Concerned About Unconventional Mental Health Interventions?

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

Friday, May 30, 2014

Ronald Federici Gets Justice at Fairfax County Small Claims Court

Listen, my friends, and you shall hear the very interesting story of a lawsuit brought unsuccessfully by the Virginia psychologist, aficionado of prone restraint, and practitioner of barratry, Ronald Federici. As you may have read if you’ve followed this blog at all, Federici has been objecting for a long time to criticisms of the recommendations he makes in his self-published book, Help for the hopeless child. He describes his methods as involving holding therapy—“sequence one and sequence two holds”, and his description closely resembles the methods used by Foster Cline and his followers, except that Federici advises placing the child in the prone position, the position well-known to be associated with deaths in restraint. Federici has objected strongly by means of lawsuits to comments criticizing these practices. He also objected to the mere fact of selected quotations from his book being posted to speak for themselves, but curiously the Amazon “look inside” feature enabled for his book does not  seem to disturb him—in fact, he must have chosen it.

For the purpose of educating the public about Federici’s methods, Advocates for Children in Therapy (ACT) has posted quotationsions from Federici’s book on its website www.childrenintherapy.org.
. For some years now, Federici has been working to have these taken down (odd, really, when you remember that you can read practically the whole book on Amazon). He began by bringing complaints under the Digital Millenium Copyright Act (DMCA), which requires Internet hosts to take down a customer’s sute that is complained about, until it can be ascertained whether it is in violation of copyright. However, not surprisingly, ACT had kept its use of quotations well within the “fair use” guidelines—less than a certain length, with clear educational purpose, and not being sold or providing other financial benefit to ACT. Therefore, Federici’s complaints culminated in decisions allowing the material to be posted again.
                                                                                                                 
Recently, Federici took another approach (and as we will see later, this approach is a bit of a habit with him). He brought a lawsuit against two of the leaders of ACT, Larry Sarner andLinda Rosa, for damages and costs due to the claimed copyright violations. The suit, amounting to $10,000, was brought in Small Claims Court in Fairfax County, VA—a venue not far from where Federici lives, but a considerable distance from Linda’s and Larry’s residences in Colorado. For those of you who have had the good fortune not to have been sued in Small Claims Court, let me say how this works: first, you cannot have an attorney with you in this court. Second, the general idea is that if you do not turn up for the court date, the judge normally will find against you and may assess whatever a plaintiff has asked. Third, it is possible to appeal a Small Claims Court judgment to a higher court, and you may represent yourself there too, but most people agree that hiring a lawyer is a much better idea.  

As it happened, Sarner was able to be in court in Fairfax County on the court day, May 16. Rosa and Sarner had previously written to the court rejecting the idea that a Virginia court has jurisdiction over people’s activities in Colorado, even if those activities are shown on the Internet and visible to Virginians. (Incidentally, there are clear precedents for this position in Virginia law.) Sarner went to court prepared to argue against jurisdiction, but his preparation turned out to be unnecessary--  because Federici did not appear! The judge asked Sarner whether this kind of suit had happened before (answer: yes), and ended up sanctioning Federici by awarding Sarner  $1500 in costs.

How has this all come about? Are there no mechanisms other than the courts for mediating professional disputes or responding to professional criticisms? Of course there are such mechanisms, and they are used effectively by the great majority of psychologists. Generally, professional criticisms and disagreements are made public in professional journal articles, in presentations at professional conferences, in panel discussions, and in public debates.  The public nature of these presentations enables other professionals to provide arguments in support of different positions and, it is to be hoped, increases the probability that a logical and evidence-based conclusion will be reached.

Regrettably, Federici has taken none of these routes to dealing with professional criticisms. He has never published any research evidence to support the methods he advises. He has self-published a book, Help for the hopeless child, in two almost identical editions. Criticism of the methods advocated in that book had already appeared before the second edition was published, so it would have been quite possible for Federici to address the existing concerns in the second edition, but he did not do so. Nor, as far as I can tell, has he published any discussion of his treatment methods in any professional journal, or presented them in any venue that would have allowed critical comment. He did not respond, as far as I can tell, to criticisms of his some of his recommendations in the 2006 task force report by the American Professional Society on the Abuse of Children and Division 37 of the American Psychological Association. These facts mean that there has never been any opportunity for direct debate about either the theory (if any) behind Federici’s methods or the level of empirical evidence supporting these methods.

Federici has chosen not to use any of the procedures that are normal ways of resolving professional disputes and responding to critical analysis. Instead, he has resorted to personal and legal attacks on the persons he regards as his primary critics. I will omit any discussion of the personal attacks, which descended to a squalid level, as can be seen in quotations from Federici in an article in Harper’s in 2013 (http://harpers.org/2013/10/cold-war-kids). (Incidentally, his statement in the Harper’s article that one of his critics has had a sex-change operation presumably refers to me, as he has been making this claim for years despite all evidence to the contrary.)

Let me run through some of Federici’s legal actions aimed at stopping public criticism of the methods he recommends in his book. (By the way, I have no way of knowing whether he himself does any of the things he recommends; following a meeting in court, he once asked me to come and work in his office, but I did not do so.)

The first legal action taken by Federici in 2009 involved invoking the DMCA (see above) against the Internet host, Project DOD, then the host of the Advocates for Children in Therapy (ACT) website. This situation is described at http://blog.ericgoldman.org/archives/2009/12/512f_claim_dism.htm. Federici claimed that ACT,  had violated copyright by posting quotations from his published work. This complaint was followed under DMCA  by the taking down of the web pages, etc., until ACT through a counternotification showed that they had meticulously followed fair use guidelines. Federici’s complaint was followed by similar complaints by such persons as Nancy Thomas, Gregory Keck, and Arthur Becker-Weidman, all of whom complained (with equal inaccuracy) that their copyrights had been violated. The situation culminated in a “reverse DMCA” case in which DOD, the Internet host, complained that Federici was carrying out harassment in an effort to get both ACT and DOD off the Internet. The complaint was dismissed on jurisdictional grounds.

Soon after this lawsuit, in 2010, Federici brought suit in Fairfax County Small Claims Court against ACT, Sarner, Rosa, myself, Psychology Today (which had posted my blog at that time), and a number of other people. He charged defamation and interference with his business and asked for damages from each defendant ($3000, if I remember correctly). I attended the court, representing myself and ACT. Federici claimed that he had had patients cancel appointments as a result of what I and others had written on the Internet. He provided a stack of e-mail printouts in support of this contention, but I pointed out that there was no evidence that these were real people and that he had not written the messages himself. The judge found for all the defendants except Psychology Today, which defaulted by failing to appear (and was most annoyed about the whole thing--  this is why I don’t have a PT blog any more but also why Federici will never have one).

Federici appealed the case to the next higher court (which I have already described at http://childmyths.blogspot.com/2011/06/that-lawsuit-again-ronald-s-federic-vs.html), and the court dismissed the case on personal  jurisdictional grounds. It turned out, in fact, that I had never written any of the things attributed to me in the complaint, and it was not known who did write most of them. But Federici saw the bright side of the outcome and later stated that the judge had recognized him as an “international public figure”. In fact, what the judge said was that since this was what Federici claimed for himself, he must understand that the bar for defamation was much higher than if he admitted to being an ordinary person.

The Internet being the enemy of privacy that it is, it turns out that Federici has a strong tendency to use the courts for all kinds of problems, not just to quell professional criticism. If you go to http://www.courts.state.va.us and search civil cases in general district courts, you can see quite a history (choose Fairfax County District Court). What’s especially interesting is the way he has “non-suited” a number of the cases he has brought--  he has terminated the proceedings after having served the defendants and put them through all the agitation and planning, taking off work, etc., that occur when people think they must appear in court. (It’s also interesting, at the same Virginia website and at the similar site for Maryland courts, to see the number of traffic offenses he has racked up. There are other places to see other interesting litigation he’s involved in, but since there are other people involved, I won’t give directions.)

Is all this litigation by a psychologist in violation of the American Psychological Association’s code of ethics? This is a slippery problem, and I doubt that inciting to unnecessary litigation is an offense that can easily be included under ethical issues for psychologists. However, there are some principles of ethics for psychologists that in my opinion have been violated by Federici (see www.apa.org/ethics/code/principles.pdf). One of these principles is that of integrity: “Psychologists seek to promote honesty, accuracy, and truthfulness in the science, teaching, and practice of psychology. In these activities psychologists do not steal, cheat, or engage in fraud, subterfuge, or intentional misrepresentation of fact.” A second principle is that of justice: “Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices.” Using the courts rather than normal professional actions to carry on a professional dispute is, I believe, potentially in violation of both these principles.

It is my hope that Ronald Federici will publish the rationale and evidentiary support for his recommended methods in a peer-reviewed journal. As for myself, I would be more than happy to meet him in a public debate or panel discussion, even at short notice.

Update: Federici has not filed an appeal in the recent matter, and the period of time he had to do so has expired.


If any reader is in contact with Patrise Holden, of the northern Virginia-DC area, would you call her attention to this post? I believe she would be interested.



Tuesday, May 20, 2014

An Important Statement on Adoption, by Adoptees

At http://www.thelostdaughters.com/2014/05/adoptee-reactions-to-reactive.html?m=1, Karen Pickell has posted a powerful rejoinder to the recent Huffington Post claims about adoptees and Reactive Attachment Disorder. In addition, this post includes an essay by Matthew Salesses in which he rewrites part of Tina Traster’s book, from the point of view of her lonely and puzzled adopted child. Both these statements point to the failure of adoption education to provide real insight into the nature of the adoptive process to all adoption candidates.

Adoption education, as required by the Hague Convention, has a lot to do. There are legal and financial issues to be considered, as well as general advice about childrearing that may be needed by adoptive parents who have no other children. All these things have to be covered in a small number of hours, and they have to be taught to people who are excited and emotional and just want to get the lessons over so they can get their children. It’s a bit like having a lecture about estate planning a few hours before your wedding.

Adoption education, if done well, can cover many points that adoptive parents will eventually need to know. If they don’t learn every bit of the legal and financial information, at least they can take home the fact that this information exists, and some idea about how to find it when they want it.

However, it’s a lot harder to teach the realities of emotional connection with a frightened young stranger. It’s especially hard because many adoptive parents—like other members of the public—believe they already know all about early emotional life. As the Zero to Three Benchmark Study some years ago showed, many adults know a good deal about young children’s motor and cognitive development, but most, including parents, know very little about social and emotional development. What’s more, much of what they “know” is wrong, which makes it especially difficult to correct their thinking. When you add to these misunderstandings  the fact that a “faux theory” of attachment is being provided by individuals like Nancy Thomas and Tina Traster, so that people come to adoption education committed to bizarre beliefs, it is not surprising that adoption education does not do the job we want it to do.

Here are some points that I would like to add to what Karen Pickell and Matthew Salesses had to say:

  1. When you adopt a child, you are not “bringing your son or daughter home”.  Only in a legal fiction or in evangelical religious belief is that child at that point your son or daughter. He or she may become your son or daughter, and you may become the child’s mother or father, but this will take time and effort. You will have to get to know each other, and that work will be mostly your responsibility--  just as getting to know a child you have just given birth to is your adult responsibility. Your home is not the child’s home until it has been made so by good experiences, which you must try to provide (and by the way, this does not mean going to Disney World).
  2. Children don’t “love” their parents as their parents love them. (Even adult children don’t love their elderly parents in the same way the parents care for them!) Even under the best circumstances, with unbroken relationships and constant kindness, infants, children, and adolescents are not capable of adult love. How much less should we expect  adopted children, with their experiences of disruption and anxiety and possibly far worse things, to love in the adult sense? Adult love surely means understanding of and consideration of the needs of the loved person, even putting those needs ahead of our own at times. This kind of love is what children need from adults, but cannot give to adults. To be able to love in an adult way means to be able to recognize needs that are different from our own and to be able to delay our own gratification when a loved one’s needs are more serious than ours.
Expressing love symbolically, by gazing into someone’s eyes, snuggling up to them, or saying “I love you” is not real love, and is not of much use unless two people share a symbol system. Being asked to do these things may be very uncomfortable if they are unfamiliar, as they will be to most adopted children. Demanding that a child make “eye contact” with you as an expression of love is putting your own needs first, not the child’s.

When reading about the concerns of adoptive parents whose children do not “show affection on the parent’s terms”, I’m often reminded of a case of a mother who was very angry with her child who accidentally scratched her face with his fingernails. She said, “he does it on purpose. He knows it hurts,’cause I said ‘ow’.”  This child was two weeks old. It’s obvious that this mother was expecting far more than her baby could give her--  but isn’t it also obvious that adoptive parents who expect instant love, displayed as specific behaviors, are also expecting far more than the children could give, even if they had been together since birth?

Tina Traster, in her New York Times blog, recently told how her adopted daughter said “you’re not my real mother” and Traster replied, “Oh yeah, then who is?” The daughter cried and complained that this was “so mean”, and indeed it was. Traster apparently does not know that even the most “attached” child says things like this, including “you’re not the boss of me”. Rather than accepting this as typical of a developmental stage, and perhaps suggesting a different way for the girl to state what she was feeling, Traster responded with the most devastating possible comeback: You don’t have a mother. If I abandon you, there is no one to care for you. Having had her needs quite predictably ignored, Traster got out the heavy artillery—because she thinks a child can love her as she wants to be loved.
  1. Hating your child is part of parental love. There, I’ve said what most experienced parents know, but some adoptive parents don’t seem to understand. The intensity of parental love derives in part from its profound ambivalence. Naturally, we feel angry at people who seem to demand our constant attention and delays of our own gratification, and who only rarely give us the smile or other response that rewards us and keeps us marching on. But we are also fascinated by them, engrossed in them, and adore them. No wonder we can’t stop thinking and talking about them, but also, no wonder we have moments when we feel like attacking them. (Most of the time, we don’t attack, because we realize that the consequences of doing so are far worse than whatever is annoying us now, and actually we don’t want to hurt them.)  
It’s extremely hard to explain this fact of parenting life to people who have not had children, so it’s not surprising that adoption education doesn’t succeed in getting it across. But to understand this reality might help adoptive parents feel relatively comfortable with their own complex emotions, and save them from having to blame the “problem” on something wrong with the adopted child.

These comments are obviously only a bare beginning of what we ought to be telling adoptive parents when we attempt to educate them, and of course what we can possibly tell them is severely limited by time constraints. But if we were to focus on information of this kind, and perhaps limit the legal information to handouts, we might have a chance at fighting the harm done by people like Traster and Thomas.

     


Wednesday, May 14, 2014

Stopping Holding Therapy Is Not Enough

After Candace Newmaker’s death at the hands of her therapists in 2000, some professional organizations released resolutions condemning various alternative psychotherapy practices. Some, like the American Psychological Association, rejected “rebirthing”, the form of treatment during which Candace died, but did not mention holding therapy. Others stated their rejection of holding therapy, a method that had also been used with Candace and that is known to have caused some injuries and deaths. A task force report by Division 37 of APA and the American Professional Society on Abuse of Children (APSAC) in 2006 also referenced some adjuvant treatments associated with holding therapy, for example, withholding or forcing of food, but even that report was relatively unconcerned with the adjuvant treatments that had been proposed and used by “lay therapists” like Nancy Thomas.

Following Candace’s death and the public criticisms of holding therapy by professional groups, the organization that had been the primary supporter of this treatment changed its position. In position papers in 2003, the Association for Treatment and Training of Attachment in Children (ATTACh) stated opposition to the highly coercive holding therapy and approval of a new method claimed to be more sensitive to children’s needs and wishes. ATTACh did not specifically state rejection of the adjuvant treatments that had often been used with children  receiving holding therapy, but it was noticeable that Nancy Thomas, who had been a major participant in ATTACh conferences, appeared there less and less frequently.

In spite of the occasional criticism of her methods, Thomas, who is a charming and entertaining presenter, retained and continued to build her audience. Her presentations contained and still contain dramatic claims about the number of murdering children she has fostered and treated with such effect that 85% of them are completely cured of the “attachment disorders” she considers them to have. Her advice about treatment of childhood mental illness and behavioral problems continues to include limiting of food choices, confinement to a bedroom, the use of door alarms, and feeding of sweet foods with the intention of creating emotional attachment.

Certainly there is no evidence to suggest that such techniques are helpful for any form of childhood mental or behavioral disturbance, but we can ask in addition whether they are actually harmful and as deserving of rejection by professional organizations and legislators as holding therapy itself. To examine this issue, let’s look at the events surrounding the suspension of a psychologist’s license by the Oregon Board of Psychological Examiners (http://obpe.alcsoftware.com/files/miller.debra%20(kali)%20a.f._559.pdf). The Board gave an Order for Emergency Suspension of the license of Debra Miller, Ph.D., in March, 2014, on the grounds that her continued practice constituted a serious danger to the public health or safety.

In a PowerPoint presentation (www.ohsu.edu/xd/outreach/occyshn/training-education/upload/Reactive-Attachment-Disorder-Handouts-Miller.pdf), Miller made it clear that she supported what I can only call the worst of the worst of holding therapy proponents’ views, using infamously unreliable and unvalidated checklists for diagnostic purposes. And, although holding therapy itself was not mentioned in the pdf  cited in the previous paragraph, she did recommend to parents that they use adjuvant treatments of the type encouraged by Nancy Thomas. In the license suspension document, a description is given of the practices recommended by Miller for the father and stepmother of a 12-year-old boy who later attempted suicide by strangulation, and who when brought for medical care stated his distress over the treatments he had experienced. These included having to sit in his father’s lap while making eye contact and being fed milk from a bottle, crawling on the floor for 20 minutes each day, having to urinate into a jar in his room, being confined to a room with an alarm on the door, and being required to address his stepmother as “Queen”. As is typical of practices of the Nancy Thomas type, the boy was also required to do jumping jacks (these exercises are claimed to bring oxygen to the brain) and to practice “power sitting” or “strong sitting” in a specified position for periods of time. Other “neurodevelopmental exercises” involved somersaults and “log rolling”. The suicide attempt was preceded by a period during which the father was making the boy drink water and then try to urinate into a jar every 15 minutes.

In explaining this license suspension, the Board of Psychological Examiners referred to the statements of APSAC and other groups over a number of years, warning against inappropriate diagnosis or treatment of Reactive Attachment Disorder. In addition, the Board noted that the methods Miller recommended “may actually serve to increase emotional lability”. As they pointed out, “the techniques recommended by Licensee in this case (or taught by unlicensed practitioners that Licensee referred her clients to) created the potential for misinterpretation by the parents and a high risk for physical and psychological damage to the child that could have contributed to [his] feelings of hopelessness, which is a significant predictive factor for suicide.”

As far as can be seen, Miller did not carry out or recommend rebirthing or any version of holding therapy; she only recommended the adjuvant treatments associated with those techniques. Unless a child is harmed, as occurred in this case, it is highly unlikely that such treatments will ever be called to the attention of authorities--  and even if such attention were sought, the relevant authorities are usually not familiar with the practices, and it is doubtful that a serious investigation would occur. Practitioners who use or recommend the methods favored by Miller are usually quite safe from criticism, for these reasons, except in cases where a child’s distress and depression culminate in injury. In addition, these practitioners generally do not carry out the methods themselves, but leave the hands-on treatment to parents, making it difficult to establish the therapist’s responsibility. In the present case, a younger or less articulate child, or one with physical or mental challenges, might well have been unable to tell the story that led to the practitioner’s license suspension.  

It has been an important task over the last 15 years to convince the professions and the public that holding therapy is an inappropriate method of treatment for children (and indeed, not all professionals are yet convinced of this). But as the Oregon case shows, there is further work to be done. Psychotherapists who teach parents to use methods like limiting food or forcing drinking, or even like required bottle-feeding of older children, are very much in the wrong. They can cause direct harm to children and families, as we have just seen. They are almost sure to cause indirect harm by delaying effective treatment and by wasting family resources.

We need to see professional organizations publicly rejecting the adjuvant treatments that have been recommended by holding therapy proponents, and we need to see related education of state licensing boards, not all of which are as knowledgeable as the Oregon group.

ADDENDUM: Another case involving Miller can be seen at www.publications.ojd.state.or.us/docs/A119529.htm. In this case, there was a disagreement between a divorced couple when the father wanted to stop the therapy Miller was doing with his children. The nature of the therapy is not mentioned in this document, but would be interesting to know.



   

Tuesday, May 13, 2014

Eye Contact, Ear Contact, and Autism

Of all the topics I’ve ever dealt with on this blog, the one that has continued to attract the most attention is children’s eye contact. Hundreds of people daily read blog posts on this topic, and when I look at the questions that are asked and bring readers to this site, the great majority of them are about eye contact. People know that unusual use of the gaze is characteristic of autism and become concerned when a child does not look at the adult’s eyes in the way they might expect.  

Unfortunately, that justified concern is all too often coupled with unrealistic expectations about the development of eye movements and eye signals as part of communication. Some young parents become very anxious when a baby of a few weeks old does not readily gaze at someone’s face, or even when a nursing baby closes the eyes while sucking. It seems that people expect very young babies to use the eyes in almost the same way that adults do, rather than understanding that communication with the eyes--  and even vision itself—are not completely developed at birth. It seems to be forgotten, too, that human beings have communicative modes other than eye contact, and that failure to develop speech is an outstanding characteristic of autism.

It is not possible to diagnose autism from a baby’s use of gaze at a few months of age. but could it be possible to see the beginnings of other features of autism at that early stage? Babies don’t talk, of course, but might there be something about their sounds and their responses to others’ sounds that could predict development along atypical lines? A group of French investigators, Julie Brisson and her colleagues, looked at 13 babies who were later diagnosed as autistic (LDA) and 13 others who were typical in their development (TD). All the babies’ families had taken home movies that recorded the sounds made by the babies and their mothers in the first six months of life. (Of course they did not know at the time which babies would develop in which way; the investigators asked for the movies taken earlier, after the children had been diagnosed with or without autism.)

An interesting part of this study was the examination of the mothers’ speech to the babies, as well as of the babies’ own sounds. No matter what language a person speaks, he or she talks to babies differently than to adults. The type of speech used with babies is sometimes called “motherese”, but is also referred to as infant-directed talk (IDT) to differentiate it from adult-directed talk (ADT). IDT uses a higher pitch and more intonation or change in pitch, as well as repeating phrases or words more frequently than in ADT. Babies are typically very interested in IDT and will pay attention to someone speaking in that way, even though they will ignore the same person speaking ADT. It seems to be the case that adults are “taught” to use IDT to some extent by the responses they get from interested babies. If a baby was not interested in IDT (as might be the case for a baby developing along an autistic pathway), he or she might not reward an adult by attentiveness, so the adult might quite unconsciously not use IDT so much.

As babies develop through the first months of life, they are already beginning to change the sounds they make toward a more speech-like pattern. Because autistic children often speak late or have trouble developing speech in other ways, it’s possible that the LDA babies already showed unusual sound production patterns before they were six months old.

Brisson and her colleagues found that even in the first six months the sounds made by LDA babies were more monotonous and less complex in their sound patterns than those made by TD babies, although they were similar in pitch and duration. The mothers’ speech to the LDA babies used shorter utterances than speech to the TD babies, which might have been because when the babies failed to respond to talking, the mothers tried following up with a shorter message (like the baby’s name). But with little feedback or reinforcement of their efforts, the mothers may have become less likely to talk to the LDA babies.

Could we say, then, that the mothers somehow caused the infants’ autism by failing to talk to them enough? This is not likely to be an accurate conclusion, because there seems to have been a pre-existing characteristic of the baby that discouraged the mother from talking, or at least failed to encourage her as more typically happens. In either typical or autistic development, the development of communication is transactional--  each of the pair affects the other, and the way they do so changes over time. However (and this is my speculation, not Brisson’s), it’s an interesting question whether the LDA babies might have developed more typically if the mothers’ speech to them had been “artificially” increased by training, rather than by the usual rewarding baby responses. In a 2012 article in Science, Beaudet speculated about the possibility that the genetic factors in autism may make LDA babies need different nutrients than those appropriate for TD babies, and if they received an appropriate diet the LDA babies might develop more typically. Beaudet’s idea has not been supported by much evidence so far, but it is an intriguing one—and it does suggest the idea that there could be a parallel in terms of a “speech diet” designed for LDA babies.

Let me just emphasize that this discussion is by no means intended to blame mothers of autistic children. Transactional processes being what they are, a mother’s speech behavior is as much shaped by her baby’s responses as the baby’s sound production is shaped by the mother. It’s possible that LDA babies don’t have the ability to “teach” their mothers how to talk to them as TD babies do. Talking IDT is not something that’s easy to do voluntarily--  just for fun, try to talk to another adult or an older child as if you were talking to a baby. But if it turned out to be a good idea to help mothers of LDA babies do more of this (which we can’t really tell from this small study), we could certainly find ways to encourage them.

ADDENDUM: I forgot to give the citation for the Brisson article. It is Brisson, J. et al (2014). Acoustic analysis of oral productions of infants later diagnosed with autism and their mothers. Infant Mental Health Journal, 35, 285-295.


Why We Don't Need the Concept of Repression

People don’t remember their earliest experiences, right? Unless you’re a member of the Association for Pre- and Perinatal Psychology and health (APPPAH), you probably agree with Freud that there is a normal “infantile amnesia”. (If you belong to APPPAH, you may think babies remember their births and can tell you about them.) So why is there “amnesia” for the early years? Some have argued that unless we have the words to encode memories, we can’t later access them in verbal form, and since there is little language ability until after age two years, this would explain why we don’t remember those early experiences.

Other people claim that we cannot remember early experiences, even (or especially) dramatic ones, because we have repressed them. The idea of repression is that human beings have the capacity to defend themselves against anxiety by becoming unable to know or remember frightening events. Proponents of the repression concept usually also posit that repressed memories continue to exist in a way inaccessible to the conscious mind, and that they can have a variety of impacts on both mental and physical life.
J.F. Kihlstorm has summarized these beliefs as “the trauma-memory argument” (see http://socrates.berkeley.edu/~kihlstrm/Tsukuba05.htm). Here are the elements of Kihlstrom’s summary:

1. Traumatic experiences can cause the activation of mental defenses that result in amnesia for the stressful event.
2. Only explicit memory is affected, but there may remain implicit memories like “body memory”.
3. If there are “body memories”, this is evidence that there was a traumatic event.
4. The traumatic memory may be recovered in explicit form spontaneously, or as a result of guided imagery, hypnosis, or sedation with barbiturates.
5. It can be inferred that the recovered memory is correct if it seems to explain the person’s symptoms, or if he or she gets better after the memory is recovered.
6. Without recovering the memory, the person cannot cope with the traumatic event.

(Please note that this is Kihlstrom’s summary, not his own position.)

The trauma-memory argument and the concept of repression assume that all experiences are remembered, no matter when they occurred, and a failure to have an explicit memory is due to the activation of a mechanism that defends against trauma. Infantile amnesia presumably occurs because there are so many traumatic experiences young children undergo. (Of course, we get into some interesting side issues when we think about other forms of forgetting. Does my husband really forget to mail the letter because he found it so traumatic when I asked him to do it? Do students fail exams because they were traumatized by the material they were trying to study—or even found it linked mentally to some already-repressed memories? We do seem to need some other explanations of forgetting, in addition to--  or instead of--  repression.)

A recent study on memory has supplied a likely candidate for explanation of the forgetting of frightening or painful events. This candidate is a normal process, neurogenesis, the creation of new neurons. And while I am usually the first to query generalization from a study using mice to conclusions about humans, I do think there are interesting implications here.

Katherine Akers and her colleagues published in the May 9 issue of Science an article entitled “Hippocampal neurogenesis regulates forgetting during adulthood and infancy” (pp. 598-602). Neurogenesis occurs at a high rate during infancy, but it continues to occur in adulthood. Also, it can be speeded up or slowed down by drug treatment or by exercise like forced running in a wheel. Mice easily learn fear of a place when they receive electric shocks to the feet in that place, and they later show their learned fear by “freezing” rather than running around exploring when put back in that place. Adult mice remember their frightening experience over time and continue to “freeze” after as much as 28 days after the original learning. Infant mice, on the other hand, have already forgotten their experience and do not “freeze” a day later.

Akers and her co-authors showed that adult mice forgot their painful experience more quickly when they exercised—an event that leads to increased neurogenesis. And, drug treatments that slowed neurogenesis in infant mice also made them less likely to forget the experience, as they showed by being more likely to “freeze” in the situation where they had experienced shock. The investigators also compared their results with mice to a similar study using guinea pigs and degus, rodents that unlike mice are “precocial”, or capable of caring for themselves soon after birth, and that have a relatively slow rate of neurogenesis in infancy. These animals showed the same level of memory for a shock in infancy and in adulthood, but could be made more “forgetful” by forced running (again, this increases neurogenesis).

These results did not explain all events of memory or forgetting, but did explain events related to the hippocampus, which supports explicit, declarative memories.


The real difficulties in moving from this work to treatment of problem memories of trauma in human beings are obvious, and Akers and her colleagues certainly did not suggest in their article that PTSD patients should be given an exercise wheel to run in. However, their evidence clearly shows a mechanism for restructuring memories that leads to genuine forgetting and that does not require repression to make traumatic memories inaccessible; those memories cannot be accessed because they are actually no longer there. Many years of argument to the effect that memories are not repressed and recovered are now buttressed by systematic evidence about neural mechanisms that support forgetting of traumatic events.  

Saturday, May 3, 2014

Flattened Skulls: Helmets? Not Much Use; Tummy Time? Quite Helpful


Ever since the “Back to Sleep” program started 15 years or so ago, parents in the U.S. have been advised to put their babies to sleep on their backs--  a position that was said to be preventative of SIDS (see http://childmyths.blogspot.com/2012/04/causes-effects-statistics-and-sids-or.html). More and more (though not all) parents have been following this advice, but have not nearly as frequently been complying with the recommendation for plenty of “tummy time” or the motto of “back to sleep, tummy to play”. As a result, there have been considerable increases in the number of babies who have asymmetrical skulls, deformed by constant pressure in one area—perhaps 20% of infants now have this problem. If unresolved, the flattened head shape will lead to a continuing odd shape, often accompanied by unusually imbalanced positions for the ears. Even though every face has some lack of symmetry (why a double picture of the right side of your face looks rather different from a double picture of the left side), skull deformities can create an unusually asymmetrical face.

Some facts of bone development complicate this situation. Young infants have soft skull bones, whose bony plates have not knit together, and still have some open areas with no skull bones--  the well-known “soft spots”. These characteristics are essential in order for the baby to be born vaginally, as the head needs to be compressed and molded in order to pass through the narrow space formed by the mother’s pelvic bones. As time passes, the bones grow to completion, and pressure can no longer change their shape without breaking them. However, during the first year, the still-soft skull bones can be molded into different shapes when pressure is applied to them in the same way over long periods.

Pressure that changes bone shapes can occur when a baby sleeps in the same position most of the time. Babies who sleep prone (on the tummy) can move their heads to right or left from soon after birth, but babies who sleep supine (on the back) tend to have the head fall to one side under its own weight, and do not develop the muscular strength to move it from side to side for quite a few months. Tummy-sleepers thus do not have constant pressure in one area, but back-sleepers often do. As the skull bones harden, the back-sleepers’ head shapes may harden into the lack of symmetry that has been created by their sleeping positions.

For some years, it’s been thought that if a baby’s head was becoming deformed, the softness of the bones that caused the problem could also be called on to correct it. A specially-created helmet, worn most of the time between 6 and 12 months, could apply pressure on the parts that protruded too much, and leave space for the growth of those that were too flat. (This method had actually been pioneered by indigenous peoples of the Americas, who bound their babies’ heads to create the shapes they thought were beautiful.)

Helmet use was one of those things that “stood to reason”. But did it work? This question was recently investigated in a study reported in a British Medical Journal article (van Wijk, R.M., et al (2014). Helmet therapy in infants with positional skull deformation: Randomised controlled trial. Vol. 348, g2741). They found that the improvements in babies’ skull shape were about the same whether they were given helmets to correct moderate to severe deformations, or just left alone. The parents’ satisfaction with the babies’ appearance was about the same for the two groups. And refraining from treatment was a great deal cheaper and easier for everyone involved. (But it should be noted that none of the babies in this study had any complicating problems like tightness of neck muscles on one side, nor did they have very severe cases of skull deformation.) Incidentally, a New York Times article by Catherine Saint Louis (http://well.blogs.nytimes.com/2014/05/01/helmets-do-little-to-help-moderate-infant-skull-flattening-study-finds/?_php=true&_type=blogs&_r=0) noted reports from parents suggesting that three-quarters of the time, the helmets shifted or rotated on the head, thus failing to provide the specific pressure pattern they were designed for.

This looks as if helmets are not doing the intended job of correcting skull changes in infants. Perhaps a better approach is preventing such changes. How do parents do this but at the same time use the prone sleeping position that is recommended to them? Well, let’s go back to “tummy time”. Babies need to have early and frequent experiences of being in the prone position. When tummy sleeping was the pattern, it was usually suggested that babies be put prone to sleep as soon as the cord fell off, and that’s what I mean by “early” experience. “Frequent” means several times a day, for 10 minutes or more at a time.

Not only does this early and frequent experience of the prone position help prevent constant pressure on one part of the skull, it also enables the baby to develop muscles and motor skills that are much easier to use in the prone than in the supine position. The young baby’s physical characteristics, with its heavy head and legs drawn up under the belly, make it much easier to lift the head  in tummy position than to do the same thing when on the back. Head-lifting leads to getting the forearms up into pushing position and before long enables the baby to get first the head and then the whole chest up and have a good look around--  something that supine-lying babies will have to wait months before they can accomplish and enjoy. They can also see things and eventually reach for them. There are still-unexplored motor skills differences in early infancy for tummy- and back-lying babies, and all the “milestones” you see in the baby books were developed back when most babies slept prone.

The Times article presents some other suggestions for preventing skull flattening, like limiting the time spent in car seats. There’s also a suggestion for repositioning, or changing the side the baby’s head turns after they are asleep. There’s no mention, however, of an old-fashioned technique for this: because very young babies tend to turn their heads toward light, they can be alternated in the direction they lie when put into the crib, so that sometimes they turn left toward the light, other times right. This may keep them from developing a very strong preference for one head position rather than the other.

Let’s go back to tummy time for a minute. Quite a few parents of young babies forget about it for the first busy weeks of a baby’s life--  then they discover that the baby Does Not Like It. Babies learn quickly how things are “supposed to be” and tend to complain when we do something new to them. So, part of the solution here is to begin early. But if you have already waited too long, and baby objects, you need to try to make it comfortable and interesting for the baby. Try putting the baby on a soft pad on a table top, so you can sit in a chair with your face at baby level. Make sure there’s enough light for your face to be seen. Then make this play time as you talk in your high-pitched talking-to-baby voice and make whatever interesting faces usually get baby attention. Just putting the baby down somewhere with a toy or two or a wind-up music box will not do the job that a real live interactive person can do to persuade a back-sleeping baby that the tummy position is a lot of fun. If you make this time your play time, you and your baby can enjoy it together, while also preventing any serious problems with skull flattening.    




Thursday, May 1, 2014

HuffPo Spreads Garbage About Reactive Attachment Disorder

The Huffington Post has once again posted a story that is startling in its inaccuracy, but perhaps not surprising in its blatant appeal to sensationalism. Like many such stories, it is about BAD CHILDREN Who Might Kill You, and although it does not specifically say you’d better attack them first, such is the implication of the story. I refer to the description of Eric Kinzel’s family at http://www.huffingtonpost.com/2014/04/23/reactive-attachment-disorder_n_5199552.html, starring that darling of Focus on the Family and the Westminster dog show, Nancy Thomas.

The HuffPo story purports to tell about two adopted children, both of whom had been badly neglected and one of whom was afflicted with a “rare disorder” associated with the absence of emotional attachment, Reactive Attachment Disorder. Local practitioners identified the disorder and told the father that without treatment the child would become a psychopath. Nancy Thomas, a “therapeutic parenting specialist” (i.e., a foster parent) later stated that the disorder came from fear of abandonment and created “destructive instincts”. The child was eventually removed from the Kinzel family.

I want to note some claims made by participants in this program and comment on each of them.

  1. Reactive Attachment Disorder is easily diagnosed by means of a checklist. On the contrary, there is no validated method for diagnosing Reactive Attachment Disorder, particularly for children past toddlerhood. (Unusual social behaviors may combine with past history to suggest this diagnosis in children who have not yet developed more mature social skills.) The checklist referenced by Nancy Thomas in the HuffPo program is in fact derived from a much older list that was supposed to identify whether children masturbated (!). It is also associated with the Randolph Attachment Disorder Questionnaire, a paper-and-pencil test (to be answered by parents, not children) devised by one Elizabeth Randolph and never subjected to the serious validation work we demand of diagnostic instruments. The criteria mentioned by Thomas are highly subjective, by the way: that the child is “charming”, “has no conscience”, and does not make eye contact “except when lying”; a parent convinced by Thomas (who is remarkably charming herself) can easily see these characteristics in almost any child.
  2. Reactive Attachment Disorder is associated with psychopathy. The claim that children diagnosed with Reactive Attachment Disorder will grow up to be psychopaths/serial killers (as exemplified by Hitler and Ted Bundy) is a commonly made by proponents of the alternative psychological theory of attachment espoused by Thomas and others. This claim is simply PFA--  Pulled From the Air. Many serial killers are known to have been neglected or abused children, but the great majority of these unfortunate children do not become psychopaths. Even if all serial killers were known to have been neglected or abused--  and this is NOT known—it would be a fallacy to state that all such children become psychopaths. (And, by the way, I am not claiming that psychopaths and serial killers are the same thing; I’m just borrowing the language of Thomas and her friends.) Incidentally, reports from the English-Romanian Adoptees study show that children who might actually have been diagnosed with Reactive Attachment Disorder as preschoolers were in fact outgoing, sociable, and popular as adolescents.
  3. Reactive Attachment Disorder is present at birth. Kinzel reported being told that “when a pregnancy is not wanted, the woman’s body puts out different chemicals than in a wanted pregnancy. And even before the baby is born they can have RAD.” Certainly the stress of an unwanted pregnancy can cause hormonal differences, but so can any other form of severe stress; is the claim that all stressed pregnancies, including those where the father is deployed with the military or where another child is seriously ill, will cause Reactive Attachment Disorder? This is difficult to fathom (and am I the only person who is reminded of that statement about women’s bodies being able to prevent pregnancy if they’re raped?). In addition, all the established information about attachment shows that attachment of a baby to a parent is not present at the time of birth, but develops gradually and is demonstrated only in the second half of the first year. No attachment, no attachment disorder, this would suggest; therefore, no Reactive Attachment Disorder at birth. To claim that an unborn or newborn baby is aware of a mother’s rejection is essentially to range oneself on the side of the Scientologists and the primal therapists, not on the side of child development research.
  4. Reactive Attachment Disorder can occur because of events after the toddler period. Kinzel also says he was told “Usually a psychopath is damaged before 3. But RAD can be at any time.” There is no question that neglect, abuse, and unpredictable living conditions or custody can distress and disturb children of any age, and adults too, for that matter. Older children who are ill-treated will be angry and depressed and may well learn by imitation to be cruel to others. However, Reactive Attachment Disorder is a disturbance of a basic social behavior that involves a preference for the company of familiar people, especially in threatening or stressful conditions. This social behavior typically changes dramatically after the preschool years, as children learn social skills and advance cognitively so that they can tell real threats from “scary” ones. Even ill-treated children continue to develop in this way. The idea that Reactive Attachment Disorder suddenly “strikes” an older child is reminiscent of Jenny McCarthy’s claim that she saw her son’s soul leave his eyes when he was vaccinated.
  5. Reactive Attachment Disorder involves failure of cause-and-effect thinking. Now, this one is a pip. I have no idea where Thomas et al picked it up, but it sure sounds scienterrific, doesn’t it? I won’t even get into the fact that cause-and-effect thinking is present  even in babies a few months old and would be necessary for the learning of language, for play even at the peek-a-boo level, and for holding a bottle (but, of course, Thomas says not to let them hold their bottles, because they might not learn that parents are the only authority and source of satisfaction). What Thomas and the gang really mean, I think, is that children who are diagnosed as having Reactive Attachment Disorder by quasi-professional therapists are usually in the office to begin with because their parents haven’t managed to get them to be obedient or compliant. This situation is described by saying that they don’t connect bad behavior with punishment because they haven’t got you-know-what. But wait! These are the same children who are falsely charming and manipulative in order to get their own way--  so don’t they understand that being charming causes the effect they want? It seems they have cause-and-effect thinking and don’t have it at the same time, depending on what they’re doing and what the alternative therapist wants to explain. (But although she doesn’t say so publicly, I have to wonder whether Thomas thinks demons make them do it.)

It was a pity, really, to put Kinzel out in the limelight like this. He was either confused by the situation, or he can’t tell the difference between “conscious” and “conscience”--  though this may be the result of being talked at, at length, about his “psychopathic” adopted child. But of course the real point of this program was to advertise Thomas and her empire of therapeutic foster care and camps. I noticed no reference to the fact that a few weeks ago the American Psychological Association cancelled the continuing professional education credits that were supposed to be earned by attendance at one of Thomas’s lectures. (I have the e-mails to show this, so there’s no point coming after me with lawyers.) Some of us are watching the titans of the RAD biz, but whether we can fight their commercial power successfully, I don’t know. HuffPo is no help--  that I do know.