Concerned About Unconventional Mental Health Interventions?

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

Wednesday, September 25, 2013

An Orphanage Study: High Tech, Perhaps Not So Much Science

There’s been a good deal of discussion recently about the possible effects of neglectful orphanage experiences on children’s development, with some claims made about damage to brain development in the proposed “Children in Families First” legislation. A recent publication is bound to be made grist for this legislative mill, and I would like to go over some aspects of the study before this happens. The paper is by Jamie L. Hanson et al (“Early neglect is associated with alterations in white matter integrity and cognitive functioning”) and was published in Child Development, Vol. 84(5), pp. 1566-1578.

Before I address the Hanson et al paper, let me point out that I am far from claiming that neglectful care, whether in an institution, a foster home, or the birth family, can possibly do infants and toddlers any good! Nor am I about to say that Hanson et al are wrong in their conclusions, and I will note that the paper’s discussion carefully lays out cautions about the results. However, I am concerned that this paper’s technical pizzazz and use of neuroimaging have the potential for convincing readers that a clear statement about the relationship between experiences of neglect and brain development has been made, whereas it seems to me for various reasons that it has not.

Hanson et al looked at a measure of white matter organization in the brain and compared 25 adolescents who had been adopted from orphanages to 38 individuals in the same age range who apparently had not been adopted (at least I don’t see a statement about this) and were growing up in homes of about the same SES as the post-institutional adolescents. There were 15 males and 13 females in the post-institutional group and 23 males and 12 females in the comparison group. Nineteen of the post-institutional children had been adopted from Romania and Russia, 3 from China, and 2 from Bulgaria, while one family did not report the country of origin. The groups were not different on measures of pubertal status. Neurological measures mapped brain connectivity, not brain volume, and found associations between experience of neglect, decreased white matter in the prefrontal and temporal cortex, and increased problems on a spatial planning task and on a visual learning and memory task. There were also developmental problems in other brain areas that did not appear to be related to the behaviors measured.

This paper reported an enormous amount of difficult work aimed at answering a question of real practical import. So, why do I think it’s a problem if anyone rushes to make use of this study for political purposes? It’s because I have a number of questions about the whole thing.

Most of my questions turn on the fact that adoptive parents were the source of information about experiences of neglect. As far as I can see, the paper fails to state how these parents were brought into the study. Were newspaper advertisements used, or were there contacts with organizations of adoptive parents? Or, is it possible that Hanson et al had a list of nearby foreign-adopted children in the right age range and were able to contact parents and find a reasonable number who were interested? In any of these cases, it is likely that the parents’ own interests and beliefs determined their participation in the study, and those interests and beliefs could also have determined their recollection and reporting of details about the children’s early experiences.

Hanson et al noted that “there was variability in the duration and exact timing of the neglect suffered” as it was reported by the parents, and that the parents’ reports were not correlated with brain or behavioral findings. In other words, the expected dose-response relationship--  more neglect, more problems of brain and behavior--  was not demonstrated. The range of ages at which children had been adopted was from 3 months to 92 months, but the range of time spent in institutional care was 3 to 64 months, suggesting that one or more children had not been placed in the orphanage in the first months of life.

In the adoptive parents’ reports, they “consistently reported [that in the orphanages children had] few one-to-one interactions with caregivers, lack of toys or stimulation, and very little linguistic stimulation before 2 years of age”. Objective reports about orphanages in the past suggest that these are probably correct statements, but one wonders how the parents were able to make such reports. How long did they spend at the orphanage, and how much were they actually able to see of institutional life when no visitors were present? Could it be that their descriptions of their children’s early experiences were determined by what they had heard and expected about these institutions, rather than their own experiences? The highly technical side of the study gives us great detail about neurological and cognitive events, but without clear evidence about experiences of neglect, it’s not possible to conclude that neglect caused the problems.

What else could have caused the adopted children’s developmental problems? Hanson et al point out that there was no information available about prenatal history or about possible malnutrition. (Relevant to this, I searched the paper for references to head size or weight and stature, all measures potentially reduced by malnutrition, and did not find any—although pubertal status ia also a useful measure.)

 Hanson et al noted that malnutrition and social neglect could play separate or interactive roles in shaping development, but I would suggest that elements of social neglect often cause malnutrition even though enough food is available. Most family babies probably have occasional experiences of poor feeding because of maternal distraction (I am thinking of a mother at a party who couldn’t get her 6-week-old to take a bottle as they stood in the middle of a crowded, noisy room), and babies in medical care may be fed insensitively (I am thinking of a NICU nurse who cleaned and diapered a preterm baby with terrible diaper rash, then perched the screaming baby on the end of her knee and pushed a bottle into the child’s mouth). But these events are probably intermittent and temporary for most babies outside of institutions, whereas in an institution it may be a consistent experience to have food spooned in too rapidly or a bottle that is too hard to suck, when overworked and undertrained staff just try to get through the task. A study of the feeding patterns that had been in place at the children’s orphanages might give some very useful information, combining an index of neglect with a view of nutrition.

One of my concerns about this paper is the ease with which proponents of some system changes may jump to the conclusion that effects of neglect on brain connectivity have actually been shown, rather than that a method for looking at this issue has been created.  A second concern is that readers will equate “orphanage” with “neglect”. Given sufficient funding and well-trained staff, there is no reason why group care has to be neglectful. And, if caregivers have few resources and poor information, there is no reason to think that foster care or adoption  never involves neglect--  or even abuse.




Friday, September 20, 2013

In the Wake of the Reuters Report, A Scientifically Questionable Legislative Proposal

You would think that the Reuters investigation of “re-homing” of unsatisfactory adopted children would be followed by legislation that would protect all adoptees, foreign or domestic, in the United States. Instead, we see introduced in the Senate a bill called the Children in Families First Act of 2013 (CHIFF). Senators introducing this bill were Landrieu, Blunt, Burr, Inhofe, Kirk, Klobuchar, Shaheen, Warren, and Wicker. If any of these are your senators, I hope you will try to make them understand what they are doing. If not, please join me in contacting your own senators and representatives and cautioning them about giving support to CHIFF.

A summary of talking points about this bill can be seen at www.childreninfamiliesfirst.org/wp-content/uploads/2013/08/CHIFF-Messaging-Points.pdf.  According to this summary, “CHIFF fixes the functional problems without (sic) our government bureaucracy with a smarter, not bigger, approach that will allow international adoptions to become a strong and important part of how we protect children”. The bill itself, at www.childreninfamiliesfirst.org/wp-content/uploads/2013/09/CHIFFBill.pdf, is worth the attention of everyone with an interest in children’s welfare.

The bill begins with a statement about “the core American belief that families are the best protection for children and the bedrock of any society” and proposes “ensuring that every child can grow up in a permanent, safe, nurturing, and loving family”. What is not revealed at this point is that the bill has less to do with children living in the United States than with other countries that rely on institutional settings to care for children without responsible parents or other kin. As most societies assign child-rearing tasks to near kin whenever possible, it seems hard to consider this an exclusively “core American” position. It is also difficult to envisage how family love can be legislated. (As for the geological metaphor, I am puzzled, but suspect that bedrock and apple pie are in some way related.)

The issue I would like to address with respect to this bill is its effort to call in some science to support its proposals. This is seen in the talking points mentioned earlier, which state: “Today’s science shows that children cannot are terribly damaged, often irreparably, by living in institutions or without any parental care (again, sic)”. The bill itself says, “Science now proves conclusively that children suffer immediate, lasting, and in many cases irreversible damage from time spent living in institutions or outside families, including reduced brain activity, reduced IQ, smaller brain size, and inability to form emotional bonds with others.”

Let’s look at these points under a strong light.

  1. Who are the children? Parts of the bill refer to children as persons under 18 years of age. Do all children from birth to the 18th birthday experience the same effects from group care? No, certainly not, and to claim that they do is to fly in the face of the well-established principle of developmentally appropriate practice, a guideline based on both common sense and observation of different care needs at different stages of development. The children to whom the bill’s statements might apply are infants and toddlers, who are far more vulnerable to the effects of caregiving quality than are older children--  and certainly than adolescents.
  2. Does the science now show that children suffer the stated damage from living in all institutions, by virtue of their being institutions? No; the evidence is that neglect by caregivers distorts developmental trajectories in early life. Institutions may be highly neglectful, and no one has forgotten the ghastly Romanian warehouses (incidentally, these throve where abortion and contraception were prohibited). “Natural experiments”, like the Hampstead nurseries administered by Anna Freud during World War II, the Bulldogs Bank children who came as a small group of toddlers from a concentration camp, and the “children’s house” residents of the traditional kibbutz, have all shown that excellent care and development can be achieved in a non-family setting.
      When institutional staff are neglectful, and developmental problems result, a major  reason may have to do with the poor nutrition that results when caregivers feed  insensitively and unresponsively, failing to work with a child’s eating rhythm or state of    arousal.  Family caregivers may also present these problems and cause unwanted outcomes; children adopted into “mega-families” may experience neglect in this way.All caregivers can be trained to do a better job of feeding and to reduce the           possible effects of neglect.

  1. Does the science show immediate effects of institutional life? No, certainly not. Length of time spent in even the worst institution will have a significant effect on the developmental trajectory for most children, and none are instantaneously affected. (The reasoning behind this exaggeration is not at all clear to me.)
  2. Does the science show lasting and possibly irreparable damage from institutional life for all children? No, it does not. The English-Romanian Adoption study followed over 300 adopted children into adolescence (Rutter et al, Deprivation-Specific Psychological Patterns: Effects of Institutional Deprivation [Monographs of the Society for Research in Child Development, Serial No. 295, Vol. 75, No. 1, 2010). Rutter’s study concluded that “A striking finding at all ages was the heterogeneity in outcome. Thus, even with the children who had the most prolonged experience of institutional care, there were some who at age 11 showed no sign of abnormal functioning on any of the domains we assessed. Conversely, there was a substantial proportion of children who showed impairments in multiple domains of functioning” (p. 14). This heterogeneity suggests that institutional care may be only one of many factors that interact with genetic background and post-adoptive care to determine a child’s development.
  3. Does the science show an inability to form emotional bonds with others? This is difficult to answer, because the bill does not define “emotional bonds” in any way. However, if we consider this in term of age-appropriate attachment behavior: No, it does not. Of the children Rutter’s group studied, there were cases where children were unusually friendly to people outside the adoptive family, but by the time they reached adolescence most of these children were viewed positively as outgoing and socially engaging. Megan Gunnar, writing in the Deprivation-Specific volume, proposed that these behaviors, sometimes defined as “attachment disorders”, were not in fact caused by differences in attachment.
      However, it may well be true that the children’s ways of communicating their need for parental care may be difficult for adoptive parents to “read”, and this may be the basis of  some of the Reuters reports’ quotations from parents who said they could not “bond  with” an adopted child.

It seems, then, that the scientific basis presented by the authors of CHIFF does not provide any reason to accept the proposed bill. But does the bill in itself contain any desirable plans? Much of the bill, with its concerns about whether UNICEF has a more powerful effect on international policy about children than the U.S. does, is clearly driven by ideological motors. This is made plain when the bill and the talking points are walked back to the organization Children in Families First, and we see the involvement of the Christian Alliance for Orphans (see Kathryn Joyce’s The child catchers) and Saddleback Church. These contributors may be the source of concerns mentioned in the bill about Muslim fostering practices and attitudes toward adoption in the Western sense.

However, the bill does contain a highly desirable repetition of a previously agreed-upon change: that administrators shall “establish and operate a database containing data respecting children involved in intercountry adoption cases who have immigrated to the United States.” This would be a helpful and appropriate move toward protection of adopted children--  especially if it were written to include domestically-adopted children as well, and either to remove from the States to the Federal government the role of overseer, or to require States to do this job properly. Enforcement of data collection through adoption tax credits and adoption assistance programs could help to establish the proposed database.  


ADDENDUM: An article by McCall et al in the most recent issue of Child Development ("Maintaining a social-emotional intervention and its benefits for institutionalized children", Vol. 84 (5), 1734-1749) reports a comparison of a Russian Baby Home that maintained its usual practices with another that gave staff additional training and a third that used staff training plus structural changes (reduced group size, assigned caregivers, fewer caregivers, and elimination of graduations to other wards). Developmental scores improved significantly for the third group of infants, and were maintained over the next 6 years. This finding contradicts the assumption of the CHIFF initiators that institutions of all kinds have equally ill effects.

FURTHER ADDENDUM: https://www.facebook.com/StopCHIFF lets you state your opinion of this bill.


  

Tuesday, September 17, 2013

The Reuters Investigation into "Re-Homing" Adopted Children (Part II)


The recently released Reuters investigation of “re-homing”, or offering adopted children to be taken by another family (http://www.reuters.com/investigates/adoption/#article/about) provides a helpful interactive table with links to the ads written about particular children. The report provides a limited analysis of the ads, with indications of the children’s age range, gender proportions, and special needs. With the help of Linda Rosa of www.childrenintherapy.org and www.scienceinmedicine.org, I’ve been trying to see what further information can be extracted from the ads Reuters found on an Internet bulletin board (now taken down).

Several points need to be kept in mind about the Reuters data. One is that the ads considered had been posted over a period of five years, so without at all minimizing the importance of these findings it’s wise to understand that this number of new ads did not run every week. It’s also hard to know how many of the children who are “re-homed” are advertised in this way, or indeed how many of the ads were successful in transferring children. There seem to have been some clerical errors in the graphic representation as well, because whereas one child figure icon usually represented one child, there are cases where there is one icon but reading the ad shows that there were two children being offered, and one case where there are two icons but only one child described. There are also some ads duplicated verbatim and one or two where the same child may be being described in different words. Trying to figure this out, we came to a count of about 276 children.

We also had to consider that we knew nothing about the children themselves, but could only examine the statements in the ads, and were thus best advised to look at the ads’ statements without considering whether or not they were accurate. The ads could be considered to reflect what their writers (sometimes, but not always, adoptive parents) thought were important things to say about the children. (However, by no means all the ads described the children or gave reasons for the decision, and a few were asking for respite care rather than a new adoptive family.)

Because Linda and I have both been working for a long time on alternative beliefs about and treatments for child mental health disorders attributed to attachment problems, we wanted to see to what extent the ads referred to attachment disorders as important reasons for disrupting or dissolving an adoption. We read all the ads and counted 77 cases in which the reason for “re-homing” was specifically stated to be Reactive Attachment Disorder (RAD). Some of these ads said there was a diagnosis of RAD, while others simply said the child “had RAD” or was thought to have the disorder. In 45 other cases, the writers referred to attachment issues, a failure of bonding on the child’s or adult’s part, or simply not loving the child.

It was difficult to tell what was meant when a child was described as having Reactive Attachment Disorder. Where specifics were given, there were many references to aggressive behavior, lying, stealing, and manipulation of other people---  none of these part of RAD by the official DSM description, but problems often named by attachment therapists and included on checklists that purport to allow diagnosis of RAD or its alternative model, Attachment Disorder (AD). The majority of the children were of school age, and no evidence-based method exists for  diagnosing RAD in children past preschool age, so unless the ad writers meant that the children were diagnosed years ago, it seems that they must have meant that the diagnosis was by an alternative therapist using the alternative model. One child was said to have Reactive Attachment Disorder  many years after being adopted at 3 weeks of age—not a possibility from the conventional viewpoint.

Some of the ads that did not mention RAD by name were difficult to understand. One, for example, said a child was “reactive in her behavior”--  a new concept for me, unless it means “impulsive”, and a usage that made me wonder whether the first word in Reactive Attachment Disorder is being used independently to describe some aspect of behavior.

The term “bonding” was used frequently, and again it was not clear what people meant by it unless they described the situation. In many cases, it was the child who did not “bond”: “she will not allow herself to be close to my husband and I”; “she has never bonded in 9 years with us”; “people begin to blame us for the lack of a bond”.  In other case, though, the parents feel no bond to the child: “I’m not bonded to this child, nor is she bonded to me”; “I don’t like him very much”. One adoptive mother said “I just cannot bond with him” after she saw her preschool son touch a younger sister’s genitals. Another couple stated about their 4-year-old adopted son: “We do not love this child and know that he deserves to have truly loving and committed parent(s). He has attached very well to us…”.  In several cases, it was the decision of the adoptive mother that the child had to go.

Presumably, most or all of these adoptive parents had undergone home studies and had had to make some efforts to adopt these children, including some hours of training as required under the Hague Convention. The frequency with which they spoke of attachment and bonding suggests that they had what they believed to be some accurate knowledge about these events. But did they? I am not simply splitting hairs when I ask what they meant, or thought they meant, by attachment or bonding. Had these people succumbed to the idea that attachment is not only intense and lasting, but that it lasts in the same intense form throughout life? Did they also believe that the mutuality of attachment meant that they, the parents, must have intense positive emotions toward the child at all times, or something was wrong?  Was their goal in adopting to achieve the high of a love affair, but asexual, and sustained for many years?

There is no question that we adults are thrilled when a child seems to like us and discouraged or bored by a child who seems uninterested in us. That’s one of the reasons why parents in Mary Dozier’s ABC program are helped to see the subtle signals by which fostered toddlers communicate their need and desire for nurturing. Could the adoptive parents who wrote the ads not detect the children’s signals, or could they not tolerate the times when the children were not interested in them? Did they not understand that anger on both sides is part of an attachment relationship at times?

I do not want to ignore the facts that a number of the children had special needs that overwhelmed their adoptive families, or that some were dangerous to themselves and others. In a couple of cases, serious illness or death of a parent made care of an adopted child very difficult. These are situations that can also affect birth families and that can never be completely planned for.

My concern, however, is with the number of adoptive parents who may have obtained their beliefs about attachment and attachment disorders from unconventional “attachment therapists”. (Two children were said to be receiving horse riding therapy, an approach that makes sense for cerebral palsy but not for mental health problems.) An overemphasis on attachment can prevent parents, therapists, and educators from identifying and working on treatable problems, as Matt Woolgar and Stephen Scott have pointed out (“The negative consequences of over-diagnosing attachment disorders in adopted children: The importance of comprehensive formulations.” Clinical Child Psychology and Psychiatry, http://ccp.sagepub.com/content/early/2013/04/08/1359104513478545). It’s possible that some adoptive parents who were less convinced that “it’s all about attachment” might have looked for more complete evaluations, have found appropriate help, and have avoided the “re-homing” bulletin board.
   



Sunday, September 15, 2013

Not-Quite-Forever Families: The Reuters Investigation Into "Re-homing" of Adopted Children (Part I)


There is a remarkable report at www.reuters.com/investigates/adoption/#article/about. This document describes an investigation into the ways some American adoptive parents seek informally or privately to disrupt the adoptions and place the children in others’ homes, permanently—a process they call “re-homing”.

The Reuters report is remarkable in more than one way. As an investigation of  adoption disruption, it moves beyond the limits of anecdotes and looks at one of a number of Internet bulletin boards that carry ads offering adoptees to new families. It provides an interactive graphic that allows the reader to examine over 200 such ads and to see at a glance how many boys and how many girls were “offered”, how many children had special needs, whether they were adopted from the U.S. or from abroad, and what their birthplaces were. (There are a number of other interesting questions to be asked about these ads, and I hope to be able to provide some information about these in the near future, as well as to suggest some conclusions that might be drawn from the information collected by the Reuters investigators.)

The Reuters report is also remarkable in terms of one of the responses it’s received. At http://www.pbs.org/newshour/bb/nation/july-dec13/adoption_09-11.html, Adam Pertman of the Evan B. Donaldson Adoption Institute, a leading U.S. adoption advocate, stated that he had never heard of this practice! (This reminds me of the advice to Alice that she should be able to believe six impossible things before breakfast.)

Perhaps Mr. Pertman was not paying attention when this issue came up in the past, but others of us had noticed it. For example, the USA Today reporter Wendy Koch described in 2006 the situation of the Schmitz family in Tennessee, a “megafamily” with 11 adopted children, many with special needs, whose mistreatment of the children led authorities to discover that most of the “adoptions” were informal. The children came from different states, which were paying for their care, and at least one child’s origins were not known (www.usatoday.com/news/nation/2006-01-18-swapping-children_x.htm). In a recent comment on the Reuters story, a member of the megafamily, now grown up, told how she was made to dig a large hole and told that it would be her grave. She had been re-homed to the Schmitzes after her original adoptive family decided to disrupt her adoption, but no legal formalities or investigations occurred (http://investigations.nbcnews.com/_news/2013/09/09/20389254-adopted-girl-says-mother-forced-her-to-dig-her-own-grave?lite).

There are many anecdotes in circulation about adoptive families who “handed off” unwanted children to others at highway rest stops or in fast food restaurants. I can give more details of one case where I provided some testimony, but naturally I will conceal names and places. This story involves a couple in a Southern state who went to Russia seeking to adopt about seven years ago. They wanted to adopt a boy, and had decided on a specific boy who was about 8 years old at the time, but were then informed that if they took the boy, they must also take his 5-year-old sister, whom I’ll call Irina. The adopting couple agreed to do this (and, by the way, there was a similar situation in the adoption of Maxim Kuzmin, the Russian 3-year-old who died in Texas last winter.) They took both children home and cared for them for a couple of years, but in fact they did not like Irina and complained that she did not attach to them and they could not bond with her (what people mean by these terms is an issue that needs much discussion with respect to the Reuters report). They sought the help of two social workers who identified themselves as attachment therapists and who stated in court that they had received training paid for by the state. One of their recommendations was that Irina spend time in respite care, in the home of another family, leaving the adoptive parents and brother to relax on their own.

After several intervals of respite care, Irina’s adopters decided that they did not want her to return. They communicated their decision to the social workers, who told Irina that she was to stay at the respite home; the adoptive parents did not see her even to say goodbye. The respite family was licensed to do foster care, and after a while they agreed to adopt Irina. In the state where they lived, it was possible to do this by direct consent, with a notarized statement from the original adoptive parents, and because the respite family was licensed for foster care I would guess that a home study was waived. In any case, Irina stayed with the respite/adoptive family and did well in school for a couple of years, but at about age 10 she ran away. She was soon brought back by a sheriff’s deputy. After her second attempt to leave, the deputy who brought her home made an excuse to come into the house. He noticed some unusual things, for example that there were very few furnishings in Irina’s room and that there was an alarm on her bedroom door, and he reported these matters. A prosecutor who was aware of some of the unorthodox and potentially harmful parenting methods associated with Attachment Therapy began an investigation.

However, the respite/adoptive parents knew how to move quickly to get Irina out of that jurisdiction. They sent her to a boarding school run by their church in another state--  a school that had been investigated for abusive treatment in the form of physical restraint of children, but had argued successfully that guidelines about restraint and seclusion did not apply to schools. It was, and probably still is, a school where a number of Russian adoptees waited to be 18 without visits to their adoptive homes or even from their adoptive parents.

Perhaps this story will help flesh out some of the statistics of the Reuters report. But those statistics, and some further analysis, are worth looking at, and we’ll come back to them.
    


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Sunday, September 8, 2013

Banning a Pseudo-therapy: A One-Off, or a Breakthrough?


A New York Times editorial this morning commented on the unanimous upholding  of the California law prohibiting “conversion therapy”, aimed at changing the sexual orientation of minors, [ without that comma this reads very oddly indeed] by the Ninth Circuit Court of Appeals (www.nytimes.com/2013/09/08/opinion/sunday/banning-a-pseudo-therapy.html?partner=rss&emc=rss&_r=0). According to the Times, the panel of judges concluded that the law did not violate the free-speech rights of therapists and minor patients or the fundamental rights of parents, because it did nothing to prevent licensed therapists from discussing the pros and cons of conversion therapy with their patients. The law regulates conduct, not speech, the panel reasoned, and lies well within the power of the state to prohibit practices it considers harmful to minors.” (Not to change the subject, but this does make me wonder whether contributions of money will no longer be protected as political speech, or whether the Citizens United decision will somehow be twisted around to declare that conduct is speech and therefore is protected under the First Amendment…. We’ll see.)

How did this legislation get passed either in California or in New Jersey? Organizations of licensed mental health practitioners of all stripes have usually resisted any state regulation of their practices and have made clear their sense that professionals were best regulated from within their own professional group, but in this case professional organizations were highly supportive of the bills.

The Times editorial commented that the California legislature “relied heavily on professional reviews of the scientific literature” , but in fact very little systematic research on conversion therapy has ever been published and hardly amounts to enough for a meaningful review. Reports of adverse events have been anecdotal and in many cases were supplied by former conversion therapy patients, many of whom were quite justifiably angry at the whole experience. The reports of harm included depression, suicidal thoughts and behavior, and substance abuse, all of which also occur outside conversion therapy.

So, am I saying that conversion therapy for minors should not be prohibited? No, certainly not, and I testified in favor of the New Jersey bill, rejecting the treatment on the grounds that it borrowed unsupported beliefs and methods from other alternative psychotherapies which I would also like to see prohibited. What I am saying is that the science, although supportive of the legislation insofar as it could be, was not a serious factor in passage of these bills, but simply a decorative feature brought in as an extra talking point.  

How, then, did the bills really get passed? I am convinced that the actual motivating force was the enthusiastic organized pressure exerted by the LGBT community and the current groundswell of approval for LGBT freedoms. Essentially, LGBT groups argued that therapists ought not to try to change young people’s sexual orientations--  that whether such attempts “worked” or not, they were an intolerable interference with the rights of the individual, and many who had experienced the treatment had reported how unhappy it made them. The fact that the science, such as it is, supported these claims was simply a useful addition to the basic argument.  

I’m thinking about this in some detail because I wonder whether the conversion therapy legislation will open the doors for prohibition of other “pseudo-therapies” (to use the Times term) for children and adolescents. Legislation prohibiting treatments like “holding therapy” has rarely been passed, probably because mental health professionals who do not approve of these treatments are almost as likely to oppose such legislation as those who do approve. As I said before, generally speaking, organizations of mental health professionals have feared and fought efforts to regulate their practices. When therapists have injured patients (cf. John Rosen, Jacqui Schiff, Connell Watkins, etc.), legal proceedings against them have handled the events as examples of assault or of child abuse, not in terms of the use of potentially harmful therapeutic methods. In most cases, the state has no option for proceeding against a professional whose methods may do harm, and in mental health circles there have been few cases where a professional organization has disciplined someone for potential injuries (although sexual acts are always a reason for discipline even when no definite injury can be demonstrated).   The upshot of all this is that  legislation is the most powerful way to regulate potentially harmful practices, but the legislation opposing conversion therapy is a rare success in achievement of such regulation.

If the conversion therapy legislation is a breakthrough, it is possible that prohibition of other potentially harmful psychotherapies for children can be realized. The science is there, in better quality and quantity than what was brought into the conversion therapy discussion. It’s possible that professional groups, having swallowed the oft-rejected option of regulation by the state in the one case, may accept it in other cases as well. But, where is the enthusiastic, highly organized  group who will apply pressure on legislatures as the LGBT community did? This I don’t see, and I believe that organized pressure was the major reason for successful legislation.

There is increasing concern among psychologists and psychiatrists about the possibility of adverse reactions to various forms of psychotherapy, and research is much more likely than it once was to look for such problems. Unfortunately, some treatments for children are not likely ever to undergo formal reviews for safety and effectiveness, nor are therapists using these methods likely to be disciplined if a problem occurs. The reason for this is that alternative psychotherapies for children increasingly have parents do the actual treatment; if there are adverse events, the parent is at fault. All the therapist does is to instruct the parent and provide information, in return for payment, and since 1976 such commercial speech has been considered to some extent protected under the First Amendment.

It’s discouraging, all of this. But it reminds me of a statement whose source I used to know: “The day is short, the workmen are lazy. The task is difficult. It is impossible to succeed. Nevertheless, we are forbidden not to try.”  


Saturday, September 7, 2013

Stop Spanking Children? First, Let's Stop Intruding On and Frightening Them

Like many other people, the psychologist Elizabeth Gershoff is opposed to spanking children, and she argues strongly against the practice in an article called “Spanking and child development: We know enough now to stop hitting our children” (Child Development Perspectives, 2013, 7(3), 133-137). Gershoff points out the unlikelihood that parents will manage to use physical punishment effectively and discusses spanking as a human rights violation.

But interestingly, a foremost evidence-based intervention program for at-risk foster children does not  tell parents not to spank. ABC (Attachment and Biobehavioral Catch-Up), the program created by Dr. Mary Dozier of the University of Delaware, does not include suggestions about spanking in its coaching of foster parents of infants and toddlers. Answering questions about this at an infant mental health organization’s meeting yesterday, Dr. Dozier said the research group had decided to omit this issue rather than destroy their credibility with parents by coming across as “weird psychologists” telling people not to spank--  when in fact most parents world-wide do  occasionally spank their toddlers.

ABC is most concerned with encouraging sensitive and responsive caregiving for infants and toddlers with backgrounds of serious neglect or abuse. These at-risk children need foster parents who can provide the optimum environment for improved development by understanding their needs and sensitively reading their signals.  ABC coaches foster parents to be aware that these children need nurturance although they don’t appear to want it. In one video clip, a toddler was seen falling down, starting to get up, then lying down again--  all without crying or calling to his foster mother. But the mother had been made aware that he needed nurturing even though he did not seem to “say so”, and she went to pick him up; both smiled and the pick-up had clearly been what he needed. ABC also coaches foster parents to behave contingently by imitating a child’s movements or by following the child’s lead in play rather than doing something that is instructional or “more interesting” and ignoring the ideas that have engaged the child.

Parents who increase their nurturing behavior, who read signals sensitively, and who follow the child’s lead are less likely to get into situations where they see no option but spanking. In that sense, ABC follows the old behaviorist model of reinforcing desirable behavior and leaving less time or opportunity for undesirable behavior. And even though the ABC program does not mention spanking, it does focus specifically on some undesirable behaviors and try to  diminish them.
Even parents who have increased their level of nurturing and contingent behavior toward young children may still have habits of approaching the children in undesirable ways that disrupt progress toward good communication and biobehavioral regulation. One problematic behavior is intrusiveness. Intrusive parents tickle, chase, or tease young children excessively and fail to pick up cues that the children are distressed--  cues that are often subtle or difficult to read in infants and toddlers who have been neglected or abused. Intrusive parent behavior can be dysregulating, especially if the unobservant parent does not realize that the child has been pushed to the point where some calming and nurturing is needed. (Parental intrusiveness over the years has been related to later mood and behavioral disturbances by the psychologist Brian Barber.) Certainly, parents who are habitually intrusive will have a hard time following the child’s lead as the ABC program encourages them to do. Yet, just as it is hard to get children to stop doing things we don’t like, it is hard to have any success in telling intrusive parents to stop being so intrusive. For ABC coaches to try to do this would be likely to frighten or anger parents and damage their alliance with the coaches, so the approach required is to wait for non-intrusive behaviors and comment on them positively, pointing out how well the child responds to this.

In addition, to undesirable intrusive behavior, parents may habitually behave in frightening ways. These may involve yelling, looming over the child, giving angry looks, or even giving intentional frights by jumping out of hiding or threatening to leave. Parents may act frightening in order to intimidate a child and keep him uncertain in ways the parents think will increase compliance--  but in fact the dysregulating effects of fear and uncertainty may make it even more difficult for the child to stay calm and understand what is wanted of him. Some parents may behave in frightening ways simply to “get a rise out of” the child, who seems to them unsatisfyingly unresponsive or inattentive, and others may do so simply in imitation of adult behavior they have seen or experienced. Increasing empathy and sensitivity to child cues can help parents reduce their frightening behavior, especially if they also discover that nurturing and contingent parenting can help the child be more responsive to them.

Which would be better, a parent who never spanked, but often behaved intrusively and frighteningly, or one who occasionally spanked but rarely intruded or frightened in other ways? My bet would be that the better outcome would result from the second way of parenting—and we do have evidence that people can be helped to stop intruding on and frightening children. Concentrating on spanking gives a lively topic for unending discussion, but perhaps is not of much help with respect to actual improvements in parenting.


P.S. A query: what do you think many neighbors and family members would say to the mother in the ABC program who picked up the child who had fallen but was not crying? “You’re spoiling him” is what I hear in my imagination. And perhaps this would be an unwise move for a healthy child from a stable, caring family background--  but don’t forget, we’re talking here about infants and toddlers who are in foster care, very possibly because they have been neglected and abused. Nevertheless, we can learn a lot about parenting in general from seeing what works for foster parents of at-risk children. 

Monday, September 2, 2013

Attachment Disorders Versus Depraved Hearts: Further Adventures with Unconventional Mental Health Perspectives

On many occasions, I’ve posted on this blog comments about “attachment disorders” in adopted children--  not Reactive Attachment Disorder as described either in DSM-IV-Tr or in DSM-5, but a notional set of problems posited by proponents of Attachment Therapy. The symptoms of these disorders include disobedience, a love of blood and gore, cruelty to animals, “crazy lying”, making eye contact only when lying, the absence of conscience, aloofness, ingratitude, etc. Such disordered moods and behaviors, according to supporters of Attachment Therapy, occur because the children had emotional attachments broken by separation or were never given an opportunity to attach, because they were taken from their birth mothers early, or because they were abused or neglected, or because they experienced many changes of caregiver. With the rationale that a missing early experience can be supplied at any time during development, proponents of this approach claim that they can create the missing and vital attachment at any point in later development. In this stance, they ignore facts of developmental change, as well as a variety of social, genetic, and biological factors that are at work in determining personality and mental health.

There are some reasons to think that Attachment Therapy and its associated views are to come extent connected with evangelical religious beliefs (as I have pointed out at http://thestudyofnonsense.blogspot.com). But I have discovered to my surprise that people of more extreme evangelical beliefs actually consider Attachment Therapy to take an excessively worldly perspective. They reject the idea of attachment disorders as causes of childhood mood and behavior problems and instead seek Biblical explanations.

In a 2006 master’s thesis, for an M.A. in Biblical Counseling, entitled “The Biblical View of Reactive Attachment Disorder” (www.lincolnchristian.edu/library/tren/091-0077.pdf), Linda J. Rice set out a view of disturbing behavior in children that is at odds both with Attachment Therapy and with conventional understanding of child development and mental illness. According to Rice, the problem with the children in question is not that they have suffered a lack of attachment, but that they have depraved hearts.

Although Rice includes the term Reactive Attachment Disorder in her thesis title, and although she begins her second chapter with a description of Reactive Attachment Disorder as given in DSM-IV –Tr, she quickly shifts  gears to bring in symptoms of attachment disorders as proposed by Attachment Therapists. Noting that the DSM description is too vague, she writes that “practicing mental health professionals have supplemented specifics to aid in diagnosis”. Rice follows this comment with a list of symptoms drawn from the work of well-known Attachment Therapists such as Magid and McKelvey, among them the problems I alluded to in the first paragraph of this post. In an interesting departure, she refers to a child with Reactive Attachment Disorder as “a RAD”, apparently subsuming the individual identity in the diagnosis--- which may or may not be a step forward from the habit of calling such children “RADishes”.  She also refers to the children as “dissociated” but apparently means by this that the child is emotionally disconnected from others, not that he or she has moments of dissociation and lack of awareness of the environment. At the end of the chapter, however, she draws back from the frightening picture she has been painting and acknowledges that not all children with early behavioral problems will be criminals.

Rice’s next chapter explores possible causes of the problems she refers to as Reactive Attachment Disorder. Beginning with the psychological view of attachment, she refers in the same paragraph to John Bowlby, founder of attachment theory (not therapy) and Robert Zaslow, initiator of therapies that use coercive restraint in attempts to change moods and behaviors; although Zaslow apparently believed he was following Bowlby’s view of attachment, most of his approach was not based on attachment theory, but it has been the foundation of  various complementary and alternative holding therapies and attachment therapies. In this and the following chapter, Rice goes on to a freewheeling summary of ideas about attachment and childhood mental illness, mixing conventional and unconventional ideas from “attunement” to the “bonding cycle”.

Chapter 5 continues in a similar manner with information about brain development and chemistry. Here, too, there is an idiosyncratic use of the word “dissociation”, apparently to mean social inhibition. There is a certain sense in this chapter of tidying up the picnic and closing the tailgate before getting down to the real business of the thesis, an analysis of children’s mood and behavior difficulties in terms of Biblically-sanctioned ideas.

In her chapter on the Biblical approach to Reactive Attachment Disorder (so-called), Rice begins with a list of objections on Biblical terms to the explanations offered in the previous chapters. Here is her list:
Human beings are not evolved mammals, but are created in God’s image, so it is a mistake to consider  human problems  without a focus on human moral desires, consequences, and laws.
The mind is not the brain, and moral choices occur in the heart (spirit; the inner thoughts and desires of the immaterial part of man ), not in the neurons.

Genetics and brain damage cannot cause misbehavior or wrong moral choices, because bodily events are not involved in moral choice.

Responsibility is not in factors outside the child, but has to do with the fact that he is a sinner whose own lusts and rebellion create conflict; children are not innately good and are responsible for their own selfish behavior.

Hope is not in man’s ways; attachment therapy cannot transform the heart; a relationship with God can do so.

True change is not temporal, and a child who is a therapy success has simply become a well-behaved sinner rather than a dysregulated sinner.

Having rejected the “psychological” approaches described in her previous chapters, Rice goes on to discuss Reactive Attachment Disorder in Biblical terms as a problem resulting from fear, anger, and a desire for control rather than submission. She makes it clear that according to Biblical definitions of love as self-sacrificing, a baby cannot love its mother, and quotes St. Augustine to the effect that the apparent moral innocence of infants is simply a matter of their weakness and inability to carry out their selfish desires. Acknowledging that young children do not know about good and evil, she nevertheless point out that ignorance does not cancel guilt, and that true compassion will punish wrong behavior rather than letting it pass.

Harsh though Rice’s Biblical view of infants may seem, she also examines the Biblical view of parents and their appropriate behavior. They are not to provoke children to anger or to alienate them by harsh treatment, but instead should behave lovingly and kindly in order to comfort the baby and allow him to be attracted and persuaded to their beliefs. Helping the child to feel comfortable and to behave well, Rice says, prevents him from becoming habituated to angry, rebellious ways.

In a final chapter, Rice pursues her position that only redemption can cure reactive attachment Disorder. She argues against the efforts of therapists to cause children to trust their parents and thus to achieve attachment. Instead, she comments, “This emphasis distracts from the real problem, that the child does not trust God…. Shifting the child’s trust to parents keeps it misplaced on mankind.” Thus, “Teaching and inducing trust in God is where the energy of counselors and parents should be directed.” Rice further notes that “Brain damage cannot destroy the conscience because the brain is not the conscience organ. Conscience is a moral capacity. Therefore, even mentally handicapped people can know right and wrong, and confess sins, and can trust Christ for salvation. Everyone has a conscience. The problem with a seeming lack of conscience is not absence but to what direction it was trained…. Through salvation, instruction, and discipline exercised with compassion, there is hope for a hardened child to choose to heed his conscience and practice obedience and compassion.”

I am fascinated by a number of aspects of Rice’s presentation--  not the least of them being the awareness that Attachment Therapy is under attack both from conventional psychology and from a religious position. Rice’s examination seems to me (a freethinker with Quaker leanings) to make Reactive Attachment Disorder (as she defines it) fit perfectly into a fundamentalist Christian world-view. In making it fit, of course, she rejects the tenet of conventional psychology that human beings can be understood without the assumption that they have any non-material components, and instead posits a motivating principle that operates independent of brain functioning. She also commits what psychologists call the fundamental attribution error by focusing on the nature of the individual rather than taking into account events in the environment. But of course, she knows she is doing these things, and believes that she is right and the  psychologists she references wrong.  Unfortunately for those of us who are genuinely interested in vernacular beliefs about psychological issues, Rice is vague about exactly how she thinks children with behavioral disorders should be treated. Like some proponents of Attachment Therapy, she believes that children can make moral choices for obedience and compassion; whether she includes in this the voluntary control over vomiting and defecation that Keith Reber’s 1996 paper suggested, is not at all clear to me. Certainly she has presented a framework that is closed to outcome research by any researcher outside Rice’s belief system.







  

Un-Universities: Don't Waste Your Money on Their Degrees or Their Graduates

Diploma mills, “wannabe unis”, or un-universities--   whatever you call them, we seem always to have with us on the Internet organizations that will sell what appears to be evidence of undergraduate, master’s, even doctoral degrees in range of subjects. They claim to be accredited, and no doubt are--  by an accrediting board of their own devising. They rake in a chunk of their clients’ hard-earned money (although of course nothing like the cost of taking years to work on a legitimate degree) and provide in return documents that are easily identified as fraudulent by any knowledgeable reader. Unfortunately, they don’t just defraud their clients, but enable those clients to work a similar trick on the unsophisticated purchaser of their ill-trained services.   

A reader recently sent me some correspondence he had had with Ashwood University (www.ashwooduniversity.net) about a doctoral degree (“with thesis”). Wikipedia clearly identifies Ashwood as an unaccredited organization that provides degrees on the basis of life experience. Life experience evaluation is not always fraudulent, as witness New Jersey’s Thomas Edison College; an individual who has worked in bookkeeping may have mastered the material of a first accounting course, and someone who has worked under supervision with young children may have mastered information that would be learned in an introductory course about early childhood education. However, when an organization claims to evaluate life experience at the level of an undergraduate education, not to speak of a doctorate that would normally require 2 years or more of work after a master’s degree and the writing of a dissertation, it becomes difficult to imagine how any life experience could possibly provide an equivalent. (Unless, I suppose, you are one of the Rothschilds and carried out research privately following a private education.)

Material at  www.geteducated.com/diploma-mill-police/degree-mills-list/ashwood-university-accreditation confirms the Wikipedia assessment of Ashwood. Ashwood is not accredited by the Council on Higher Education or the U.S. Department of Education. (Incidentally, one of the ways you can know whether a U.S. institution is accredited is to examine its website to see whether students are eligible for loans or grants for which the FAFSA application is required. Unaccredited institutions cannot correctly state that their students are eligible.) Although many un-universities state that they are accredited, the real question is, accredited by whom? Accreditation by a shadowy self-appointed accrediting agency is for practical purposes not actual accreditation. The geteducated site points out that several states have specifically noted that Ashwood is not what it makes itself out to be.

The geteducated site also noted that there are two genuine, accredited, distance learning institutions with similar names: Ashford University of Iowa and Ashworth University of Georgia. It’s characteristic of un-universities to choose names that resemble those of respectable institutions--  for example, “Columbus” sounds all right to people who are really thinking of “Columbia”.

The reader who sent me his correspondence with Ashwood had asked the organization about a doctoral degree (I don’t know what the subject was to be). Here was part of the reply, apparently written by someone who had no editor at hand:

“This is in reference to your doctorate degree. As you do understand that the documents were awarded to you on the basis of your working experience and you never wrote any thesis to earn this degree but traditionally a student has to write thesis and do a lot of research to earn a PhD or Doctorate degree, that is why we wrote thesis on your behalf and forwarded them to the relevant authorities and on the basis of which you will get a Thesis approval letter for the  Doctorate degree and it will also be Notarized, Attested and legalized for you to easily use it. Traditionally, when a student is awarded with a thesis approval letter he/she also needs to get his/her title of “DOCTOR (Dr) and PhD” registered in front of his/her name, but as per your records this formality is not yet completed, that is why we need to get your title registered as Dr xxxxxx PhD with the higher authorities for you to officially use it with your name on your business cards, resume, driving license, passport etc. this will be the last requirement as far as your Academic profile is concerned and once this process is completed there will be no requirements from you whatsoever. This requirement is mandatory for the Educational Department and once this process is completed you will  receive your documents in the next 25-30 days time.”

The paragraph above is absolutely sic except that I omitted a number of uses of bold print. Capitals and the paucity of punctuation marks are as I found them.

I must say that this Ashwood statement gave me some degree of pause. Do they think I have a real doctorate, I wonder, even though I did, in the traditional manner, write my own thesis? I have never had any title “registered” and would not know who the higher authorities who do this might be. My diploma and the signatures of my dissertation committee were never Notarized or Attested or even legalized, yet I have “easily” used them to get jobs since I was 25 years old. As for using my degree on a business card--  I can do that, and so can anyone else, whether they have such a degree or not, as long as they do not use it to defraud. I could have named my cat Dr. Hicks Mercer and did once have a pet named James B. Klee, Ph.D. but informally referred to as J.B. (For that matter, there is the story of Dr. Zoe D. Katze, a handsome animal who became a diplomate of the American Psychotherapy Association, but that’s a different kind of fraud.)

By the way, I wonder whether communications like this letter from Ashwood are responsible for people calling or even signing themselves Dr. Na├»ve Person Ph.D. You don’t need both! The name is followed by Ph.D., and the degree-holder may be addressed as Dr. Person, but probably should not be in situations where someone needs first aid. I feel suspicious when I see this redundant use of the credential.

However, back to our Ashwoods. The Ashwood un-university has posted a rejoinder to criticism at www.ashwooduniversityscam.com. Cleverly and deceptively, they have chosen that “scam” title to make it appear that the site contains further negative evaluation--  but it doesn’t. On the contrary, it reports “research” showing that Ashwood is legit. This consists of a survey asking two questions: a) Do you think Ashwood University is a diploma mill?  And b) Is Ashwood University scam or not? (sic, as usual). The conclusion was that 99.9% of an unspecified number of Ashwood degree recipients thought Ashwood was fine.  So, “Research shows that it is safe to take degree from Ashwood University. Though there are negative feedback but satisfied people won the argument. Myths surface when you are don’t know something and believe rumors. This document must have helped considerably in removing misconceptions that you may have about Ashwood University.” (And indeed it did help considerably; I hadn’t realized quite how bad it was.)

Why is it a problem that organizations like Ashwood offer faux advanced degrees? The thing is that however feeble and silly some dissertation titles sound to the general public, in fact one learns a great deal in the course of writing such a document. The only comparable “life experience” would be writing a professional book or long journal article and having it reviewed, revised, edited, and published, which only a very few people do without having first earned an advanced degree (and those who do so can be respected and employed without that degree). It is almost invariably the case that a person who has not written a dissertation in a subject knows much less about the subject than someone who has done the study and writing.

In addition, there are some very special considerations when an individual has bought a degree (from $1399 at Ashwood, it appears) that puts him or her in a position to deal with others’ mental illness or social problems. Not only does the student at a legitimate university learn much in the way of scholarly work, but he or she also receives the mentoring of highly qualified people in the field, and is required to master the ethical guidelines accepted in a profession. I myself would not care to put myself under the treatment of a psychologist or clinical social worker who had avoided the intensive training in professional conduct that is part of training in an accredited institution. I would also be most concerned about the ability of such a practitioner to understand the evidence that does or does not support the safety and efficacy of a treatment.

The morals of the story are these: if you are tempted to appear to qualify for a job by buying a degree, please realize that you may well be identified as cheating, and your money will not be refunded to you when things don’t work out as planned. (Besides, what if they taught you to write like that Ashwood paragraph!)  If you are a person looking for a psychotherapist and you see that a person’s degree is not from a legitimate university, no matter how nice and sympathetic you think he or she is—look elsewhere, and do this especially if you are seeking treatment not for yourself but for a child or some other dependent person. That practitioner is attempting to defraud you and other potential clients.