Concerned About Unconventional Mental Health Interventions?

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

Tuesday, December 22, 2015

Diagnosing Reactive Attachment Disorder: Don't Try This at Home


Rather regularly, I get blog comments, e-mails, and even phone calls from mothers who have read about RAD on the Internet and know that this is exactly what their children have. It doesn’t matter that much of the on-line information is not actually descriptive of Reactive Attachment Disorder; many of these parents are positive that they know what’s wrong, and all they need is to find someone who specializes in attachment disorders to treat the children and get rid of the disorders. Can I suggest a suitable person, they ask, because they are having trouble finding such a specialized therapist.

No, I can’t, and here’s why.

1.     1.  Unless you are looking at DSM-5, you will probably not find on the Internet much that actually describes Reactive Attachment Disorder. Most of the material that purports to do this focuses on disobedience, surliness, aggression, theft, and cruelty to others. These are all serious matters, and a family with a child or children presenting these  problems is certainly in need of good professional help. However, the behaviors are symptoms belonging to a range of other diagnoses, and not to RAD. Note: it’s possible that the children have attachment disorders in addition to these other problems, but the attachment disorders are not the cause of the very concerning behaviors, and “fixing” the attachment problems does not “fix” the antisocial behaviors.

2.    2.  Well-trained clinical psychologists may have most experience and interest in working with one problem area, but they are competent to deal with the full range of childhood mental health issues. Such a professional begins the process of diagnosis by considering all the difficulties that may be behind disturbed moods and behaviors. He or she will pay attention to the child’s cognitive and language development and to areas where the child is behind, up to, or beyond what would be expected at this age. The psychologist needs to be open to consideration of a full range of problems that may be present. To make best use of this professional help, parents need to bring in the best information they can about how the child seems to feel and to act in specific circumstances, and they too need to keep open minds about the causes of problems rather than trying to “cut to the chase” by insisting on one diagnosis or demanding that a therapist focus on a problem as the parent sees it.

3.      3. When children show disturbed relationships with others, and especially when there is antisocial behavior involved, parents need to realize that the child lives and acts within a network of family and other social connections. One possibility behind disturbed behavior is that events or actions of others in the family are making it difficult for the child to reach his best levels of thinking and behavior. These factors can range from marital tension and disagreement to sibling conflict and school pressures to inappropriate disciplinary methods. A therapist who addresses such problems is not assigning blame or pointing to anyone’s guilt, but is dealing with the fact that a child’s mental health problem is bound to be, in one way or the other, a problem of the whole family. Working with the child means working with the family, little as most stressed-out parents care for this idea. These facts also mean that the most accurate diagnosis of a child’s problems is only the beginning of the discussion.

4.      4. The assumption that many, even most, child problems are derived from attachment difficulties distracts parents from seeing the whole child, and unfortunately it can also distract some professionals in the same way.  A 2013 paper by the British psychologists Matt Woolgar and Steve Scott outlined a number of cases in which psychological staff focused on children’s attachment  issues to such an extent that they failed to notice  serious problems that were unrelated to attachment. When parents go out of their way to find professionals who state a specialty of working with attachment issues, and who also are willing to accept a parent’s statement that a child’s problem is Reactive Attachment Disorder, chances of  inappropriate exclusive concern with attachment are much increased.

When a child shows serious mood problems or frightening antisocial behavior, it’s a mistake to jump to the conclusion that Reactive Attachment Disorder is the problem. In fact, it’s a mistake to jump to any conclusions, or even to reach them without a thorough evaluation of the child and the family. Please don’t depend on a diagnosis you reached at home with the help of friends or the Internet, or search for a therapist who will concentrate on a narrow set of problems as instructed.  Look for a professional with thorough training in clinical work with children and adolescents and let that person make the complete assessment that is needed before a therapeutic plan can be created.

   

Sunday, December 20, 2015

The Jackson Abuse Case: Religious Beliefs, Old-Fashioned Punishment, Nancy Thomas, or Mrs. Great Santini?

A former Army major, John Jackson, and his wife, Carolyn, were recently sentenced for child endangerment because of the injuries they caused to children in their care (whether these children were being fostered or had been adopted is not clear—media reports run about half and half). [CORRECTION: According to the indictment, available on line, one child had been adopted and the other two were in foster care.] In “disciplining” the then-toddler  or preschool-age children. who were already developmentally delayed, the Jacksons employed hot-saucing, feeding of hot pepper flakes, forced feeding of salt, and withholding of food and water for offenses like walking or eating too slowly or putting fingers into the mouth. There were broken bones, too, including a fractured spine. Further descriptions are at www.northjersey.com/news/prosecutor-army-major-wife-abused-adopted-kids.1.1111774  ; www.nydailynews.com/news/crime/ex-army-major-wife-convicted-abusing-3-n-foster-kids-article-1.2286026 ; www.nj.com/news/index.ssf/2015/former_army_major_wife_sentenced_for_torture_of_th.html .

John Jackson was given a sentence of probation and a fine, while Carolyn Jackson was sent to prison for two years. Rather ironically, it seems to me, it was argued that Major Jackson should not be taken away from his children! One of the couple’s biological children testified about the mistreatment of the foster/adoptive children, so one must wonder about the advantage to him of having his father left available to him.

Prosecutors had asked for a sentence of 15 to 19 years because of the intensity and duration of the abuse. The judge, Katharine Hayden, cited John Jackson’s military record as a reason for giving him probation only—a decision whose implications for punishment of other abusive military people are limited only by one’s imagination. Hayden did agree that Carolyn Jackson had endangered the children’s welfare, and indeed breaking someone’s spine or inducing hypernatremia can scarcely be argued to be in their best interests, even by defense lawyers.

According to the Philadelphia Inquirer, ”Defense attorneys argued during the trial that the Jacksons’ child-rearing methods might have been objectionable but they didn’t constitute crimes, and that the foster children had preexisting health problems.” Granted that desperate lawyers seek desperate arguments, this one nevertheless seems to be not just one but several pips. First, hot-saucing and forced feeding of salt certainly would be crimes if they were committed against adults. Second, let’s look at other forms of corporal punishment. Although spanking of children remains legal, the cut-off point for its legitimacy is usually considered to be the point where its intensity or duration leave physical evidence in the form of bruises or other injuries; when this occurs, this form of punishment becomes abuse. The parallel for other methods of physical discipline would reasonably be that a method that causes visible physical harm, like blistering from hot sauce or hypernatremia from forced salt ingestion, rises (or sinks) to the level of abuse and is far beyond being merely “objectionable”. I believe this argument is an adequate counter to the claim that the Jacksons’ actions did not constitute crimes.

Now, let’s look at the second part of the defense attorneys’ argument: the foster children had preexisting health problems. Now we are definitely in an upside-down moral universe! “The children were in poor health and developmentally delayed; therefore it was permissible—perhaps even advisable?—to brutalize them. This would teach them not to be so sick and motivate them to speed up their development.” Outrageous to state this baldly, of course, but is this not the implication of the defense argument? In fact, in reality, the children’s health and developmental problems made them especially vulnerable to the impact of abuse, and according to their present foster mother, they continue to bear the emotional scars of their time in the Jackson household.

Why did the Jacksons treat the children as they did? Evidently, they offered their biological children the explanation that it was necessary to discipline the foster children in these ways. The parents did not use the same methods with the biological children, although Carolyn Jackson apparently gave a thorough belting to her son when she discovered that he had told a family friend how the foster children were treated. Did the Jacksons believe that the methods they were using were actually a form of intervention, a “treatment” that would help the foster children get onto an improved developmental trajectory? It’s possible that they did think this; they may have been using a version of the Nancy Thomas treatment in which food and water are withheld to motivate children to comply with parental demands, or they may have believed that the children were possessed by demons and that the demons could be expelled by discomfort, allowing the children to return to normal health and development.

It’s also possible that what we see in the Jackson case is simply the perpetuation of the “good, old-fashioned” view of physical punishment as the cure for all childhood behavior problems, and the assumption that whatever punishments were familiar in one’s own early life are the best way to guide children today. This view is sometimes associated with the belief that following one’s parents’ child-rearing ways shows respect for the parents, and failing to do so shows disrespect. In families and subcultures where lack of respect for parents has a strong religious implication of disrespect for divine authority, this can be a powerful factor. There are many unanswered questions about the role of religious belief (including assumptions about demon possession) in this case, but religious positions have played such important roles in other child abuse cases that I think it is a mistake to ignore this as we try to understand what happened here.

Finally, with all due respect to the thousands of well-functioning military families, it would be absurd to ignore the part played here by authoritarian attitudes that punish deliberate and inadvertent disobedience equally. John Jackson has been administratively separated from the Army and I cannot find whether he is actually discharged, either honorably or otherwise. His military record has saved him from imprisonment in the civilian world, but there may be a limit to what even the military can tolerate, especially because this matter became public knowledge and makes the military look bad, which officers are not supposed to do—in church terms, it’s like causing scandal in the congregation.  

Many questions remain unanswered about the Jackson case. I hope further investigation will occur and be made public. The U.S attorney is apparently considering an appeal… and there remains a question about why the Jacksons were never charged with the death of one of the children. Another desirable investigation would look into the conduct of caseworkers responsible for monitoring the foster children.




Saturday, December 19, 2015

How Babies Remember: A Tribute to Carolyn Rovee-Collier

Because babies can’t speak to tell us what they know, and because they don’t know how to encode whatever they have learned into language when they begin to talk, all kinds of peculiar claims have been made about their knowledge and memory of their experiences. these range from the idea that babies remember their prenatal lives right back to conception, to the belief that they remember being born and can articulate these memories later, to the assumption that they remember nothing at all even at age 2  years “because they’re too young to notice”.  It’s been pretty rare for people to figure out ways to investigate how babies learn and how their memories work.

One of the few people to create a method for looking at infant memory was Carolyn Rovee-Collier, whose death in 2014 was a great loss to the field of developmental psychology. Rovee-Collier’s work was an excellent example of something I’ve always thought to be true—that in order  to have real insights into ways to study babies, one has to have spent a whole lot of time with them. (No doubt what I am about to say will offend some readers, but I think this is a bit like what Daniel Lehrman and other comparative psychologists used to say about the study of animal behavior.) There’s a sort of total immersion that occurs when you are paying most of your attention to a baby for a long period of time. You begin to see things that were invisible to you before, just as an experienced dancer sees things in a dance performance that even the most enthusiastic non-dancer will miss.

Not all parents observe carefully, but Carolyn Rovee-Collier did while one of her children was an infant. She noticed that when her baby had discovered that by kicking his feet he could make a mobile swing, he kicked again when put back into the same setting, even though things had changed so he could not make the mobile move. At a few months of age, he had learned and remembered something he could do to make an interesting event happen.

Later on, Rovee-Collier systematically investigated the circumstances of learning and forgetting for infants of different ages. Her method—originally used to entertain her baby so Mom could get some work done!—was formalized under the name “mobile conjugate reinforcement paradigm”. The baby is put in a crib with a colorful print crib liner, a mobile is provided, and a ribbon is tied to the baby’s ankle and to the mobile so kicking will make the mobile move. (Do I need to say that babies are not left alone with the ribbon tied? This could be quite dangerous, so don’t try it at home unless you are staying nearby!) Whether the baby learns is measured by the increase in kicking; whether he or she forgets is measured by noting how long it takes for kicking to resume when the baby sees the print crib liner again. The baby learns not just that an action causes interesting results, but that the action works in certain circumstances and not in others, just like the “time, manner, place” learning that makes up so much of what we try to teach small children.

Just as you might expect if you didn’t think babies could remember their own births, younger babies learn more slowly and forget more quickly than older ones. Two-month-olds take 7 to 9 minutes to learn to make the mobile move, and forget  how it works in two days. Three-month-olds learn in 4 to 6 minutes and remember for 6 or 7 days. Six-month-olds learn the trick in 1 to 3 minutes and remember for 15 or 16 days, and after about 9 months the memory lasts for many weeks.

Now, here is the interesting thing that shows how the mobile conjugate reinforcement paradigm is relevant to ordinary real life learning. Babies remember longer when their memories are “reactivated” by letting them see (just see, not make the mobile move) either the mobile or the print crib liner at some time before they are tested. The timing of the reminder is critical, and it seems that some time must pass before the memory is affected by the repeated experience. For three-month-olds, at least 8 hours must pass before the memory is reactivated as shown by kicking in response to the crib and mobile, and it takes 3 days for the maximum effect of the reminder. A three-month-old who gets two memory reactivations (reminders) will remember what was learned for twice as long as the first learning lasted. By age 6 months, only an hour need pass before the reactivation effect is seen, and it takes only 4 hours to reach the peak effect.

The take-away message from Rovee-Collier’s work is that younger babies do learn, but they learn slowly and forget quickly unless they are reminded, not by having exactly the same experience as before, but by seeing the setting in which they learned. Even with a couple of reminders, three-month-olds remember the event for only two weeks. This suggests that a single experience in infancy is not likely to be remembered long, and that early learning that lasts will be likely to involve the many repetitions of familiar daily caregiving routines in familiar places. Only after about 9 months do we see quicker and longer-lasting learning. Another implication, and an important one, is that babies are motivated to learn not so much by gratification of physical or even emotional needs, but by the need to experience mastery over the environment and to make interesting things happen.  


It’s good to keep these things in mind when confronted by claims of prenatal and birth memories and their lifetime influences.

Tuesday, December 8, 2015

Worrying About Autism? Some Information

Two posts on this blog draw the most reads and comments week after week: these are http://childmyths.blogspot.com/2011/07/eye-contact-with-babies-what-when-why.html and http://childmyths.blogspot.com/2013/11/infants-autismand-eye-contact.html. Both of these posts have to do with infants’ eye contact with their caregivers, and by extension with symptoms of autism—readers who write comments and queries are almost always worried about autism, not about the visual impairment that might also underlie problems with eye contact. Recently, there have also been concerns about odd movements like hand-flapping that may be associated with autism, and some readers have been worried about whether some hand movements might indicate Rett syndrome.

For worried parents, one of the real problems is that they don’t actually know what “autistic movements” look like. Another is that infants are individuals who often don’t conform to averages of development that parents read in “the books” of norms for developmental milestones; they reach some milestones earlier than the average, then turn around and act a bit delayed on others. In addition, neither autistic or typically-developing children are “all autistic” or “all typical”, and their behaviors overlap quite a bit, especially during the toddler and early preschool periods. A fourth, and very real, problem is that it’s still not understood how autism can be predicted accurately for children who are still under a year old--  but this is exactly the age period when parents are most likely to start agonizing and watching for those “red flags”.

Here is a very fine video that shows behavioral differences between typically-developing toddlers and same-age children who are later diagnosed as autistic:


When you watch this, please notice that all the children are over 12 months of age. Don’t try to generalize from this information to younger infants. One of the features of autism is developmental delay, so an autistic child may act in some ways much like a younger child--  it’s important to realize that this cannot be reversed to mean that the younger child must also be autistic, or to assume that developmentally appropriate behaviors of the infant are signs of autism.

The first concept covered in the Kennedy Krieger video is the child’s ability to use play in ways that include other people, not necessarily as a formal “game”, but as part of a social interaction like pretending to eat or to feed another person. The typically-developing child in the video offers a “bite” to an observer and takes a “bite” himself. This ability develops after about a year of age, and its absence in a younger infant would be no reason for concern. He also follows what an adult does, imitating in a meaningful rather than a mechanical way. The same-age child who is showing signs of autism does none of those things, and he does not respond to his name, which is unusual at this age (though it would happen much more frequently with children some months younger). Although he acts as if he likes to be tickled by his mother, he doesn’t respond socially.

The second point is the making of social connections by typically-developing children, by looking at people and responding to gestures. The little boy in the video even makes an effort to turn and look at his mother, and he looks at an item pointed at by an adult, continuing the “conversation” by pointing at it again later. Another boy of the same age shows symptoms of autism by flapping his hands in excitement, but without looking at the adult; a typically-developing child may also flap his hands, but he looks at adults while he does so and seems to use the gesture as communication. The autistic child does not look at an object an adult points at, but instead looks at the adult’s finger (as a much younger infant might do).

The third important point in the Kennedy Krieger video is the typically-developing child’s capacity to carry out and enjoy social communication. The child in the video is fascinated by a moving toy, but frequently looks at adults and then back at the toy, while smiling. When the toy stops moving, she wordlessly communicates to the adult that she needs help to start it again. An autistic child of the same age watches the toy carefully, but does not smile at adults or look at them to create social communication. He does not respond to a gesture by which an adult asks to have the toy. His mouth and torso become tense and stiff as he handles the toy.

Watching this video may give you some hints about differences in behavior between typically-developing and less typical children, but remember, these differences do not apply to children under a year of age. There may be differences at earlier ages, but they are not yet well understood. In addition, remember that typically-developing preschool children sometimes do “autistic” things, and autistic children sometimes do “typical” things. It’s the general pattern of behavior that is of importance. Finally, keep in mind that even the children who are diagnosed as on the autistic spectrum as toddlers and preschoolers may well look much more typical as time goes on.





Wednesday, December 2, 2015

Social Workers Gallop Off in All Directions

I recently came across a document that stated that the National Association of Social Workers has endorsed “equine-assisted therapy” (EAT) for mental health problems. “Wha-a--?”, I said, and began to look up whether there had been such an endorsement. Now, this can be hard to do; I know NASW sometimes passes resolutions at their annual conference, and these can be hard to locate later for those of us who are out of the social work loop (e.g., the resolution against Holding Therapy some years ago). I didn’t find a resolution about EAT, but I did find that NASW had given continuing education credits for a class on this topic (naswct.org/wp-content/uploads/2015/04/NASW-Conference-2015-Brochure.pdf).

Horseback riding has been used therapeutically for many years for children with cerebral palsy and other neurological disorders that contract muscles and distort the structure and function of the limbs. Riding provides a warm and gentle stretch for leg muscles and is so enjoyable that children are distracted  from any discomfort. But, of course, this does not mean that people with other kinds of disabilities--  people who don’t need their muscles stretched—will also benefit from horseback riding. (Similarly, prescription eyeglasses that correct visual disabilities don’t help hearing impairments.)

For some time now, there has been a strong tendency to equate mental illnesses with “brain disorders”. Certainly it’s true that at some level every mental illness has a foundation in brain function and even structure, but this does not mean that it makes sense to force all mental illnesses and all results of brain injury or atypical development unto the same category. I understand the motivation to do this forced combination—everyone knows the results of an injury are not the victim’s fault, and some people still think that the mentally ill could stop being sick if they really tried, so presenting mental illness as equivalent to brain damage supports the important argument that the mentally ill should not be stigmatized.

The two things are not really exactly the same, though, and their treatments cannot be identical. Brain disorders like CP can have powerful effects on the body  and affect children’s behavior and development by damaging physical growth and abilities. Horseback riding helps corrects muscle and bone development and use; it does not cure the brain damage that caused the problems of physical development. It won’t cure any posited brain disorders that may lie behind mental illness, either.

Horseback riding, and learning to handle and care for horses, can be great fun for kids, and shared enjoyable activities are an important key to social skills, sharing, taking turns, and understanding other people. Sharing such activities with a social worker or other helping person can improve interactions and help establish a strong relationship.

But these points are a far cry from evidence that EAT in itself is an effective treatment for autism, ADHD, or other disturbances of children’s mental life. There is very little evidence to that effect.  In a recent review, Kendall et al (2014; Explore, 10(2), 81-87) described EAT as under-researched and largely anecdotal in its support. Even though there are randomized designs used in some studies of EAT, they generally fall down by having a treatment group who have elaborate social, interactive, and riding experiences, but are compared with another group who are given no new experiences at all. This failure to isolate the horseback-riding variable means that no one can know whether apparent benefits came from increased social experience, from interactions with social workers or other helpers, or from riding itself.  

In addition to the lack of empirical evidence supporting EAT as a therapy for children with developmental delays or other mental problems, there has been a strong tendency for advocates of EAT to make exaggerated, even ludicrous, arguments for the treatment. I discussed some of these  several years ago at http://childmyths.blogspot.com/2011/02/clever-hans-rides-again-equestrian.html. I was responding to claims that  horses know when a child is lying (they don’t care for this, it seems), and that a horse’s gait is “downloaded” into a child’s brain, thus apparently doing an end run around all the problems that have been blamed (wrongly) on a lack of crawling experience.  These both summon entertaining images--  a deeply disapproving horse shaking its head at a fibbing child (but why lie to a horse?), and the probable human gait that would be based on a “downloaded” horse pattern. (This last makes me think of playing horses as a little girl and being both horse and rider simultaneously.)

Perhaps NASW feels that interest in EAT by social workers can lead to some serious research about the treatment’s effectiveness, and that is possible, even though much about the treatment is implausible. Nevertheless, it would be wise to limit shows of approval like continuing education credits until better evidence is presented. It would also be a good idea to draw the line clearly between the “downloading” faction and the work of those who are interested in the actual possibilities of this proposed treatment modality.


Parental Alienation Advocates Cite-- WHO?

Like advocates of other ideas, proponents of the idea of parental alienation (PA) like to list their intellectual ancestry and show how their beliefs have a respectable history. But as I was glancing at some PA material, I came upon a citation that rather astonished me: PA advocates attributed the earliest reference to the PA idea to Wilhelm Reich! This was done in an article by the usually meticulous and cautious Richard Warshak and picked up again in a book edited by William Bernet.

Now, I would not want to fall into the trap of assuming that just because most of what a person wrote was pernicious nonsense, he or she could not have had any ideas worth following up. I’m also aware that Reich has some admirers to this day and they continue to publish the Journal of Orgonomy. However, most of Reich’s beliefs and practices were such that I can’t imagine that most psychologists or psychiatrists would care to associate themselves with them, and I can’t fathom why the PA group want to do so.

Here are some facts about Wilhelm Reich:

He was part of a group rejected as doing “wild psychoanalysis” by conventional Freudian analysts. This group, including Sandor Ferenczi, was characterized by hands-on, physical treatment methods, among other things. The “wild psychoanalysts” owed much to Georg Groddeck, who had earlier claimed, for example, that problems of childbirth, such as an awkward positioning of the fetus, resulted from the mother’s psychological reluctance to give birth.

Reich believed that an energy form called “orgone” was involved in sexuality and physical health, and that sitting in a box insulated against the escape of orgone would cure cancer and other diseases. His insistence on continuing to sell orgone boxes led to charges and conviction of fraud, and he died in prison.

Reich claimed that through hands-on treatment he had cured his infant son of the Moro (“startle”) reflex; this reflexive movement pattern largely disappears by about five months of age, as voluntary movement patterns take over, and this is presumably what happened in the case of the Reich baby. Why Reich, a M.D., would not recognize a normal infant movement pattern and would try to “cure” it is a difficult question to answer.

Reich’s theory of personality involved “character armor”, a stiffening of muscles accompanied by rigid thinking, emotion, and behavior, and caused by birth and other early experiences. Relaxing the muscles was claimed to restore flexibility of thinking and feeling to a normal and desirable level; without such restoration, a person could not experience life fully. (I should note that in the 1940s and ‘50s, this belief, although not widely accepted, was not considered necessarily to be a “fringe” notion, and was described briefly in an abnormal psychology textbook published about 1960.)

Reich’s treatment for “character armor” as a psychological disability involved a semi-nude patient and therapist. The therapist treated the stiff muscles that were thought to cause psychological rigidity by thrusting his fingers or hand into the patient’s armpits or against the ribs. (Does anyone remember Rolfing? How about Holding Therapy?) Bruising and considerable pain resulted.

None of these disturbing beliefs and practices indicates that Reich never made a correct statement in his life. However, it’s hard to belief that PA advocates really wanted to take on the Reichian baggage just in order to claim an early reference to their ideas. Could this have been like Darwin’s fox terrier—the reference was cited again and again until no really knew how big a fox terrier was or how peculiar Reich had been?


Whatever the rationale for citing Reich, I would think that PA advocates would do well to delete these references and concentrate on determining the incidence and prevalence of the family issues that concern them, not to speak of assessing the efficacy of the interventions proposed as treatment.