Concerned About Unconventional Mental Health Interventions?

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

Wednesday, March 27, 2013

The Investigation of the Death of Maxim Kuzmin (Shatto)


Yulia Massino has called my attention to a report on the autopsy of Maxim Kuzmin (Shatto), the Russian-adopted three-year-old who died in Texas last January (http://www.oaoa.com/news/crime_justice/law_enforcement/article_53ef4076-9663-11e2-9e1b-0019bb30f31a.html). The autopsy report was released following a request under the Freedom of Information Act.

The report does not answer a great many significant questions, but it does clarify some points that have been made, denied, and then made again. It includes the fact that although Maxim showed a few bruises and scratches when first seen by a pediatrician in the U.S., at the time of his death from internal bleeding he had many bruises at different stages of healing. It also explains that the pediatrician had indeed prescribed an antipsychotic drug after concluding that Maxim was schizophrenic, and that Mr. and Mrs. Shatto, the adoptive parents, had stopped administering the drug three days before the child’s death, because it appeared to them that the medication made it difficult for Maxim to swallow.

The report also notes that Maxim had “breath-holding” incidents and had fallen off a chair after choking on a bite of cooked carrot. When Mrs. Shatto came out of the house and saw Maxim lying on the ground, she believed that he had “held his breath” and lost consciousness. According to the report, she grabbed and shook him while calling out his name. When this had no result, she grabbed him by the neck with both hands and shook hard until bubbles of blood came out of his mouth.

On the day of Maxim’s death, according to the report, he woke at a normal time in the morning but resisted Mrs. Shatto’s efforts to take him to the bathroom. According to her, he “had a fit” and went back to bed, where he remained until she woke him and his napping brother in mid-afternoon.

There is much to talk about here. An important unanswered question about this tragic story has to do with the diagnosis of schizophrenia and the treatment prescribed. Again, the report does not tell everything, and there may be a reasonable answer to this question--  but, are we to take it that the pediatrician made a diagnosis of schizophrenia (very rare in young children) on the basis of the parents’ comments alone? I certainly agree that parents know their children better than anyone else, but in the case of two months’ acquaintance with a child accustomed to a different language, even those who know him best may not know very much. A home visitor or other observer could have contributed much of importance to the diagnosis, for example whether any disturbing child behavior was related to adult actions or other events. Did the adoption agency (still unidentified as far as I know) not provide home visiting as part of post-adoption support? Did the physician not seek more objective evidence than the parents could provide?

Given the surprising diagnosis of schizophrenia, surely there must have been some uncertainty about both diagnosis and treatment. Were there any efforts at professional parent education and social support before medication was prescribed? When there is an unlikely diagnosis like schizophrenia, and when medication specifically approved for children does not exist, why was this treatment given without any attempts at less dangerous approaches? Or, were there other approaches taken, and these have not been included in the report because the right questions were not asked?

Side effects of antipsychotics (and of course we do not seem to know exactly which one was used here) include constipation, difficulty in urinating, and drowsiness. Maxim was reported as resisting toileting and being drowsy on the day of his death. He had been withdrawn, apparently abruptly, from the drug three days before. Did he have persisting effects from the drug? Or was the abrupt withdrawal in some way implicated in his death? Were the Shattos in touch with the prescribing doctor about side effects--  and did they discontinue the medication on their own decision, or did they have guidance in how to do this gradually?

A few weeks ago I commented on this blog that permission for adoption from abroad should be based in part on availability of a range of services that may be needed. The Shatto case exemplifies the problems I was talking about. As far as one can see from the report, their pediatrician not only prescribed in a possibly questionable way, but may have failed in his responsibility for parent education about the use of powerful drugs.

The adoption agency also appears to have failed in both post-adoption services like home visiting and in pre-adoption education. So far, it does not appear that the Shattos learned any Russian or any other means of communicating (like signing) with children who were likely to be language-delayed because of their care history. Mrs. Shatto appears to have misunderstood Maxim’s episodes of “breath-holding” which is an involuntary response to being startled or alarmed, sometimes seen in young children. (Falling off his chair when choking may have been an episode of this.) When she thought he was “holding his breath”, she shook him and shouted, responses which are neither necessary nor beneficial when a child has temporarily lost consciousness in this way. Why she subsequently seized him by the neck with both hands and shook him is incomprehensible except as the panic reaction of a person without the first-aid training that she should have received from the adoption agency.

Perhaps there was some sort of sexual abuse in Russia, as suggested, but if there was, it is hardly relevant except as a way of distracting from the central issues. Sexual abuse, repugnant though it is, does not cause schizophrenia or make young children injure themselves. My question about what happened in Russia is this: who decided that an older couple should take two young children, a year apart in age, and at developmental stages that require even more skill and attentiveness than are needed by infants? This is not the first time I’ve heard of this arrangement being encouraged, or even pressed, by Russian institutions, and permitted by U.S. adoption agencies who ought to know the difficulty being created for the na├»ve adoptive family.

Murder mysteries sometimes feature a situation in which each of many people contributes to a death, making it difficult to know who is to blame. Maxim’s death is similar, it would seem. A dozen people, perhaps, each made some contribution to the outcome. There is no point thinking of any of them as “a murderer”. But if Russians want to understand what happened, and if we in the U.S. want to keep adopted children safe, we need to know the whole truth and to answer all the questions I’ve posed here.



   


Monday, March 25, 2013

Attachment, Empathy, Conscience: What Are the Connections?



A reader recently commented on this blog and referred to the belief that unless a child develops a secure attachment, he or she will be unable to feel empathy for other people and also will have no conscience. This statement is often made by proponents of attachment therapy as well as by many others. Is it just one more example of the current tendency in some circles to reduce everything in personality development to some aspect of attachment? I think it may be useful to go through some of the relevant facts and logical connections between facts, and to try to see what causal associations there actually are between attachment and other developmental milestones.

Let’s begin by looking at the assumption that attachment must be secure in order for empathy to develop. This seems most unlikely simply from a statistical perspective. About 35% of normally-developing toddlers are evaluated as insecurely attached on the basis of their behavior in the Ainsworth Strange Situation. Can it be that 35% of the older population is entirely without the capacity for empathy? Recognizing the frequency of selfish, egocentric, even narcissistic behavior, nevertheless it seems impossible that empathy is totally absent in that large a group, or that a society could function if a third of the population could not recognize or respond to other people’s emotions. In addition, insecure attachments, although not seen as ideal in terms of attachment theory, are within the normal range of personality developments, and it seems implausible that an important aspect of human behavior like empathy would be non-functioning while related aspects are normal. These things raise questions about whether secure attachment could be a necessary cause of empathy.

Thinking about empathy itself is an important step in examining these issues. Empathy can be thought of as responsiveness to other people’s feelings, but there is more than one way that responsiveness can occur. There is cognitive empathy, or accurate identification of facial expressions or other emotional messages like voice tone or posture and gestures. Even newborn babies show some of this ability by imitating facial movements like mouth opening, and it’s posited that they have “primary intersubjectivity” or the awareness that the face they see belongs to another person. Emotional empathy, the next step, involves a sharing of the emotions another person displays, but this does not happen all at once. After a couple of months, babies respond to smiles with smiles, and are disturbed if a person who usually responds to them stares blankly. By 7 or 8 months (yes, the time when attachment is first evident), babies recognize expressions of fear and respond to them with anxiety. They use social referencing--  looking at the faces of familiar people--  to see what those people feel about new events and people. If the familiar caregiver looks scared, the baby avoids the new thing; if the familiar adult looks happy, the baby explores it. So, that kind of empathy is certainly well underway by the end of the first year, at about the same time that attachment is really perking for family-reared children.

What about what we might call “functional empathy”--  not only identifying and feeling with another’s feelings, but also behaving in a kind and helpful way when someone is in distress? This is a much trickier development. Unfortunately, we human beings of all ages have complex responses to others’ distress, and our responses are not all helpful by any means. Sometimes we laugh when someone gets hurt---the basis of the Three Stooges’ popularity, but also of the embarrassing impulse to laugh at a funeral. Sometimes we get angry when someone displays distress and we can’t or don’t want to be of help; we tell them the problem was their own fault and maybe they’ll know better next time, or accuse them of manipulating people by pretending to be hurt. We may even attack a person who displays distress. Physical abuse of infants is often in response to the infant’s crying. Even normally kind parents under stress may threaten or actually smack a child who is whining or complaining (classically saying, ‘I’ll give you something to cry about”).  And toddlers and preschoolers too show all these kinds of responses to others’ distress.

So, how does it come about that a lot of people, both children and adults, respond helpfully a lot of the time, when they get other people’s messages of pain or fear?  Almost all will have had mixed experiences of responses to their own distress. Very few, if any, will have survived without ever having anyone respond to their needs and related emotions. Very few, if any, will have had caregivers who were always willing and able to respond to a child’s distress. Most will occasionally have had a parent unable to respond (for example, I remember having an allergic reaction and not being able to speak to my two-year-old for perhaps 15 minutes while the medicine went to work). Many will have had a caregiver laugh at a fall or other accident that later proved to be more serious than it looked. And probably most will at least once have had a stressed-out parent respond with an angry look to one-too-many complaints. Children who become nurturing and helpful as they get older seem to be the ones who have most often had sensitive and responsive care from adults who identified the child’s emotions correctly and acted as well as they could to comfort and soothe. Their experience with good role models tells them the ideal way to act, and like adults they do this as well as they can in given circumstances. (This does not mean, of course, that as children they can understand or deal with some of the powerful emotional issues of adulthood, nor should they be expected to empathize with many adult emotions.)

Given all of this--   does attachment (secure or insecure) serve as a necessary foundation for empathy? There seems to be no reason why the first should be the basis of the second. However, it is reasonable that this might appear to be the case. Secure attachment grows through experiences of pleasant social interactions with caregivers who are interested, engaged and engaging, sensitive and responsive to child messages. Although most parents and caregivers are better at dealing with certain child ages than with others, it’s generally true that those who have been sensitive and responsive (and fostered attachment) early on will continue to behave in the same way with an older child--  and thus will foster positive, helping behavior toward others’ distress. If the child who has become attached stays with the same caregivers, their continuing modeling of empathy and nurturing will help shape the same kind of behavior in him or her. Although the responses the child gets to his or her own distress are probably most important, such caregivers will probably also model empathy by direct instruction (“we pat the kitten very gently”) and by observable nurturing behavior to other people (“let’s get Grandma a cup of tea, she’s tired”).

But as usual, it’s not as simple as one experience, one child outcome. The researcher Grazyna Kochanska has looked at conscience development as an outcome not only of parenting methods, but of the child’s basic temperament. For children who were not very fearful, secure attachment in infancy was a good predictor of later conscience. For temperamentally fearful children, a better predictor was the mother’s use of gentle discipline. Kochanska referred to attachment as an “alternate pathway” to conscience.

Rather than secure attachment causing empathy, it may well be that “good things go together”, as so often seems to be the case in child development.
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Tuesday, March 19, 2013

More on the Death of Maxim Kuzmin (Shatto)



An announcement at http://permianbasin360.com/fulltext?nxd_id=257022 states that the adoptive parents of the Russian-born three-year-old Maxim Kuzmin (Shatto) will not be charged in his death. The case has been closed  by the grand jury and the death ruled an accident, with the speculation that Maxim was in some way struck and injured by a playground glider while his mother briefly went indoors. The district attorney noted that Maxim was small and undernourished, and that “with the behavioral disorder he was prone to hurt himself.” The behavior disorder was not specified.

Texas child protective services is continuing an investigation into the family’s circumstances, according to the news release.

I have no wish to charge Mr. and Mrs. Shatto or anyone else who might be associated with Maxim’s death, unless much different evidence turns up justifying prosecution. I would say, though, that it is a mistake to close the door on this case as an accident, a random event whose causes cannot be ascertained. If this death were an isolated incident, that decision would make sense. However, it is one of a number of deaths that share certain characteristics--   adoption, undernutrition, physical injury, and the claim that a behavior disorder has caused the child to hurt himself.

Prosecution, and judicial findings of guilt or innocence, are desirable if the goal is to punish guilty people. If the goal is to prevent more deaths that follow the pattern described above, however, grand jury investigations and prosecutions may not be the best way to go. Those investigations focus on evidence of law-breaking and direct responsibility for children’s injuries or deaths. Even a successful prosecution of culpable persons fails to examine the possibly systemic causes for these advents.

Can we examine these cases and decide whether the pattern is coincidental, or whether there are indeed systemic reasons for these occurrences? To do so would require examination of a good deal of evidence and would need a broad perspective rather than the narrow focus on persons who may be accused of abuse or even murder. Although the evidence turned up by the district attorney would be relevant, this broader approach could only be managed by an investigative group like the one we have been told that Senator Mary Landrieu would head in the Shatto case, or, to some extent, by the investigation that Texas child protective services is still carrying out.

One important question in all these cases has to do with the claimed behavior disorder that causes self-injury. Certainly some children are impulsive and poorly self-regulated and get many bumps and bruises because of this, but it’s hard to imagine death resulting except in some very unusual situations. Other children injure themselves directly, and self-injurious behavior can be associated with autism, with Lesch-Nyhan syndrome, and with Rett syndrome, which is exceedingly rare in boys and is associated in boys from the time of birth with other problems like breathing disorders. Reactive Attachment Disorder, so often referenced in discussions of adopted children, is not in itself associated with self-injurious behavior. (However, advocates of holding therapy, who claim a version of attachment disorder that only they can detect, do argue that children can injure themselves badly in order to cause trouble and blame to be directed toward their adoptive parents. One chat group in 2001 even suggested that Candace Newmaker had died intentionally, just to cause trouble.)

In the Nathaniel Craver case, and in the ongoing Chritton case, defense attorneys have claimed that injured or dead children had been caused to bring harm to themselves by their Reactive Attachment Disorder. While this is not likely, the statement does raise some important questions. Was Maxim diagnosed as having Reactive Attachment Disorder, and if he was, who diagnosed him? If he had that diagnosis, was he being treated, and by whom? What advice about home care did the Shattos receive, if such a diagnosis was made? And, if there was such a diagnosis, was it by some circular reasoning based in part on the existence of injuries, which were later attributed to the disorder?

If Maxim was not diagnosed with Reactive Attachment Disorder , was he diagnosed with autism, Lesch-Nyhan syndrome , or Rett syndrome? The latter two very serious disorders would have been readily apparent before he left the orphanage, but because children who have been in institutions are often delayed in speech, autism might not have been diagnosed. I think the two syndromes mentioned can probably be dismissed as unlikely, but if they were present Maxim would have had to receive medical and other treatment. Was he receiving such treatment? As for autism, the related developmental delays may not have been obvious to anyone at this point, but it would be important to know whether he was receiving any treatment such as speech therapy or ABA—or whether the Shattos were trying to deal with a serious problem on their own.

Another topic that needs to be dealt with in order to understand Maxim’s death has to do with his poor nutritional status. Children who have been in institutions are often undergrown, as staff and other issues interfere with their taking as much food as they need, and the kinds of food they need. Maxim had only been with the Shattos for 2 ½ months at the time of his death, but surely they are likely to have sought a medical evaluation and should have received advice about his dietary needs and suitable growth goals. (If their pediatrician was not able to manage this, post-adoption services should have provided help such as reference to a group like the SPOON Foundation, which specializes in feeding help for parents who have adopted from abroad.) Were Maxim’s growth and nutritional status where they might be predicted to be after a couple of months in the adoptive home, or were they still at the levels seen when he was first examined? (The growth and nutritional status of the younger adopted child, Kirill, would make a useful comparison here, perhaps showing whether Maxim had some undetected medical problem that could have been implicated in his death.)

Horribly, apparently at least one person has adopted a Russian child for sexual purposes. I find it difficult to believe, however, that many adoptive parents in the U.S. have obtained children for the purpose of injuring and killing them. (My reasoning is that the number of people who want sex with children is probably a good deal larger than the number who find it pleasant to injure them.) This position leads me to explore the systemic reasons and the context in which adoptee deaths have occurred, with the hope of finding a background to the death pattern I mentioned earlier. Understanding that background could help prevent more deaths of children and disasters to surviving members of the adoptive families, including other children.





Saturday, March 16, 2013

Warnings From the Attachment Industry: Examining Online Material About Attachment Therapy



Looking over the details of attachment therapy web sites is always interesting and revealing. Somehow, laborers in the attachment biz seem to make the same mistakes repeatedly. Maybe they never read anything that contradicts their viewpoints--  but of course that would mean omitting a great deal of relevant material, without which an educated perspective is impossible.

 Today, I notice that at www.instituteforattachment.org, mouthpiece of the Institute for Attachment and Child Development in Colorado, includes a message called “Beware of Attacks on Attachment Therapy”. The author, Forrest Lien, provides a mixture of truths, half-truths, and errors to support his argument that people like me are mistaken in their concerns about attachment therapy.

Lien distances his organization from the lady formerly known as Connell Watkins, but also describes Watkins as having “wrapped a child up in a blanket which affected her breathing and she died”. This description seems to me to parallel the statement that Jesus was in an upright position with his arms extended, this influenced his health, and he passed away. Both are true, but a bit incomplete. Lien’s comments about Candace Newmaker may appeal to those who have seen the related “Law & Order” episode, in which the scriptwriters avoided the issue by having the child’s death due to an allergic reaction to the blanket. But the reality is that Candace suffocated because of pressure exerted against her immobilized body by a number of large adults who believed they were imitating the experience of childbirth and that this would cause Candace to be the “real” attached child of her adoptive mother. Silly and pointless as it may be, rebirthing should not be fatal. It was fatal in this case because of the factor Michael Shermer has called “death by theory”. That is, Watkins and her fellow-therapists were convinced of the basic tenet of attachment therapy, promulgated by Foster Cline, that a display of power and authority was necessary in order for a child to become attached to a parent. Watkins persisted in her actions for 70 minutes, ten times longer than the usual rebirthing session--  70 minutes in which the child initially begged for release, vomited, defecated, and for the last 30 minutes was silent. It was not the blanket that affected Candace’s breathing; it was the deep conviction of the therapists that in order to be successful they must ignore the child’s “lies” and force her compliance.  
Lien is perfectly correct in saying that rebirthing is not holding therapy, and it is wrong to equate the two. This error on the part of a Congressional resolution and of the American Psychological Association has caused a great deal of trouble, although it pleased holding therapists, who were happy to point the finger at rebirthing and away from their own principles and practices. In fact, rebirthing is quite unlikely to do either harm or good--  unless it is intensified to a dangerous level by beliefs like those Watkins held.

Interestingly, Lien notes that his organization stopped using holding therapy in 2006 (even though, as they state, it was not the same thing as rebirthing). Six years after Candace Newmaker’s death! Several years after a number of publications pointed out other child deaths associated not only with the therapy, but with the belief system that equates obedience with attachment! Can we believe that people who took that long to drop a particular practice have also dropped all of the harmful mistaken beliefs that supported the practice? I find it difficult to believe, and my difficulties are confirmed by the rest of the www.instituteforattachment website.

As usual, some of the principles that make attachment therapy dangerous are seen in the list of symptoms of Attachment Disorder given on this site. There we are, at “What is Attachment Disorder?” --  the same old same old claimed symptoms, totally different from the characteristics of Reactive Attachment Disorder as described in DSM. Manipulativeness, lack of conscience, remorse, or empathy, inability to give or receive love, lack of cause and effect thinking (ever wonder how they can be so manipulative without this?), lying, destructiveness, cruelty, and of course superficial charm. But Reactive Attachment Disorder is officially characterized by either excessive clinging and dependency on caregivers or by a lack of normal preference for familiar people. Where did the IACD Attachment Disorder  list come from? It’s a combination of a number of old checklists, including one that’s supposed to identify psychopathy. How did this list get associated with Reactive Attachment Disorder, the term used at several places on the website? Do the website authors hold that Reactive Attachment Disorder is the same as Attachment Disorder? If not, what is the evidence that there is a distinct disorder called Attachment Disorder? If www.instituteforattachment.org is not sure what problem it’s treating, it seems a bit arrogant to declare that the treatment is a safe and effective one.

Given the apparent confusion about the problems being treated, perhaps, it’s not surprising that www.instituteforattachment.org features among “research articles” a piece on the Randolph Attachment Disorder Questionnaire, which makes many of the  assumptions noted in the last paragraph. The RADQ is an instrument that has never been published in a peer-reviewed journal and one whose efforts at validation involved having the same person administer questionnaires to parents and make diagnostic decisions, a pretty sure way to create bias in the results. It’s not clear on the rest of the site whether IACD even uses the RADQ, and indeed they should not, because not only is the instrument poorly validated, its author states perfectly clearly that it is NOT an assessment for Reactive Attachment Disorder, but for “something else”—Attachment Disorder. This does raise the question, though--  if IACD does not use the RADQ, why do they post information about it? Is the answer that they actually do use it, or is the presence of the RADQ on the site simply a code that communicates to some readers the real belief system at work here?

I didn’t come here to argue that IACD uses directly harmful methods, that they killed Candace Newmaker, etc. I do believe that some psychotherapeutic methods are indirectly harmful, in that they are ineffective but delude parents into avoiding more effective treatments. This problem points up questions about the effectiveness of the treatments used by IACD. Exactly what these are is not obvious, of course; however, some of the articles and other materials give us an idea. For example, there is a piece by Sebern Fischer touting neurofeedback, a method that has never been supported by adequate outcome research. An article by Victoria Kelly claims that physical contact and eye contact are important factors in treatment of childhood emotional disorders--  a claim that has never been supported by evidence, and that in fact has been tested only by proponents of holding therapy.

There are some other questions that the web site put into my head, but did not answer. Why does www.instituteforattachment.org state in a testimonial that a child diagnosed with PDD was successfully treated with their methods? Is this a claim that PDD is caused by the same factors that appear to create RAD? Is it that, as someone commenting on this blog remarked the other day, that all but clearly genetic early mental health problems are due to attachment difficulties? And what would be the ground for making these claims?

Another question: children treated at IACD are apparently sent to “therapeutic foster homes” for periods of months. If the goal is to create emotional attachment to their parents, what would be the rationale for this separation? Do Forrest Lien and his staff believe, like the old holding therapists, that they can create an attachment in a child and then transfer it from one attachment figure to another? How would that work, when attachment is a matter of a relationship, not some entity inside the child?

And finally: is it true that IACD uses the Attachment Disorder diagnosis? When seeking third-party reimbursement, do they use that term, or do they claim DSM code 313.89, Reactive Attachment Disorder?  It’s my understanding that  public funds are received by IACD, and surely there is a problem if in applying for such funds the organization substitutes an acceptable diagnosis for one that is not evidence-based.

Until IACD and other organizations can correct their misinformation and answer these questions, I will continue to hold the position that attacking attachment therapy is not only an appropriate action in terms of the evidence--  it is in fact a professional responsibility.



Thursday, March 14, 2013

The RAD Defense: Questionable Testimony in the Chritton Trial


What is the RAD defense? It’s an argument in a court of law, claiming that harm done to a child was not the fault of an abusive adult, but was in some way related to the child’s diagnosis of Reactive Attachment Disorder. The RAD defense may argue that the child injured himself or herself—as, for example, in the case over a decade ago of the Russian adoptee toddler David Polreis, who was said to have beaten himself to death with a wooden spoon, or the more recent case of Nathaniel Craver, who was said to have hurled himself against a stove until he inflicted fatal head injuries. The RAD defense does not appear to have been successful in the sense of leading to acquittal of those accused of child abuse, but it may have acted to mitigate their sentences.

Now the RAD defense is back with us in a complicated though fortunately non-fatal case. As many readers already know, in the Chritton case a teenage girl was found walking barefoot in the Wisconsin winter. She was taken to a hospital, where she was found to weigh only 68 pounds and to be of very small stature for her age. She told a story of having been kept in a basement by her father and stepmother, given little to eat, and provided with very limited toilet facilities. This story, shocking enough in itself, was further complicated by the presence in the house of a step-brother who was a sexual predator and by the apparent failure of social services to manage any part of the situation. While in the hospital, the girl developed refeeding syndrome, a potentially fatal physical response to the restoration of a normal diet after long starvation.

The father and stepmother, Chad Chritton and Melissa Drabek-Chritton, are being prosecuted on a number of charges. Their lawyer has invoked the RAD defense, claiming that the girl starved herself as a consequence of Reactive Attachment Disorder, as recounted here: http://host.madison.com/news/local/crime_and_courts/judge-in-chad-chritton-s-child-abuse-trial-questions-one/article_dfd1c8ec-8b83-11e2-b7c2-001a4bcf887a.html?comment_form=true.

To support the RAD defense, the Chritton attorney has called an Iowa therapist, Rhonda Lettington, who testified about the “numerous symptoms” of RAD and stated that medical records show that the girl has the disorder.

In my opinion, calling Lettington was a desperate move on the part of the defense, and I am surprised that she was qualified as an expert witness by the judge (still, I suppose they have to qualify somebody). Let’s look at her credentials. According to her website, www.lettschatreactiveattachment.com, Lettington has a bachelor’s degree in psychology (and I as a long-time professor thereof can tell you that this teaches very little indeed about mental illness), a master’s in community counseling and one in professional development (?), and certification in alcohol and drug counseling. She is a licensed mental health counselor and belongs to several counseling organizations. She has trained in EMDR, a poorly-evidence-based but probably harmless technique, and in Healing Touch, an “energy therapy” that uses touch or hand positions near the body for spiritual and other benefits and that remains unsupported by evidence as a treatment for physical or mental disorders. Lettington appears to have no training in assessing or treating childhood mental illness, but she has some adopted children, so I suppose she says this has trained her.

This is exactly the kind of person I try to direct people away from when they ask for advice about childhood mood or behavioral disorders. Assessing and treating such disorders requires training at the doctoral level and specialized work on child development and family issues. A degree in counseling is simply too general to be of use in these complicated situations where mental illness can interact with normal developmental change and where parental moods and practices require expert guidance. By the way, the use of “alternative” methods like EMDR and Healing Touch should be red flags warning knowledgeable persons away from a practitioner.

Let’s also look at the claims about Reactive Attachment Disorder that Lettington makes on her website. It’s no surprise to find the good old checklist trotted out (just like the one at www.attach-china.org that I mentioned the other day).  Some of the items here--  apparently meant to be applicable for children of any age—are a high pain tolerance, a lack of cause and effect thinking, and destructive or cruel behaviors. These, and the other “symptoms” cited, are in no way connected with the description of Reactive Attachment Disorder in DSM. Lettington would appear to have recounted this list to the judge, but we can’t tell yet whether anyone else’s testimony has corrected her. Interestingly, at the bottom of the list, Lettington also says that physical health is affected by RAD; although the original description of RAD in DSM-III did consider RAD to be the appropriate diagnosis for some cases of  infant failure to thrive, it has not otherwise, or since then, ever been spoken of in the mainstream literature as having physical effects. (Of course, such a claim does provide a foundation for the RAD defense, if no one contradicts it.)

We can also have a look at the links provided by Lettington’s site. Interestingly, there is a link to Families by Design, Nancy Thomas’s outfit. Did the Chrittons get some information about Nancy Thomas parenting, with its limitations on diet? I have no idea, of course, but the existence of this link certainly raises questions. Had the Chrittons consulted Lettington? Was their treatment of the girl advised by her, or simply accepted as a possible approach?   Or is it just that Lettington, like many another alternative therapist, believes in principles that are without empirical foundation but make the RAD defense possible?  

On the basis of other cases involving the RAD defense, I have one prediction: whether  Lettington or another practitioner advised the Chrittons, that person will not be prosecuted. If convicted, the Chrittons will be punished, but their advisers--  in person, on videos, or in books—will be free to give the same dangerous advice to other families. The First Amendment is supposed to be limited in the sense that one may not falsely shout “Fire!” in a crowded theater. Is it not time that we limited the protection of people shouting “RAD!” ?
  



Tuesday, March 12, 2013

Attach-China: What Treatment Methods and Principles Does It Support?


In response to my open letter of a few weeks ago to Mary Landrieu, on the subject of pre- and post-adoption training and services, Lynne Lyon of Lawrenceville, NJ has provided her own open letter intended to contradict my statements, especially in reference to certain organizations ( see http://childmyths.blogspot.com/2013/01/russian-adoption-letter-to-mary.html; scroll down to comments). In this post, I will repeat Lynne’s statements and refute them by referencing material from www.attach-china.org, one of the organizations whose methods and principles I challenged.

Lynne begins her letter with a red herring alluding to outrageous statements about rape. She then quotes part of my original letter, which refers to the belief that “adoptive parents can cause children to become attached to them by displaying their power and authority. In order to display authority, parents must make children completely dependent on them and obedient to them; children may eat and drink only as parents allow them, must not use the toilet without asking, and may be kept in cold or uncomfortable sleeping arrangements, including cages.” Lynne goes on to say that this is poor scholarship and that she herself does none of these things, and that I am wrong about attach-china and other groups.

I am happy to accept Lynne’s statement that she does none of the things mentioned. But I maintain that material on attach-china and other similar websites conveys support for the practices described above.

Why do I say that attach-china and other groups support the belief that adoptive parents cause attachment by displaying power and authority? Let’s begin with the material  called “When the Bonding Cycle is Broken” on www.attach.org. This material begins with a quotation from Terry Levy and Michael Orlans, formerly of the Attachment Center at Evergreen, the original hotbed of “rage-reduction” holding therapy as invented by Robert Zaslow and perfected by Foster Cline (both of whom surrendered professional licenses following injury to clients). The book quoted here, and Levy’s 2000 edited book published by Academic Press (to their lasting shame), both advocate physical restraint and provocation of children as a way to break attachments and create new ones. Levy’s 2000 book also rejoices in a lengthy chapter by Nancy Thomas, in which she advises limitation of children’s diets, isolation in locked rooms, enforced “strong sitting”, and hours of manual work as ways to treat emotionally-disturbed children. (Sylvia Vasquez, who was convicted  of keeping her adopted children in cages with buckets as toilet facilities, claimed that a book by Thomas was the source of her practices.) The quotation of Levy and Orlans’ book by www.attach-china.org conveys to readers an approval of all these people’s publications and claims.


To go on with the same material from www.attach.org: the following section cites the “bonding cycle”, an imaginary process claimed by attachment therapists to be the source of normal attachment in infancy (see http://thestudyofnonsense.blogspot.com/2012/08/parsing-attachment-cycle-fox-terrier-of.html for a discussion of the actual sources of this idea). The “bonding cycle” belief system ignores the evidence that attachment does not develop through experiences of gratified physical needs, but instead involves an interaction of pleasant social exchanges with the naturally-developing fear system in the second half of the first year. Of course, for attachment therapists simply to misunderstand how attachment comes about would be a minor problem--  except that on the basis of this misunderstanding, a commitment to the “pathophysiologic rationale” (the belief that if you know how a problem arose, you can tell how to solve it), and a belief that re-enactment rituals can undo past developmental errors, some practitioners have come to the principle that older children can become attached only if their parents control everything about their lives until the children comply. As is the case for many other mistaken beliefs about child-rearing, this one can become dangerous when parents escalate their efforts by withholding food or intensifying other sources of physical discomfort. Again, the emphasis placed on the “attachment cycle” by www.attach-china.org conveys to readers that statements about the repetition of such a cycle in treatment are somehow legitimate.

Let’s look at another section of the www.attach-china.org site: a Reactive Attachment Disorder Checklist, as usual in no way related to the symptoms of Reactive Attachment Disorder as described in DSM. And this one is of extra interest as having been acquired from Walter Buenning, well-known in past years for power-asserting holding therapy with infants as well as with older children. Although this checklists purports to be for assessment of infants, it includes some of the old goodies from checklists back to Foster Cline and before--  preoccupation with fire, gore, and evil, for instance. None of these characteristics are in fact used in conventional evaluation of Reactive Attachment Disorder, but are  given great emphasis by holding therapists who advise power assertion.

Well, this is entertaining, and we could go on and on, but let’s just look at one more interesting thing--  the www.attach-china.org material about treatment. The site references Martha Welch, whose specialty for many years has been a version of holding therapy in which young children are restrained face-to-face with parents, older children restrained in the supine position with the parent lying on top of them. This goes on for an hour or more while the children fight and scream and the parent shouts her anger and distress about the child. Welch originally proposed this as a treatment for autism, but more recently has called it Prolonged Parent-Child Embrace and focused it on Reactive Attachment Disorder. The site also references Gregory Keck and Regina Kupecky, whose support of physical restraint as a treatment method is well-known.

The section on treatment goes on to discuss neurofeedback, a method without an evidence basis, and to reference with approval its use by Larry van Bloem, a Utah practitioner whose clinic was implicated in deaths and injuries of children, and who himself was under investigation and would have had his license revoked if he had not been killed in a car accident almost ten years ago.

And finally, about the treatment section: curiously, attach-china is willing to state that sand tray therapy and play therapy are ineffective for children with Reactive Attachment Disorder. I don’t dispute this, and would agree that there is little good evidence that they are effective with any child, but I query the implication that if those two methods are not effective, the other ones mentioned must have good evidence of effectiveness. Not only is there no such evidence, but holding therapy and related parenting methods have been associated with serious adverse events as no other child psychotherapies have ever been.

On the basis of the evidence I have just put forward, I stand by my statement that attach-china and other organizations provide potentially dangerous misinformation about attachment and attachment disorders. This misinformation may create expectations and behaviors in adoptive parents that can lead to mistreatment of children, and once again I query the involvement of these factors in the injuries and deaths of children adopted to the U.S. from abroad.

I do not, of course, accuse Lynne Lyon of any of these misunderstandings or inappropriate treatments of children. I would ask her, though: if you agree that the methods and principles I attributed to attach-china are wrong and dangerous, why do you not stand up to rid your profession of therapists who are committed to dangerous advice? Why spend your time complaining about someone who is making an effort to correct potentially harmful practices?







Sunday, March 3, 2013

Unanswered Questions About the Death of Maxim Kuzmin (Max Alan Shatto)

[Russian readers can find this post translated at http://yuliamass.livejournal.com/115359.html ]


The New York Times yesterday and today noted the release of results from a preliminary investigation of the death of three-year-old Maxim Kuzmin (Max Alan Shatto), a child adopted from Russia, in Texas last January. The released information declared the death accidental, associated it with bleeding from an injury to the mesenteric artery supplying blood to the intestine, and pointed to the child’s having been diagnosed with a behavioral disorder associated with self-injury.

The investigation appears to be ongoing, and so it should be. Without at all wishing to suggest that the adoptive parents intentionally killed the child, or even that they were in some way instrumental in his death, I want to point out that the statement released last Friday was by no means a full explanation. A complete explanation of the death of any young child would be desirable, especially as it might help prevent further deaths--  but in the context of deaths by injury of a number of other children also adopted from abroad, it would appear to be essential.

No investigation can provide answers to questions that are not asked, and when I think about past investigations of adoptees’ deaths I must query whether the present investigators know all the questions they need to ask in order to provide a complete explanation.


Here are some questions I would like to have answered by the investigation:

What information was provided to the adoptive parents either before or after Maxim and his brother came to them? Were they led to expect serious emotional disturbance in the children, and were they offered unconventional advice about appropriate child-rearing methods?

Who provided the diagnosis of Maxim’s stated behavior disorder? Was this done on the basis of his behavior in the adoptive home, or were assumptions made about his early experiences and the impact they would be expected to have?

What was the diagnosis that was said to be associated with self-injury? Did the occurrence of self-injury lead to the diagnosis, or was the diagnosis that had been made on other grounds then predicted to be associated with self-injury?

If there was self-injury, what form did it take? That is, did the child sustain injuries because of clumsiness or impulsiveness, or were there attempts at other forms of injury, like tongue-chewing or lip-biting?

If there was self-injury, what treatment or support was the family receiving in efforts to prevent further injury? Had the child received either medical or psychological treatment for these injuries? Had the parents received related counseling, either from the adoption agency or from any other source?

If the child was receiving any form of psychological treatment, did this include so-called “visceral manipulation” involving deep massage of the abdominal area? (Some alternative practitioners hold that emotional memories are carried in the abdomen rather than the brain and can be influenced by massage pressing deeply into the belly. This practice has occasionally been associated with holding therapy in the past; it is exquisitely painful and has apparently caused visceral injury in adults.)


The answers to these questions would help paint a complete picture of the causes of Maxim’s death. Failure of the adoption agency to provide appropriate guidance or services might indicate negligence on the part of the agency, and failure of the adoptive parents to seek help or treatment when needed might indicate that there was neglect of the children. Inappropriate diagnosis and/or recommendations by mental health professionals may be evidence of malpractice. Any or all of these difficulties could be associated with either careless or intentional actions leading to Maxim’s death.

In closing, I would like to point out that the various references made to Reactive Attachment Disorder as a cause of the posited self-injury in Maxim’s case are at best irrelevant and at worst an intentional red herring.