Concerned About Unconventional Mental Health Interventions?

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

Sunday, April 12, 2015

Stealing Words' Meanings for Fun and Profit: Floortime(TM) and Tummy Time


In the Alice books, Humpty Dumpty and Alice have an argument. H.D. says that as far as he is concerned “glory” means “a nice knock-down argument”. Alice counters that you can’t make words mean just what you want, but Humpty says he can, and refers to “Saturday night when they comes around to get their wages”.

For Humpty Dumpty, it was the words that profited by getting paid for expressing a meaning other than their own. But people whose mental health interventions are not characterized by a strong sense of professional ethics can and do profit from using familiar words and giving them new meanings. This is especially likely when the familiar words reference treatments or concepts that are generally respected—the “new meanings” benefit from the respect that actually belongs to the old meanings.

As I mentioned some time ago in this blog (http://childmyths.blogspot.com/2011/05/what-is-floortime-well-folks-it-isnt.html), Ronald Federici and Heather Forbes borrowed the term “floortime” and applied it to their practice of physically restraining a child on the floor for supposed therapeutic reasons. As some parents and mental health professionals already know, Floortime™ has a specific meaning and indeed has been trademarked by its originators. Floortime™ is a method used by practitioners trained in DIR™ (Developmental, Individual-difference, Relationship-based treatment). Practitioners who use Floortime™ do play and interact with children on the floor, but their methods involve following the child’s lead and encouraging verbal and nonverbal communication through play. Really, no two things could be much farther apart in meaning than the respectful, empathic, interactive methods used by DIR™ professionals and the intrusive, authoritarian, coercive techniques used by Federici and his few followers. What was the point of calling the coercive methods “floortime” when this word had already been used for many years by DIR™ practitioners? Was it simply ignorance, or was it an attempt to get under the more popular umbrella of DIR™ by adopting what was essentially a stolen word? Profit, or just fun? I can’t explain it myself, but it worries me greatly to see meanings muddled in a way that advantages the muddlers.

More recently, I came across the theft of the term “tummy time”. Now, this is an expression that has been well-known to millions of parents over the last ten years, the period when infants in the U.S. have been supposed to be put to sleep in the supine position, and when developmentalists had figured out that supine-sleeping babies were not achieving motor milestones as the old standards said they should. Tummy time, a period of prone positioning for play or at least non-sleep activities, was advised as a daily experience that would foster motor development. A large number of young parents during this period have not done tummy time, because the babies don’t like it right away, but this is not the point; they have heard about tummy time and how you are supposed to do it to encourage your baby’s development.

But--  along come some other people and steal “tummy time” for their own meaning and purposes. I encountered this first in reading about the case of Kali Miller (http://obpe.alcsoftware.com/files/miller.debra%20(kali)%20a.f._559.pdf), the Oregon psychologist whose professional license was revoked because her recommendation of Nancy Thomas parenting methods was followed by the suicide attempt of a 12-year-old boy who was the target of the intervention. Miller apparently used the term “tummy time” to mean having the child crawl on hands and knees—an activity inappropriate for a 12-year-old, and without the slightest known developmental benefit for anyone whose motor development had been typical until that age.

Searching for other uses of the stolen phrase, I came across this: www.bestpractices4teaching.blogspot.com/2013/03/tummy-time-for-10-year-olds.html. This blogger states,”[I] sometimes wonder if ‘tummy time’ would work for a 10 year old”. She then refers to an article given to her by her (or, her children’s?) occupational therapist-- https://mysweetchaos.wordpress.com/2010/01/24/neurodevelopmental-reorganization/. Here we find a mother of children she speaks of as “RADishes” (I haven’t come across that one for a while). And mysweetchaos provides a post jam-packed with misinformation--  not only misinformation, but misinformation with a strong tang of Attachment Therapy beliefs about it.

I hardly know where to begin here. Mysweetchaos has provided what Barbara Pym would have called “such richness”. Starting at the top: “When a baby is on their tummy and they turn their heads from left to right to left to right and so on, this is developing their brain for reading. READING! [caps sic] When a baby moves their head up and down, they are developing their brain for math. MATH! Makes sense when we read left to right and solve equations top to bottom.” What to say about this farrago of nonsense? (I always think a farrago should be a kind of porridge, but that would work here too.) Let’s start with the simple fact that a large part of the world’s population does not read left to right. As Lerner and Loewe wrote, “the Hebrews speak it backward, which is positively frightening”, though perhaps not as frightening as mysweetchaos’s assumption that she knows what she’s talking about. Then, let’s look at the idea that “equations” go from top to bottom. Yes, children are taught to do arithmetic in columns, because that enables them to line up ones, tens, hundreds, etc. in ways that would be more difficult if the numbers were placed horizontally. But the equation, the actual arrangement that takes into account the principle of equality, can be horizontal, vertical, or diagonal. What’s more, if anyone understands equality, they know that it does not make the slightest difference whether you start on the left or on the right.

Skipping a bit, let’s go down to where mysweetchaos’s source tells her that many familiar problems (cf. “attachment disorder” checklists), like lack of empathy, overeating, poor appetite, and picking at scabs and other people, being superficially charming, etc., are due to “pons dysfunction”. The pons is a part of the brainstem that has multiple functions, including carrying messages from higher to lower areas and contributing to sleep, breathing, and bladder control. According to mysweetchaos, the developing functions of the pons have to be guided by  appropriate movement experiences, and if they were not guided, they will not develop. However, re-enacting those experiences, including crawling, patterning (honest, she says this), and vestibular movements (there are some movements caused by vestibular stimulation, but I don’t know exactly what she means) can recapitulate development and rebuild the pons. Ergo, children will develop empathy and stop being superficially charming if made to crawl around, and this is a part of “tummy time” (presumably, as recommended by pediatricians all over the U.S.). Of course, this whole discussion omits to mention children who never crawled because of paralysis or atrophied limbs, but are well-developed intellectually and emotionally, and children of previous generations who slept prone and did plenty of crawling, but who still had some cases of lack of empathy and superficial charm.

Where did mysweetchaos get all this stuff? Yes, I’m sorry to say, it appears that we have to look to her occupational therapist as her source. I don’t want to attack the whole OT profession, because I appreciate very much the ways they do things like check out people to see whether they’re competent to drive, and teach premature babies to nipple-feed. But I am tired of waiting for some OT to get up on her (usually) hind legs and state that Sensory Integration theory has never been supported by systematic evidence, or that recapitulation of development by re-enactment of early experiences is simply primitive magical thinking. I think it’s probably true that the person who connected the pons with superficial charm was probably a rogue practitioner—although not the only one around. Nevertheless, ideas apparently supported by the whole OT profession are behind these extravagant claims and the continuing commitment to patterning three decades after it was summarily rejected by physicians and psychologists.

And to call these methods “tummy time”, using the familiar words as if pediatricians recommended making older kids crawl! Is this for fun or profit?  Is it ignorance, or just the  old human urge to benefit from others’ ignorance? I don’t know, but I for one find it “positively frightening.”
  



Wednesday, April 1, 2015

"Taming Tiny Tigers", by Kali Miller: A Tale Told With Trepidation

Let me note first that the trepidation I’m talking about is my own, as Kali Miller does not seem to experience any. And my trepidation is about two things--  first, whether by discussing this at all I’m simply offering some unintentional paid advertisement for a disturbing attempt at intervention, and second, how well I can untangle the ideas so well braided in a document that mingles established concepts with fantasy.

The document I’m referring to is called “Taming Tiny Tigers”, by Debra “Kali” Miller, whose psychology license revocation I described in a post a few days ago. As I noted at that time, Miller is becoming a parenting coach now that her license has been revoked for her role in the treatment that culminated in a 12-year-old’s suicide attempt. As a coach, she will still be in a position to use the advice she has given in “Taming Tiny Tigers” (http://c.ymcdn.com/sites/opa.site-ym.com/resource/resmgr/imported/E1%20Handout.pdf).

“Taming Tiny Tigers” is an excellent example of the Trojan Horse approach that brings unsubstantiated ideas into discussion under the cover of established information. For example, Miller provides some accurate (though not particularly relevant) material about brain development. She also quotes directly the diagnostic criteria for Reactive Attachment Disorder from DSM-IV; these have changed, of course, but what she uses was correct at the time “Taming Tiny Tigers” was written. She references the much-respected Dante Cicchetti in the documents bibliography. She also points out that physical and emotional abuse are not good for kids. All good stuff, right? She must know a lot about early emotional development and later mental illness--  or so you would think until you see what else is in there.

Now let’s look at what’s inside this handsome Trojan Horse (we’ll see that much of it is similar to something that’s inside real horses). I’ll just begin at the beginning and go on until I can’t stand it any more.

The first problem that comes into view is on pp. 3-4: the good old first-  and second-year bonding cycles. Once again, I will point out that these have no parallel in conventional, evidence-based views of the development of attachment. Naturally, if a baby is not fed or cared for regularly, both physical and mental development will suffer, but attachment develops as a result of pleasant social interactions with a caregiver, not because that caregiver feeds the baby. In real life, of course, chances will be great that a lot of pleasant interaction is mingled with feeding and other care routines, but it’s the interaction and not the care that brings about attachment (which, by the way, is a very robust phenomenon, and does not often fail to happen if a few adults regularly care for a baby). The “second-year attachment cycle” focuses on rage and capitulation as contributing to some unstated aspect of attachment, whereas established information focuses on sensitive, responsive parenting that helps the child tolerate the inevitable frustrations of  this period of development. A large but unstated difference between the “attachment cycle” approach and conventional thinking about early emotional development is that the “cyclists” equate toddler attachment with obedience and compliance, whereas conventional thinking focuses on attachment as a function that helps young children explore and learn. I’ve gone into some detail about this at http://thestudyofnonsense.blogspot.com/2012/08/parsing-attachment-cycle-fox-terrier-of.html.

Let’s move on to p. 7 of “Taming Tiny Tigers”, where we’re given symptoms that are supposed to let us know that a child has Reactive Attachment Disorder by looking at events that may occur before six months of age. Here we have an interesting hint that what is being talked about here is not attachment in the conventional sense at all, but something else (undefined).  It is quite remarkable to claim that a child’s recognition or nonrecognition of the mother in the first six months tells something about Reactive Attachment Disorder, as attachment is not indicated behaviorally until after that age. Be that as it may, the symptoms Miller lists are serious problems indeed, including withdrawal, difficulty with touch, poor muscle tone, delayed motor development, and decreased vocalization. Any baby showing these symptoms does need early intervention for both physical and cognitive problems, there is no question about that . However, what they do NOT need is treatment for Reactive Attachment Disorder, especially the types of treatment Miller recommends later in the document. To tell parents of developmentally delayed toddlers or preschoolers that these early symptoms showed that they had Reactive Attachment Disorder all along is in my opinion little, if at all, short of criminal.

Slogging onward, we come to pp. 11-13. Having listed the DSM-IV criteria for diagnosis of Reactive Attachment Disorder, Miller now turns right around and introduces the infamous checklists of Walter Buenning and Gregory Keck. These completely unvalidated lists include such items as poor eye contact, wanting to hold own bottle, and preferring Dad to Mom as indicating Reactive Attachment Disorder in infants and toddlers, and for older children list the usual Attachment Therapy-related group, such as being superficially charming, not making eye contact on parental terms, “crazy lying”, and abnormal speech patterns. These lists contain a number of items like lack of impulse control that are indeed of concern, but are not aspects of  attachment problems and are not likely to be treatable by the interventions Miller offers.

What are the interventions Miller recommends? On p. 15, she suggests “brain building activities” as suggested by Bruce Perry, and of course by Nancy Thomas. In typical Nancy Thomas fashion, the list of these activities is headed by the injunction that they must be led by the adult, not the child; this injunction reflects the belief that  displays of parental authority create attachment, and that a child’s obedience shows that he is attached to an adult. The activities include many that would ordinarily probably be fun for children, ping-pong, playing catch, and jumping on a trampoline. However, when these are to be done as recommended, five or six times each day, for ten minutes at a time, at the command of an adult caregiver, the “fun” aspects seem to be a good deal lessened.

To continue with the recommendations for intervention, we see on p. 14 of “Taming Tiny Tigers” a page that is startling in its simplicity. Without elaboration, and under the heading of “Therapeutic Continuum”, this page shows a line with the words “non-directive play therapy” at the left and “holding therapy” at the right. What can Miller mean? What is she recommending? She doesn’t come right out and tell, but a look at the bibliography shows publications by the heavy-duty masters of the intrusive and potentially dangerous holding therapy, Foster Cline and Martha Welch, and by Ronald Federici, who advises restraining adopted children in the dangerous prone position. And of course, it shows many publications by Nancy Thomas, the woman who recommends that foster children not be permitted to say grace at meals, “because you don’t know who they might be praying to.”

All in all, “Taming Tiny Tigers” is a pretty disconcerting package, but Miller doesn’t have to conform to any rules to be a parenting coach. What’s more, the First Amendment permits her to pass out all this disinformation. Fortunately, it also permits me and others to have our say about Miller and her “Tigers”.