation, the individual, or the all-important time factor that determines whether punishment effectively reduces an undesirable behavior. Its “canned” nature is evident in the idea that when the punishment is ineffective, the adult simply does more of the same thing, rather than examining the situation to see whether a different approach might be more effective.

The nanny outfit has been in touch with me before, as have several others. I think this is the one that suggested Tabasco sauce on the tongue as an appropriate method for nannies to use. They seem eager to have their website mentioned, even though when I’ve mentioned it in the past I’ve criticized it unmercifully. (Parents, if you employ a nanny, you may want to make sure that she is not reading their advice!)

This time, the nanny site suggests “10 iPhone apps that help with discipline” and describe them as “most popular and useful for keeping up with kids’ behavior”. Here are a couple of the goodies :
“Timeout—Ultimate discipline tool—Tracking the length of a timeout to provide kids with a visual representation of how long they are sentenced to this punishment is a snap with this application….”

“Tymoot--  Designed by a parent for parents…  The Wheel of Discipline feature that allows your children to spin the virtual wheel in order to be ‘sentenced’ to one of eight customizable punishments”.

Think about the “timeout” method first. Timeout is not intended to be used as a punishment and would not necessarily be effective if it were used that way. The points of timeout are first to remove the child from any social situation that is rewarding bad behavior (like other kids laughing), and second, to interfere with a behavior sequence and help the child move to different behavior. Because these are the goals, “time-in”, in which the child stays close to an adult for a period of time, may be as effective as timeout, or even better. The length of the timeout or its discomfort is not the point. Neither is it the goal of timeout to  exert adult authority or to encourage wrangling with an adult about how much longer it is to go on--- the adult needs to display warmth, sympathy, and an interest in helping the child gain control over behavior. For the adult to use a “canned” approach is to remove the personal and emotional support that is key to working with young children.  

Second—about this Wheel of Discipline. Such a method delays the punishment,which needs to be immediate if it is to be effective. In addition, it makes the situation into a game, inserting a reward period before the punishment and thus effectively reinforcing the undesired behavior. It is worrisome to think of naïve nannies or parents trying to use this method to quell genuinely concerning behavior like running into the street or leaning over a banister, where ineffective guidance can put the child into serious danger.

All right, enough about the nannies. Let’s go on to my second “canned punishment example”. This is to be found at http://www.adoptionblogs.com/weblogs/author/donnav.  Donna V. has three adopted children, siblings 16, 14, and 9. And she has an “attachment therapist” who is instructing her about how to handle the children’s sometimes undesirable behavior, which she naturally attributes to Reactive Attachment Disorder.  You will understand where we are on this when I point out that the children ride horses every week to treat their RAD (see http://childmyths.blogspot.com/2011/02/clever-hans-rides-again-equestrian.html.) Donna and her attachment therapist believe that  the children must give up their wish to be in control in order to “bond”, and that only “bonding” (undefined) will correct such behavior problems as lying and stealing. Donna had been confining the 14-year-old girl to her bedroom when she did not meet the standard of being “respectful, responsible, and fun to be around”, but the therapist felt this wasn’t working because the girl was too comfortable. The isolation was then moved to the bathroom, where the girl spent 6 days and 2 nights. Then she said she was happy, was cooperative, etc.

Most interestingly, in her Aug. 20 blog post, Donna V. describes the treatment as if it is a form of behavior modification that is withholding reinforcement for behaviors that were previously reinforced. She remarks that “as my kids start to respond to the new techniques and to the horse therapy, some of their behavior is actually getting worse. Some days I think that the extinction bursts are going to kill us.” She then accurately defines an extinction burst as “the temporary increase in the frequency, intensity, and/or duration of the behavior targeted for extinction”. Apparently the assumption is that any undesired behavior is occurring because it was rewarded in the past in some way, and that now withholding the reward will eventually cause the behavior to disappear (“extinguish”, in behavior mod terms).  How this relates to needing an isolation area to be uncomfortable, or to bonding, or to horseback riding, is far from clear. It’s also unclear how an extinction (non-reinforcement) procedure can influence any behavior that is self-rewarding--  and maybe that’s why she has turned back to attempts at punishment by taking away comfort or gratifying experience like having a cellphone. In spite of the canned punishment suggested by the therapist, such punishments are very difficult to employ because of the essential timing factor. By the time the mother has discovered a lie or theft, the effective time to use punishment has passed.

Maybe a good start would be to abandon the goal of being “fun to be around”, which is an ill-defined set of behaviors. Certainly punishment for not being fun is difficult to work out, because there are so many ways not to be fun.

My suggestions? Stop worrying about how to make the child more uncomfortable. Don’t look for a punishment that will do the job in a simple way. Seek a knowledgeable therapist who practices evidence-based methods. Realize that effective child guidance does not come in canned, frozen, or evaporated varieties, but must be worked out in individual ways within a specific family context. Keep in mind that teenagers are naturally working on the establishment of autonomy, and asking them to relinquish all control is not developmentally appropriate. Don’t think that a teenager can “bond” to a mother in the sense that a toddler forms an attachment to an adult.  And, if you want to ride horses, have a good time, but don’t imagine that this is therapy--  any more than any other pleasurable activity that helps modulate moods.