Concerned About Unconventional Mental Health Interventions?

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

Thursday, February 21, 2013

Russian Adoption: Trying to Talk About Maxim Shatto



I got up at 4 o’clock this morning to go to a TV studio and be linked to a Russian Channel 1 program (“Life with Mikhail Zelensky”) focused on the deaths of Russian children adopted by parents in the United States. As it turned out, the birth parents of Maxim Shatto, the three-year-old recently killed in Texas, were interviewed on the program, and told a rather sad and somewhat sordid story of having left two young children with a grandmother who may have been a poor choice of caregiver, with the subsequent taking of the children into care and placement for adoption. (I only know this because of the services of Alexander the simultaneous translator, who was speaking into my ear while shouting and periodic applause filled the Russian studio.) You can see this at http://www.youtube.com/watch?v=BcBXI2oTN6g&feature=share.

There is so little information available about Maxim’s death that I cannot possibly say what lay behind this event. I was asked to describe attachment therapy for the program, and did so, but I was not asked whether I thought Maxim had been subjected to any aspect of that unconventional treatment. Again, I cannot think either way about this until I know much more. I am curious as to whether the little boy had failed to gain weight in his adoptive home, because this suggests the use of parenting techniques advised by AT proponents. I was also asked about restrictions on prescription of Risperdal, the adult psychotropic medication that Maxim is said to have been taking, and I was able to say that there is little control over these off-label prescriptions.

But of course these are not all the things I would have liked the chance to say. Although I am very concerned about misinformation given to adoptive parents about attachment  and about appropriate mental health treatment for adopted children, and although such misinformation may be most directly responsible for mistreatment of children, the picture is obviously much bigger than this. The absence of other information may drive adoptive parents to over-reliance on questionable mental health advice.

Aren’t all adoptive parents supposed to have some hours of pre-adoption education according to the Hague convention? Yes, they are, but there is no clear statement about what those hours cover. I understand that some programs concentrate on “scrap-booking” about the children’s lives--  a fine thing to do together, but not a matter that takes long to explain. The change.org petition I mentioned recently wanted pre-adoptive parents to be told that children with Reactive Attachment Disorder were likely to be violent and dangerous, and this request suggests to me that perhaps some pre-adoption programs already hand out this inaccurate claim.

What would be some good things to include in pre-adoption education? One topic I’d like to see covered would be the problems that children adopted from institution abroad are actually likely to have. These include difficulties with attention and distractibility, as well as with the “executive function” that allows a person to make decisions about what to do, including stopping a course of action that was undertaken by mistake or judged to be wrong after it is begun. In addition, post-institutional children are likely to have language delays and to need speech therapy. (Language delays are the source of many behavior problems, because a child who cannot understand what he’s told, and who can’t explain his problems, is quite likely to be frustrated to the point of tantrums or other displays of distressed emotions.)

What is the purpose of telling pre-adoptive parents these things? One is to clarify for them that emotional or behavior problems displayed by an adopted child may have to do with more than his or her emotional development. They may occur in connection with cognitive or language delays that are not necessarily obvious to the casual observer.

A second point of giving this information--  and this, I think, is essential--  is to allow pre-adoptive parents to look for and arrange appropriate services in the area where they live, or to discover (better now than later) that getting such services may require extensive travel. For example, in how many parts of the U.S. can people find a bilingual, Russian/English, speech therapist to work with a child whose English is very limited and whose Russian may be delayed? In how many areas can people find a therapist who can do Parent-Child Interaction Therapy, an evidence-based treatment that helps parents and children communicate and decreases oppositional behavior? If the parents cannot get access to these post-adoption services, will they find themselves limited to practitioners who use heavy-duty medication to stop “difficult” behavior? Information given to the pre-adoptive parents early--  and given consideration by the adoption caseworker—can make the difference between desperation and good functioning in the months to come.

Let’s back up a bit, though. I’ve just mentioned that the caseworker should have some idea what resources are needed and will be available to the adoptive family. This brings up the likelihood that abusive adoptive parents (like abusive non-adoptive parents) are not just “bad people” who should have been screened out to begin with. Like many events in life, abusive behavior toward children is probably determined by the interaction of multiple risk factors, like an absence of resources. If there are few such factors, abuse is unlikely; with addition of factors, it becomes more and more probable. Adoption caseworkers need to look at a whole list of such risk factors, not simply a checklist that shows whether the parent candidates are acceptable.

If a child will have many needs for professional services, and the family lives at some distance from services, that is a risk factor.

If one or both parents have a history of depression and have limited access to treatment, that is a second risk factor. (Just as perinatal mood disorders can be a factor in a birth mother’s abuse or neglect of a child, parents with a history of depression may respond to adoption with depression and inappropriate behavior.)

If the family is socially isolated, this is a risk factor. Planning to homeschool may or may not indicate social isolation, but this should be considered as a possibility interpretation.

If there are already many children in the home, if the parents have fostered many children, or if the parents are adopting more than one child at a time--  counter-intuitively, these are all risk factors that should be considered by caseworkers, because they may indicate problems with individual relationships with children, rather than the “wonderful self-sacrificing nature” so sentimentalized by the mass media.

If the potential adoptive parents believe that their primary job is to make the children obedient, this is a risk factor.

Again, we are talking about identifying risk factors for abuse of adopted children. No single one of these or many other possible factors means that an adopted child will be mistreated. Even if they are all present, abuse or neglect will not necessarily be the outcome. But as risk factors are added, and as family stresses like illness or unemployment unpredictably occur, the results may be abusive treatment, of either the systematic kind advocated by some proponents of attachment therapy, or plain old, unsystematic, common or garden maltreatment.

We can make use of information about risk factors to do a better job of screening potential adoptive parents. We can improve matters by better pre-adoption education of those who are not screened out. But forgive my cynicism if I say that we probably won’t, as long as the adoption industry makes money both inside and outside the United States.

PLEASE NOTE: A longer  Russian TV discussion of the use of attachment therapy can be seen at http://www.1tv.ru/news/world/227626. You will need to type this in, not click on it here. 


Thursday, February 14, 2013

Don't Sign the Petition About Reactive Attachment Disorder and Relinquishment


When those change.org petitions come around, it’s so hard not to sign them. They all sound good and deserving. But, of course, there’s nothing to stop petitioners from presenting inaccurate information and asking for help with a matter that is to their own benefit alone. Such seems to be the case with http://www.change.org/petitions/the-president-of-the-united-states-post-adoptive-support-for-children-with-reactive-attachment-disorder. The group posting this petition, Hopefor Healing (spacing sic), has made a series of inaccurate statements and in addition has implied that other wrong information is correct. I hope you will not sign this petition, no matter what its emotional appeal may be.

The basic ideas stated in the “RAD” petition are the following: 1) undesirable behaviors of adoptees may not be displayed until the adoption process is over; 2) these behaviors, referred to as Reactive Attachment Disorder, are highly disturbing and dangerous, and need highly specialized treatment from residential facilities that focus on RAD; 3) parents cannot afford to pay for treatment; 4) parents who relinquish custody of their children voluntarily may be prosecuted, but should be allowed to relinquish quickly;  5) pre-adoptive education should include warnings of the potential of the child for violent behavior; 6) post-adoptive services should include residential treatment for RAD (at least this is my interpretation of the words “escalated to the highest levels of care”).

Before examining these claims under a strong light, I want to refer to a related issue of genuine concern. As was pointed out in the Bazelon Center for Mental Health Law’s 2000 publication Relinquishing Custody, state laws vary on provision of mental health services for children. In some states, parents may be forced to relinquish custody of a mentally ill child to the state before treatment can be provided without charge--  a conclusion that most parents resist as long as they can. This very real problem does not appear to be what “Hopefor Healing” is talking about. They want children’s mental health interventions, as they define and desire them, to be provided at public expense, and they also want to be able to relinquish custody quickly and easily.

But let’s look at “Hopefor’s” points one by one. First, the idea that worrisome behaviors of adoptees are somehow concealed until the adoption is final. According to the long-term research done by Michael Rutter and the English-Romanian Adoptees project, children who had been in the worst of worst conditions as infants and toddlers improved gradually with time in the adoptive family, leading to the conclusion that adoption  is one of the most effective developmental interventions. Among the ERA children, even those who were seen as disinhibited and too ready to go with strangers were by their teens regarded as friendly, outgoing, popular kids. I should point out too that in the ERA study, the most common problem was delayed language development, which was certainly present when the adoption was initiated.

Second, what about the idea that the children are likely to show violent, even homicidal behavior, and that this is evidence of Reactive Attachment Disorder and should be treated as such? There are two separate issues here. Yes, of course, as is the case in any population, some adopted children may be callous and unemotional in behavior and/or may be violently aggressive. However, as Charles Zeanah, the eminent child psychiatrist, has made clear in his discussion of Reactive Attachment Disorder in preparation for the DSM-5 publication (www.dsm5.org/Proposed%20Revision%20Attachments?APA%20DSM-5%20Reactive%20Attachment%20Disorder%20Review.pdf) , in fact these characteristics are not associated with Reactive Attachment Disorder. Thus, even if there were an evidence-based treatment for Reactive Attachment Disorder, it would not be relevant to these cases--  and the fact is that organizations that claim to specialize in treating RAD do not use methods of demonstrated effectiveness. “Hopefor” is asking for children to be publicly funded for treatment that is probably inappropriate for them, as well as lacking in an evidence basis.

Third, it is no doubt true that parents cannot afford to pay for expensive, intensive treatment, and as the Bazelon Center document suggested, we as a society need to correct this problem. However, it will never be appropriate for parents to demand payment for an intervention chosen by them on the basis of their beliefs about the child’s diagnosis, nor will it be appropriate for anyone but an independent evaluator to make such a diagnosis. Caseworkers from an adoption agency and prospective therapists are not the right people to make these decisions. Even if resources were not scarce, we would need to require independent assessments and avoid the apparent confusion of “Hopefor” about the nature and treatment of Reactive Attachment Disorder.

Fourth, although parents who abandon their children may be prosecuted, those who relinquish legally are not (although they may be called upon to repay funds that have been used to care for the child). States have procedures for legal relinquishment that may involve counseling and discussion of possible consequences, as well as providing simplified procedures and “safe havens” for relinquishment of young babies. In practice, also, voluntary relinquishment may be made very simple. In one case in which I testified, a couple adopting from Russia had been persuaded to take a girl as well as the boy they wanted. They did not like the girl much, placed her in attachment therapy, and often sent her to a respite home for periods of time. Finally, they decided they wanted to disrupt her adoption, and the respite family was willing to adopt; this exchange was maneuvered by the caseworkers without the usual formalities. When the girl was apparently mistreated in the new home and the authorities were notified, the family sent her to a boarding school in another state, a school that has been investigated for the use of restraint with children and has argued that this is permissible. There she remains, probably until she ages out at 18, and there has been no prosecution of the original adoptive parents.  

The fifth point, the demand that pre-adoption counseling include the claims about violent and abusive behavior as a part of Reactive Attachment Disorder, may be the real focus of this petition. According to the Hague convention, to which the U.S. is a signatory, candidates for adoptive parenthood must receive a number of hours of pre-adoption education. At this point, the nature and provision of those hours are up to the adoption agency involved. Even the Russia-U.S. adoption agreement of last year (now in abeyance) did not outline the pre-adoption education required.  This means that--  as most agencies do not have the time or resources to write their own curricula--  it would be much to the advantage of any interested person to seize the opportunity to write and market educational material. And if this material informed prospective adoptive parents that their children might be dangerous, that the danger was due to RAD, and that only specialized RAD treatment centers could help--  why, so much the more advantageous for the whole group that pushes misinformation about adoption and attachment.

And, sixth, as above--  the petition essentially presses the claims that there is only one set of problems, one diagnosis, and one treatment that must be part of post-adoption services--  the treatment apparently being the complementary-and-alternative, non-evidence-based approach often called Attachment Therapy, an intrusive, time-consuming intervention that is not reimbursed by third-part payers, and for good reason. But what could be better for its practitioners than being able to do an end run around public and private health insurance and have public funds support them in style?

Enough said, I hope?  


Saturday, February 9, 2013

If It Isn't Attachment Disorder, What Is It? If We Don't Do Attachment Therapy, What Can We Do?


Many posts on this blog have been dedicated to explaining that Reactive Attachment Disorder does not include various disturbing traits described on websites such as www.attachmentdisorder.net. Whereas Reactive Attachment Disorder includes unusual behavior with respect to other people, including both clinging to caregivers and failing to prefer caregivers to strangers, the characteristics often incorrectly attributed to RAD include control battles, defiance, refusal of affection to caregivers, frequent temper tantrums or “rages”, physical attacks on others, cruelty to animals and smaller children, and so on.

Although some anxious caregivers easily interpret any noncompliance as pathological, of course there are a small number of children whose behavior really is disturbing, uncontrollable, and violent. Not only are adults afraid that these children will harm others (including the adults themselves), they also worry that the children’s apparent lack of empathy for others will continue into adulthood, causing them to be a danger to society and eventually to receive serious punishment for their actions.  The adults’ beliefs about the causes and solutions of these behavior problems makes them look for treatments like Attachment Therapy, and like the associated Love & Logic program, that are presented as appropriate therapies for unruly children.

But if violent and disturbing child behavior is not caused by problems of attachment—is not really any form of “attachment disorder”—trying to treat attachment is not likely to have much effect on them. Is there a more constructive way to think about the child who is described at www.attachmentdisorder.net? And can thinking in a different way guide us to more suitable treatments?

One useful approach has been to look at children who have callous-unemotional (CU) traits. Children classified in this way are described as lacking guilt and empathy, being very egocentric, making use of others for the child’s own gain, and lacking normal emotionality, especially normal anxiety (Herpers, Rommelse, Bons, Buitelaar, & Scheepers, Social Psychiatry and Psychiatric Epidemiology,2012, 47, 2045-2064). There is no clear agreement about whether these characteristics should yield a diagnosis in themselves or whether they cross the lines of various other diagnostic categories, but it is potentially very valuable to define these problems by themselves and to move away from the idea that all such troubles stem from attachment difficulties and can be cured by improving attachment. (It’s interesting, by the way, that in 9 or 10 recent professional articles on CU traits, although there was discussion of CU as a part of Oppositional and Defiant Disorder [ODD] and of other diagnoses, no author considered whether CU was part of RAD,and only one referred to an attachment status, disorganized attachment in early life, as a factor in bringing about CU traits.)

In looking at mental health issues, it is often constructive to think about mood and behavior problems transactionally. This means that mood and behavior of an individual are shaped by factors in the individual and also factors in the environment, certainly including the attitudes and actions of other people; it also means that as an individual matures and learns, the effects of transactions with other people can also change. Taking a transactional point of view, we can look at some characteristics that are thought to be typical of children with CU behavior (as discussed in the Herpers et al paper). Such children may have less anxiety than most people do, and may focus more on rewards they get from their behaviors than on possible punishing consequences, as well as having more trouble than most people in recognizing others’ emotional expressions, especially fear. The transactional approach suggests that, given the CU children’s unusual characteristics, they may respond differently to parenting methods than more typical children would. Parent training programs may be the best approach to treatment for children with CU behavior. Significantly, research on use of restraint and seclusion in child psychiatric programs suggests that reducing these methods is followed by a reduction in violent behavior (Stellwagen & Kerig, Journal of Child and Family Studies,2010,19, 588-595), and this may generalize to parenting practices as well.

One such program, Collaborative Problem Solving, developed by R.W. Greene  and described  in his 2008  book Lost at school, emphasizes the importance of taking a proactive approach to child behavior problems and to making the child an active partner in this endeavor. Rather than focusing on consequences for undesirable behavior, Greene’s CPS approach has child and adult working together to set priorities for what needs to happen, to identify and develop needed skills before the next time they are needed, and to consider situational and trigger factors that make it difficult for the child to control impulses. Attachment is not mentioned—but working together toward shared goals is one of the most important ways for human beings to create social bonds, so a developmentally-appropriate form of attachment may come in the back door as this method is put to work.

Greene stresses two important issues: the need for the adult to exercise genuine empathy and understanding of the child’s needs, and the fact that children who do not do as they are told most often cannot do as they are told, at least not at that time and place. Adults who assume that they must force a child to obey because the child is simply oppositional are missing a real empathic understanding of the child’s experience, and thus they create a transactional process with the child that takes both of them in an unwanted direction.

In Lost at school, Greene answers some questions about comparisons to other parent training programs directed at helping with oppositional or CU behavior. One comparison is between CPS and “Love & Logic”, the commercially-successful program sold to hundreds of school systems and other groups. Foster Cline, one of the forces behind “Love & Logic”, was of course an early practitioner of Holding Therapy/Rage Reduction Therapy/Attachment Therapy. In commenting on “Love & Logic”, Greene says “The Love and Logic program does place an emphasis on empathizing with kids, but the empathy utilized in this program is primarily of the emergent and perfunctory variety, isn’t aimed at gathering information or understanding kids’ concerns, and is typically a prelude to Plan A [this is Greene’s term for responding to a problem by imposing the adult’s will]. The problem-solving that takes place between kids and adults in this program isn’t aimed at reaching mutually satisfactory solutions. And the Love and Logic program relies heavily on adult-imposed consequences” (p.200)--  consequences, as I noted earlier, that may not be responded to by children with CU tendencies. Incidentally, although Greene does not mention this, Love & Logic has not been subjected to outcome research, whereas CPS has.