Concerned About Unconventional Mental Health Interventions?

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

Wednesday, December 21, 2016

One-Stop Thinking Makes People Misunderstand Child Development

We tend to be attracted by the idea of “one-stop shopping”, but we can pay the price of convenience by not getting exactly what we want. In fact, we may find ourselves regretting purchases we made just in order to save time. “One-stop thinking” presents the same problem: when we pay attention only to one factor that affects children’s development, we cut down on the time spent in consideration, but we risk making some big mistakes.

In reality, children’s physical and mental development are invariably affected by more than one factor, genetic or environmental. And usually, the influential factors are not just two or three, but many. Often, influences act bidirectionally, so that children affect their parents as much as parents affect their children. Influences can even be transactional in nature, so that bidirectional effects (for example, parents’ and children’s mutual influences, or families’ and schools’) change in their  nature over time and experience. Developmental outcomes may depend on some combination of environmental circumstances (helpful or harmful) and the characteristics of the child (vulnerable or resilient), with the best outcomes resulting for a resilient child in a helpful environment and the worst for a vulnerable child in a harmful environment.

In other words, it’s not rocket science--  it’s a lot more complicated than that (even though this statement is annoying to rocket scientists).

Recent years have seen a number of examples of one-stop thinking about child development, not by developmental scientists themselves, but by people popularizing and translating developmental research and theory. Unfortunately, oversimplified translations are often applied to pragmatic topics like how to intervene in children’s mental, behavioral, or educational problems. These may be welcomed by consumers of services, because their simplicity “makes sense”, especially if it echoes claims made familiar by repetition. Those familiar and simple claims amount to what the developmental scientist Jerome Kagan famously called “seductive ideas”—ideas that are so appealing to us that we buy into them without much investigation of their “one-stop” convenience.

Here are some familiar ideas that can lead to one-stop thinking if we do not pay careful attention.

Infant determinism is the idea that everything of developmental importance is accomplished during the first years of life. Early intervention follows on this idea by assuming that there is a desperate need to change completely the circumstances of every child who is abused or neglected in early life, most often by offering services to parents, but sometimes by foster or adoptive placement. One-stop thinking on this topic ignores two facts: that small changes in a family’s situation can help improve a child’s developmental trajectory, and that events such as school availability and neighborhood safety may later help restore derailed development. A 2014 article in the British Journal of Social Work (Featherstone, B., Morris, K., & White, S., “A marriage made in hell: Early intervention meets child protection.” BJSW, Vol. 44 (7), 1735-1749; pointed to the mistakes made when child welfare workers do not try offering needed support to families rather than hurrying to intervene; this article is of particular interest in that it places this issue in a political context.

Attachment is an important concept in the study of child development as well as in practical decisions about child care and custody. But one-stop thinking about attachment and attachment disorders focuses entirely on these topics as the unique core of personality and behavioral development. As a result, educators and counselors may attend only to a child’s attachment issues and ignore all other child and family characteristics that may be affecting development. In addition, therapies directed at changing attachment may be proposed for an enormous range of mental health problems, from autism to oppositional defiant disorder. Interestingly, the fad of the last 30 or 40 years for an exclusive focus on attachment appears to be waning, and another fad is emerging.

Trauma, in the mental health context, describes experiences of seriously frightening or painful events that interfere with important relationships and thus with development. Trauma-informed approaches are essential for work with children and parents, as reactions to trauma may involve behaviors like fearfulness and aggressiveness, sleep disorders and bedwetting, for which children are brought into treatment.  Attempting to treat these without considering the influence of trauma is likely to be ineffective, if trauma is indeed involved. But one-stop thinking about trauma leads to the assumption that where there is a mood or behavior problem, there must be trauma in the background, even though there is no independent evidence that this has occurred. There is only a step from this assumption to the whole “recovered memory” charlatanry that was thriving 20 years ago and is still in existence. Seeing trauma everywhere is the new fad that has replaced the attachment fad; even the organization ATTACh, at one time the Association for Treatment and Training of Attachment in Children and a great proponent of attachment therapies, has now caught the trauma wave and become the Association for Training on Trauma & Attachment in Children.

Neuroscience is both a critical aspect of research on child development and an insidious temptation to one-stop thinking. I recently attended a presentation on the effects of poverty on children that used multiple PowerPoint slides of children’s brains to buttress the strong existing evidence that children growing up in poverty have worse physical and mental health, and worse academic achievement, than those growing up in better circumstances. No one (including me—I didn’t want to offend the speaker who kindly gave his time) demanded to know what on earth the brain images had to do with the argument that poverty is not good for children’s development. Using the slides was only a way to strengthen, not the argument itself, but the reception of the basic argument by an impressed audience. One of the problems with one-stop thinking about neuroscience is that the field itself, and what we know about it today, is too complex and too incomplete to allow us to use this information well. For example, a recent study described by Pam Belluck in the New York Times (Dec. 21, 2016, p. A15) noted that in the course of pregnancy women lose (yes, lose) brain volume in areas that are used in understanding how other people perceive things. Those who lost most volume, in the reported study, were most emotionally attached to their babies. Thus, loss of brain volume can improve certain capabilities, which we already knew from information about hormone-determined brain changes in boy and girl babies. But—according to the famous study of London taxi drivers, increased capabilities can also go with increases in brain volume! One-stop thinking is especially dangerous when the “stop” does not offer much clarity.

A real problem with one-stop thinking about children is that we don’t just create our own mistakes. We also have other people who would like us to make the mistakes they suggest, for the benefit of their own financial or personal aggrandizement. And often they are very attractive and persuasive people who appear to offer simple, achievable solutions to our complicated, intractable problems, or those of our children. They tell us they are world experts, or have cared for thousands of foster children, or even have a direct connection to supernatural powers. When we meet these people, we need to resist their one-factor solutions and remember the adage about rocket science.

And by the way, if it seems too good to be true, it probably is.

Monday, December 19, 2016

When Proposed Childhood Mental Health Treatments Are Potentially Harmful

I recently published an article in the Child and Adolescent Social Work Journal, under the title “Evidence of Potentially Harmful Psychological Treatments for Children and Adolescents”. Interested people can read this paper at the following link:

However, assuming that most readers won’t be quite that interested, I’m going to summarize the article here and add a few comments.

The point of this paper is that there is clear evidence that certain psychological treatments that have been used for children have been harmful, and that in fact it would have been possible to predict these harms beforehand by careful examination of the principles and practices of the treatments themselves. Evidence for harm done by certain treatments goes back to the 1960s, so no one should be surprised to find that this is a possibility. Nevertheless, specific discussion of potentially harmful psychological treatments goes back only to 2007, and even then there was little emphasis on potentially harmful treatments for children. An important publication in 2007 assumed that harms can be identified through systematic research evidence, whereas in fact anecdotes and journalists’ reports may be the first line of information to warn of us of harm to children.

My paper proposes that potentially harmful treatments for children may be identifiable – before harm is done—by several characteristics that make them unusual in comparison to most childhood mental health treatments.

 One of these is that they create an emotional burden for the child, making him or her feel distressed by the treatment. Although it has been claimed that people in psychological treatment must feel uncomfortable so they can be motivated to change, this idea is not evidence-based, and the great majority of child treatments focus on comforting the child as he or she tries to master issues like anxiety resulting from trauma. Treatments that are distressing for a child run the risk of re-traumatizing rather than helping.

A second characteristic that is proposed for potentially harmful treatments for children is derived from the Adverse Childhood Experiences (ACE) study, currently underway and revealing that problems of both mental and physical health in adulthood are associated with increased numbers  of adverse experiences of painful and disturbing experiences in childhood. There are ten ACE questions used for research purposes; of these, the four following questions are most relevant to potentially harmful psychological treatments for children.  
  1. A parent, another adult in the household, or a therapist often or very often swore at the child, insulted the child, put the child down, or humiliated the child, OR acted in a way that made the child afraid that he or she might be physically hurt.
  2.  A parent, another adult in the household, or a therapist often or very often pushed, grabbed, slapped, or threw something at the child, OR at some time hit the child so hard that he or she had marks or was injured.
  3. The child often or very often felt that no one in the family loved him or her, and that no one, including the therapist, thought him or her important or special.
  4.  The child often or very often felt that he or she didn’t have enough to eat, had to wear dirty clothes, and had no adult protector.
I propose that when a childhood mental health treatment features these ACE events, this fact helps to identify the treatment as potentially harmful

The third characteristic I suggest for identification of potentially harmful treatments for children is drawn from the fourth National Incidence Study of Abuse and Neglect (NIS-4). NIS-4 identifies for research purposes a list of adult actions that are to be considered abusive to children. The following table shows adult behaviors that are relevant to the identification of potentially harmful psychological treatments for children.

Behaviors coded as physical neglect                             Behaviors coded as physical abuse  
Refusal to allow needed care for diagnosed                  Hit with hand
condition or impairment                                                 Hit with object
      Unwarranted delay or failure to seek                             Push, grab, drag, pull
needed care
Refusal of custody/abandonment
Illegal transfers of custody
Inadequate nutrition
Inadequate personal hygiene
Inadequate clothing
Inadequate shelter

Behaviors coded as educational neglect                       Behaviors coded as emotional abuse 
Permitted chronic truancy                                             Close confinement: tying, binding
Failure to register or enroll                                           Close confinement: other
Other refusal to allow or provide needed attention       Verbal assaults and emotional abuse
 to diagnosed educational need                                      Threats of other maltreatment

Behaviors coded as emotional neglect
Inadequate nurturance/affection             Exposure to maladaptive behaviors and environments
                   Other inattention to developmental/emotional needs

I propose that treatments that include these behaviors are identifiable as potentially harmful to children.

Having established these criteria for potentially harmful psychological treatments for children, I examined five psychological treatments for children to see whether they met the criteria: aversive conditioning using electric shock, holding therapy/attachment therapy adjuvant treatments associated with holding therapy/attachment therapy (Nancy Thomas parenting), “holding time” (Festhaltetherapie), and conversion therapy for change of sexual orientation. In practice, although not necessarily in theory, each of these treatments met all or most of the criteria for potentially harmful treatments for children. Two of the treatments, aversive conditioning using electric shock and holding therapy/attachment therapy, have over many years moderated their practices, but their potential for harm remains. Interested readers can look at the paper for many more details about these five treatments and for the sources I used in writing the paper..

I certainly do not mean to suggest that these five treatments are the only child mental health interventions that have the potential for harm. I would have liked to include an analysis of various treatments for children displaying “parental alienation” by rejecting and avoiding one of their parents, but there is little systematic evidence either about the effectiveness of these treatments or about their potential for harm. There is no question that they cause an emotional burden to the children. In addition to this, there is anecdotal evidence that these treatments may be associated with frightening experiences with youth transportation services, and with threats to send an uncooperative child to residential care or to wilderness programs where the child cannot communicate with anyone outside the treatment program and may be at the mercy of staff members.


Monday, December 12, 2016

Another Eye Contact Query

People keep sending comments to a much earlier post on this subject-- but there have been so many that no more fit on that page. Here is a recent one of these.

Hi Dr Mercer,
I have a 4 month old baby girl that was born 3 weeks early. Had a rough delivery with forceps and she was bradycardic for 8 min.he had mild hypotonia in her arms.
We are very worried as she has not made any eye contact with us yet or smiled at us. She started tracking objects around 3 months, but She doesn't seem interested in anything in particular. She bats at objects but can't grab them yet. Has good control of her head but has not rolled over yet(and doesn't really seem interested in trying). Pediatrician is concerned and went to see a ped neurologist but they say it's early at this age to say anything. I still feel like they must be something that can be done to see why she what is wrong with her.
Any advice?
Thank you so much 

Dear Unknown--

Her corrected age is just over 3 months, so it is not surprising that she has not rolled over and can't yet grab things. It's a good sign that she bats at objects, because this shows that she has at least some vision. The head control is also good. I'm not surprised that you are concerned about the lack of smiling by this age. However, please keep in mind that many babies who have a rough start do catch up in growth and development.

I understand how frightening and frustrating this situation must be for you, but the neurologist is right in saying that she is too young to get a clear picture of what, if anything, is wrong.

But while you wait to see the outcome, you can work with her to help support her ongoing development. Do your best to show her a smiling and interested face-- try not to look anxious or stressed when you are face to face with her. Make sure that when you look at her, there is a bright enough light on your face so she can see your features even if she has some vision loss. Don't give up if something you do (big smile, for instance) doesn't seem to get her attention--  do it several more times. Sometimes you can get a baby's attention by "looming"-- move your face toward her while you open your mouth wide, then move away while you close your mouth. In addition, you can combine several sensory events to get her interest by talking or singing while you look at her and tapping or rubbing her hands or feet. There's nothing magic here-- I'm just suggesting that you may be able to draw her into an interaction by giving her more complex stimulation.

It's true that you will have to wait for an accurate assessment, but you and she are not in suspended animation. You can still do things that will give her the best chance for good development. If you notice even a small response, keep on doing whatever seems to get her interested.

By the way, you should be sure to put away your phone and all screens when you're with her so you aren't distracted by them.

Good luck to your family, and I hope to hear in 6 months that she has made great progress!


Thursday, December 8, 2016

Is It Autism? Interesting Questions about a Toddler

Here is a comment on eye contact and other possible "red flags" for autism. It couldn't be placed on any of the pages I have on that topic, for some reason, but I thought it would be useful for other people to read these intelligent questions and my (I hope intelligent! ) responses.
Hello Dr Jean Mercer,
I'm not sure if you are still actively replying to comments, but I would love your thoughts on my 12.5 month old son.
In the effort to fully disclose, I would like to mention that my oldest son who is 2.5 followed a similar pattern of development, in which I was convinced he would be diagnosed with autism until about 16-18months old. He is now very advanced in his language and very social (almost too social!).
As with my older son, I have had long time concerns with his eye contact. This has spewed into constantly analyzing if his joint attention is enough. He has many strengths but they seem to be over shadowed by a weakness/red flag. I guess I am not sure if they are developmentally expected at this age or my my expectations are too high. I have brought concerns up to my last two well baby visits only to be brushed off. Here are my strengths and concerns:

1) Showing/giving: He has been showing like crazy lately, everything he picks up he makes eye contact and "says" something BUT virtually no giving. If I reach my hand out he will "fake me out" and hold onto it. He was giving but not showing about a month or so ago.
Showing is actually a lot more complicated than giving. For giving, he just has to respond by letting go when you put your hand out. For showing, he has to figure out where you are looking and hold an object so you can see it-- not let go, not drop it. To combine showing and giving in the right sequence is even harder. I don't think he plans to fake you out (that would require some pretty advanced cognitive skills), but he is probably not yet able to inhibit the showing action and start the giving action.

2) Pointing: he points a hundred times a day. BUT never looks at me during/after point. Very occasionally he will quickly glance my way but it's quite rare. He has done some 3 point gazes but I'd say maybe 2-3 times a day definitely not a lot.
Pointing can simply be a way of indicating behaviorally that he is interested in something-- I mean indicating it to himself, not to you. If he does do joint attention a few times a day I would say that's fine.

3) Engagement: he plays and laughs with me. BUT not much eye contact during it. In fact very little. For example we played with a ball for about 5 minutes together, he was laughing a lot (he would hold the ball and drop it and then I would roll it to him or pass to him) but I was watching intently and as much as I could tell he was enjoying it he didn't once look up at me. He focused on the ball the entire time. He also can play by himself for lengths of time without looking up (my oldest did this as well so I'm not as worried compared to the engagement with the ball example).

I think the ball play is probably still pretty challenging to him. To look up at the same time is kind of like patting your head and rubbing your tummy at the same time.  He's not ready to multitask or to stop and start actions easily.

4) other gestures: this one has me stumped. A month ago he wasn't clapping but had waved bye bye a few time on his own. He would also makes kissing noises when I said give me a kiss. Now no waving or kisses but will clap on demand. I thought he caught on to the toy telephone because he seemed to do it once but not again. He continues to say no no no while shaking his head so that's a definite strength that has stuck around. But it's like he completely forgets how to do it??? 
They do things and then don't do them any more for a while, quite often. Sometimes it's because the skill is so well mastered it's not interesting any more--  other times, who knows!

5) mirror: He shows zero interest in a mirror
Do you mean he doesn't recognize himself in a mirror? I wouldn't expect him to until about 18 months. Then you could try putting a dab of lipstick on his nose and showing him a mirror-- he will probably put his hand to his nose at once.

6) no walking but my oldest was 16 months before he walked so I'm not concerned about this
No reason to be concerned.

7) I can tell he understands some things I say, like get the ball, take a drink, where's dad etc. as for words, he has said dog, ball, and bear (along with mama and dadda), but now only seems to say ball appropriately
Receptive language (understanding) is much more important then expressive language (speaking).. Knowing what they actually say can be so difficult because they may not make the same sounds every time. You may just be missing what he says, or possibly he's busy on some other aspect of development. They don't work on everything at the same time or the same rate of speed.

He gets a kick out of feeding me, which I see as a huge strength but it's the eye contact that has me the most worried. I guess I'm hoping for either reassurance that he seems to be developmenting on the right track or a push to request services regards of being brushed off.

It sounds as if he does a lot of social interaction and that's on the right track.  They don't actually make a great deal of eye contact, if you measure it objectively-- a quick glance is all it takes, not a long gaze.

          Thank you for the support ;)

Thanks to you for the great descriptions! I'm sure other readers will benefit from them.

Just try to keep in mind that what toddlers can do and do do is so different from what adults do that it's really hard to figure them out. Jean Piaget referred to children this age as "cognitive aliens"-- their thinking is so different from ours that they might as well come from another planet. Or, as one of my grandsons says, They're ca-RAZY!

Saturday, December 3, 2016

The Gentrification of Martha Welch

My friend and colleague Linda Rosa recently pointed out to me a Wikipedia article about the Columbia University-associated psychiatrist Martha G. Welch. This article contains much about Welch, including her connection with the grape juice family and her current partner’s name. Her interest  in autism is mentioned, as well as various honors she has received from Columbia and biological research she is engaged in.

But… a lot was missing in this article, until I went to work and edited it by adding a paragraph that described some of Welch’s complementary-alternative approaches to treatment of autism. Indeed, the article as it stood cleaned up Welch’s professional life thoroughly and positioned her as a conventional researcher with no history of any fringe theories. I checked both the Talk and the History sections of the Wikipedia page, where you can see whether people have discussed or made changes in included material, but I did not see that material had been deleted, so I assume that the gentrified, non-comp-alt version was pretty much the way the article was originally written.

Of course, anyone who knows anything about Martha Welch knows better than to accept this tidied-up version. Here’s the reality.

Martha Welch many years ago visited Foster Cline and other proponents of Holding Therapy in Evergreen, Colorado. She was impressed with their intrusive, potentially dangerous methods of restraining children, techniques that they posited as psychotherapeutic. These methods were based on the work of Robert Zaslow, the California psychologist  who in the 1960s and ‘70s claimed that autism and other mental illnesses could be treated successfully with painful physical methods (until he lost his license for injuring an adult patient).  

Welch did not exactly follow the Evergreen methods, but she decided that something similar would be an effective treatment for autism. She speculated, like Zaslow, that autism was the result of a disorder of attachment—the child’s mother had not done the right things to create attachment. (On Welch’s behalf, I have to say that this exaggeration of the role of attachment in development was common at that time and has not completely left us). Welch considered that human attachment occurred in an exact parallel to the “imprinting” whereby a recently-hatched duckling follows a moving object and subsequently tries to stay near (and eventually mate with) similar objects. This ethological explanation was maintained despite the fact that imprinting has never really been demonstrated in any mammals, much less in human beings—but the possibility was given serious consideration by Konrad Lorenz and Nikolaas Tinbergen, the ethologists who had investigated such instinctive behaviors in birds and fish.

Welch suggested that attachment (which of course she saw as the key to autism) could be created long after the period when it normally occurs if a child was forcibly kept in close physical contact with the mother. (Sorry fathers, you did not really get much of a role in all this.) She developed a technique she called “holding time” (also the title of a book she published on the subject in the 1980s). “Holding time” was to take place every day, and required the child to be held in close physical contact with the mother for an hour or so, during which time the child would fight, scream, and struggle, but eventually would be exhausted and snuggle closer. Younger children were to be held straddling the sitting mother’s lap and pressed against her chest. If too big to be held in this way, they were to be made to lie supine on the floor while the mother lay prone on top of them, supporting herself on her elbows and looking into the child’s face while she told the child her feelings both negative and positive. Welch presented this method not only as a cure for autism but as a key to good parent-child relations for all families.

As it happened, Elisabeth Tinbergen, the wife of the ethologist and Nobel Prize winner Nikolaas Tinbergen, was a special education advocate, and she came to know Welch and to be fascinated by what she perceived as the benefits of Welch’s method for autistic children. Niko Tinbergen also took an interest and argued that human attachment paralleled imprinting and might be able to be manipulated in the same way (although they stated clearly that no empirical support had been found for this practice). The Tinbergens published a book encouraging Welch’s methods and connecting them with ethological theory; their book included a lengthy appendix by Welch and led to the publication of her own book Holding time.  Welch went to England and Germany on an extensive book tour, during which she instructed large groups of mothers of autistic children on using restraint methods with their children. (She also met Jirina Prekopova, another protegee of Tinbergen, who is still doing a similar form of holding therapy in the Czech Republic.) Welch also set up a “clinic” in Connecticut for instruction about this treatment for autism, although no research support had appeared to show that the treatment was effective.

In 2006, a new publication by Welch and colleagues appeared (you can look at the Wikipedia article now for the reference if you want it—it’s not easy to find on her own website). She changed the name of the restraint treatment to Prolonged Parent-Child Embrace therapy and now recommended it for attachment problems and oppositional behavior. A comparison of parents’ assessments of children before and after the treatment was presented was used to conclude that the treatment was effective—a move that ignored the many problems of this kind of research design, including both regression to the mean and developmental changes unrelated to the treatment.

Now, ten years later, Welch appeared in a Wikipedia article as a completely conventional psychiatrist and researcher, quite rehabilitated from her comp-alt days. Of course, I may be wrong in thinking that all the fringe stuff was left out intentionally. Perhaps Welch regrets her involvement with those unsubstantiated claims and recommendations? That would be interesting if true, and I would hope that in that case she would publish a statement about why she has changed her mind (although people who get involved  with the fringe rarely do this later on –cf. Dan Hughes). But it is probably more likely that this article’s take was mainly about burnishing the image.

Tuesday, November 29, 2016

Zombie Ideas Causing Trouble Again

Recently I came across the term “zombie ideas”. I really don’t remember where it was, so I can’t give due credit to the inventor, but I have to borrow this. A “zombie idea” is one that ought to have been dead a long time ago, but it won’t lie down and give up. Regrettably, there are a lot of people who welcome zombie ideas and keep them in circulation--  perhaps just because they heard of these ideas a long time ago and their vague familiarity gives them some of the credibility of tradition. Anyway, zombie ideas are definitely in our midst, and if you look through some past posts on this blog you will see that I have been aiming silver bullets at them (all right, I guess that’s for werewolves, so maybe that explains why there are still so many of the zombie kind.)  By the way, zombie ideas eat your brain and keep you from thinking straight, so they are not to be welcomed, even if like real (traditional) zombies they seem to save you from some heavy lifting.

The New York  Times Sunday business section has just given half a page to a zombie idea (Martin, C. [2016, Nov. 27]. A smashing new way to relieve stress. NY Times, Business, p. 4). This story recounts how one Donna Alexander has set up a for-profit Anger Room in Dallas, and how similar rooms now exist in Houston, Toronto, Niagara Falls, and Australia. According to the article, “the Anger Room charges $25 for five minutes [yes, you read it correctly, minutes] of crushing printers, alarm clocks, glass cups, vases, and the like.”  Persons desiring to smash things can get special set-ups for $500 dollars or so—one of those having been “a faux retail store, replete with racks of clothing.” ”.  Recently, mannequins dressed as Trump or Clinton have been available for smashing. The idea is that this is a space where “stressed-out people could relieve their tension in a safe, non-violent way”.  

The zombie idea at work here is the belief that by acting angry, people can get rid of persistent uncomfortable anger and frustration that they experience. This belief, often referred to as catharsis, dates back to the ancient Greek drama, whose audiences were thought to benefit from the vicarious experience of sadness and grief. Sigmund Freud expanded this idea to suggest that all kinds of lingering negative emotions could be re-experienced in some way and deactivated as a result. Freud’s view involved a hydraulic metaphor for emotion, as if it were water collecting and pressing hard against a dam, which could be drained in order to release the pressure.

Two points about this zombie idea: First, doesn’t it seem odd that no one ever worries that acting happy will remove happiness from your life? Presumably, if catharsis worked for one kind of emotion, it ought to work for all of them, no? Second (and more important), research like that published by Jill Littrell almost 20 years ago has clearly indicated that behaving in an angry way actually makes people feel more angry, not less.

 Although it’s clearly time for this idea to lie down and let itself be buried, Alexander and other people in the rage business find the zombie idea too profitable to let go. Is what they are doing fraudulent? Probably so, but to win a lawsuit against them, a client would have to show that the owners knew you can’t destroy anger this way, and also would have to demonstrate that he or she had actually been harmed. These things are not very likely to happen.

Although the writer Claire Martin was obviously mainly interested in the Anger Room as a business venture, she should be given credit for consulting a clinical psychologist about the emotional benefits of smashing things. The person she talked to, UCLA psychologist George Slavin, warned that physiological responses during angry behavior can actually be bad for health, and recommended that people who feel tense and angry should use cognitive therapy and stress-reduction techniques to help them feel better in the face of the stresses of daily life. He described the idea that acting angry can relieve stress as “appealing” but not supported by evidence. But although Martin included these remarks, she spent all the rest if the article talking about related business ventures.

Zombie ideas of all kinds are “appealing” in the sense that they are simple and familiar and don’t require us to do much mental heavy lifting. Some of them, like the Anger Room idea, are presented to us over and over because they can be so profitable for a few individuals—so they become even more familiar than they were at the beginning. Claire Martin’s article in the Times did this job too, even though she paid lip service to “giving the other side” in a couple of paragraphs. Her focus was on the bottom line for the entrepreneurs. If you and I want to emphasize the bottom line of our own well-being, we need to watch out for the zombies.

Friday, November 18, 2016

More Queries About Baby Eye Contact

I think nobody reads instructions! Even though I've asked people not to post queries on my first "eye contact" post, they still try to do that--  and there are so many on there already that more cannot be posted. So, let me start yet another page for these questions, and I hope the writers will find this. Here's one to begin with.

Kanza Sharjeel has left a new comment on your post "Eye Contact With Babies: What, When, Why, and How":

Hello doc
Mu son who was sga botn at 36 weeks started his eye contact at 3.5 months . Now he is 5.5 months and no babbling as yet.. Just ooo and aaa
He has just started rollinh.
I think he doesn't recognid me. He doesn't know thst i m his mother.
He looks at me wen i cal husname
But when i cal my name in a loud voice he looks at me too. Dors this mean that he doesn't know his name?
He also doesn't etend his arms as a way of saying that he needs to b picked up

Also he has just started grabing objects and mouthing them
Mu nephew is alao autistic 
Dear Kanza-- If your son was not only small for gestational age but born at 36 weeks, you should not expect him to be doing these things at the same times that a full-term baby would do. He does not sound as if he is very different in his development from a one-month-younger full term baby, He is not yet old enough to prefer familiar people, so although he may "know" you, it isn't yet important to him that one person rather than another cares for him.

Responding to the name does not usually happen until about 6 months, so he has a while to go before you would expect that. I think it's an excellent sign that he pays attention when you raise your voice-- he has learned that it's important to pay attention to the way people talk, even though he doesn't understand words yet. It's good that he is cooing, and babbling will probably start in the next month or so. I would expect him to be sitting up before he put his arms up as a signal to pick him up.

I understand why you are worried, but it seems to me that he is doing reasonably well. The best thing you can do for him is to pay attention carefully to any signals he gives you, and to try to talk to him or play with him in ways that interest him-- notice whether his eyes brighten and he seems attentive when you do something, and keep on with whatever that was for a few minutes.

Good luck to your family!

Thursday, November 17, 2016

Can Brain Science Help With Practical Decisions about Child Welfare, Custody, and Treatment Issues?

In the last week or two, I’ve come across several situations where neuroscience is referenced as helping provide understanding of interventions for children’s mental illness or educational problems. This use of scientific information is often called “translational” science, and it is receiving much well-deserved attention as we try to move from laboratory successes to practical benefits.

But, can neuroscience as it exists today tell us anything more about how to help at-risk children than we can learn from behavioral studies? That was the question I thought of when I read the following:

1.      A Norwegian psychologist working with child placement decisions expressed his concern that evidence of maltreatment is equated with brain damage and used to argue that children should be placed in foster homes.

2.      An editorial in the Brown University Child and Adolescent Behavior Letter was entitled “Distracted driving prevention needs leadership from the neuroscience community”  (CABL, Nov. 2016, p.8). The author very correctly pointed out the failure of “scare tactics” to work with teenagers with respect to drug use or criminal behavior, and expressed doubt that such an approach would be helpful in preventing teenage distracted driving. But instead of suggesting other well-established techniques that are known to change behavior effectively, the author said, “what is sorely missing is the voice of the neuroscience community… each scientific nugget… may open a door in the prevention effort”. 

3.      In Child Development Perspectives (2016, Vol. 10 [4], 251-256), Philip Fisher and his co-authors have an article with the title “Promoting healthy child development via a two-generation translational neuroscience framework: The Filming Interactions to Nurture Development video coaching program”. This very helpful-sounding program for parents and young children uses videotaped interactions between the two to teach parents to pay attention to a child’s communications, to monitor and reflect on their own behavior, and to wait for children to respond rather than moving on impatiently. All good goals, and very much in line with recent efforts to help foster good parent-child relationships—but where did the translational neuroscience actually come into this program? Did neuroscience help the authors decide how to shape their program, or did they create a program that did the things we think are good for behavioral reasons, and then seek a neuroscience context to strengthen their argument?

4.      If anyone wants more examples, just think about things like teaching to one side or the other of the brain, patterning, the “cross-crawl”, and dozens of other claims that a method has specific effects on the brain.

Let’s look at some of the assumptions that these examples share (and remember the old saying, ASSUME makes an ASS of U and ME).
 One is that behavior and mental abilities are directly related to brain structures and functions. Of course, this is true at the coarsest level. Damage the visual areas of the cortex and you don’t see. Damage the frontal lobes and you don’t plan or anticipate well. But in fact brains have a lot of redundancy and can do many things in more than one way—even the person with damage to the visual cortex may be able to walk around an object in his path, although he is not aware of seeing it. People’s brains are not all just alike, with most people having the left hemisphere dominant and a smaller number having the right hemisphere—yet right- and left-handed people can do most cognitive tasks equally well, as can men and women, whose brains have some differences.

A second assumption is that we actually have quite a clear idea of how parts of  normal. human brains work. In fact, neuroimaging gives us only a glimpse into what is happening in the specific parts of the brain we choose to look at, at a particular time.  Most of what we know about connections between different parts of the brain still involves what has been studied by autopsy in individuals whose brains have been damaged during life. And, of course, we have the problem that some of the evidence put forward as explaining human brain functioning actually comes from information chosen from a variety of animals and not confirmed by human studies (see

A third assumption, and a very tenuous one, is that we know what experiences are problems from brain development, and that we can treat those problems with appropriate interventions, reverse the effects, correct the brain’s characteristics, and end up with desirable behaviors (Cf. the first assumption, above). This assumption seems to avoid the possibility that we could identify experiences that put a child at risk, intervene successfully, and have a desirable behavioral outcome—without having any measurable effect on the brain at all!

I am not in the least trying to claim that human brain functioning is not an important and most interesting topic of study. Of course it is. But to assume that we know all about the brain, understand how brain events cause or are caused by experiences, and have interventions (other than surgery and drugs) that “fix” brains—no, none of those are true.

 So why do people bring neuroscience into discussions where no relevant information exists? The forthcoming book by David Wastell and Sue White, Blinded by science, will focus on this and similar issues and should be well worth reading. From my own perspective, I would say that today neuroscience is not only a discipline, but a rhetorical device. Whatever people would like to argue for in child welfare and related fields, they feel their arguments are stronger if neuroscience is invoked. And on the whole we let them get away with this; we don’t challenge their statements and ask what the one thing has to do with the other. To do so would for many of us open the door to a humiliating loss of face, as others whisper, “she doesn’t know how important neuroscience is!” If this happens in the context of professional work, it could mean loss of a job.

But perhaps we need to learn to tolerate this discomfort and question whether or not the neuroscientific emperor is wearing clothes. This may especially be the case when practical decisions are being made about children, as in my Norwegian correspondent’s concern about child placement.  In the situation he mentioned, the argument appears to be: “This child was maltreated and neglected. Therefore, his brain is damaged. If a parent struck a child in the head with a brick and damaged his brain, we would terminate the parent’s rights. Brain damage is brain damage, so the brain damage resulting from neglect or verbal abuse is the same as that resulting from the brick, and the response should be the same.” Can anyone step forward and say, “Wait one minute. What evidence do you have that this child’s brain is damaged in any meaningful sense? And what can you say about the outcomes for the child if this parent is helped to improve his or her parenting skills, as compared to what will happen if the child enters the foster care system?” To make the best choice for the child, we may have to abandon the easy and fashionable neuroscience rhetoric, with its scary conflation of head trauma and the problematic (but very different) effects of neglect and poor parenting.

I admit, though, that few can step forward in this way, because the practical consequences of getting “out of step” may be quite severe.   

Wednesday, November 9, 2016

Conduct Problems and Callous-Unemotional Traits: Something to Think About When You're Worried about RAD

I’ve pointed out again and again that Reactive Attachment Disorder in children is not characterized by aggressive or hostile behavior, by lying, by lack of remorse—and certainly not by an inability to connect cause and effect. But when people ask, “Well, then, what DOES my child have wrong?”, it’s an impossible question for anyone to answer without seeing the child and family in action.

Nevertheless, I want to put forward a possible set of problems that could in fact produce some of the unwanted behaviors that are so often attributed to RAD in Internet material. These are conduct problems and callous-unemotional traits (CPCU). Children who show CPCU are antisocial and oppositional, and often continue to show antisocial behavior later in their lives. These conduct problems, which may occur alone, are in CPCU associated with a number of other concerning traits. For example, they may not show guilt or remorse after misbehaving, they may show no empathy when other people are in distress, and they do not seem to care whether they themselves perform well or poorly.

These CPCU characteristics are not simply disturbing to teachers, parents, and other children; they evoke from the social environment a set of responses that are likely to worsen the child’s behavior problems.  We expect children to be upset if they do poorly at school or in sports, or even when they lose a game with other children, and we are ready to offer comfort or at least “bracing” remarks about how there will be another time or how the child should be a good loser. When a child says, or shows, that he or she does not care what happened, we tend to be at a loss for what to do—we may simply ignore the child, and then or later we may make sarcastic remarks about how we know the child doesn’t care what happens. It’s very difficult for us to model empathy in this unexpected situation, so we model indifference instead. In addition, when we see that a child “doesn’t care” about a person in distress, or “doesn’t care” about what he or she has done wrong, we often feel confused and vaguely hostile, and again model indifference or verbal attack—often, the same sort of behavior that we object to in the child.

Whether these “normal” responses of adults actual worsen CPCU behavior or not is not clear, but it certainly seems unlikely that these responses will help the child develop in a more acceptable direction. There is no evidence that any form of “attachment therapy” is effective in changing CPCU traits, nor would we expect there to be, because the issue is not about attachment-related behavior. However, it’s possible for behavior therapy to bring about changes in CPCU behavior like disruptive behavior, disobedience, tantrums, and inattention. But it may be that children who show CPCU respond differently to rewards and punishments than most other children do, and therefore behavior therapy may need to be fine-tuned to work well with them. They may do well with responding to rewards, but less well than other children when the therapy uses punishments.

An article by Daniel Waschbusch and his colleagues (“A case study examining fixed versus random criteria for treating a child with conduct problems and callous-unemotional traits”, Evidence Based Practice in Child and Adolescent Mental Health, 1(2-3), 73-85) looked at possible ways of fine-tuning behavior therapy for one child with CPCU characteristics. They looked at the results of using one approach with this child, then shifted to another approach, and compared the effects of the two.

The little boy, “Juan”, was  adopted at 17 months and began to show concerning behavior at about age 2 years. (That is, of course, a time of life when typically-developing children often begin to be resistant, to have tantrums, and to react badly to frustration, so it can be difficult to know whether a child’s behavior is or is not problematic with respect to later development.)  Entering school, he was disruptive, aggressive, inattentive, and silly, and his teacher said he did not seem to care about his school performance. His teachers also felt that he lacked warmth and kindness.

Behavior therapists working with Juan focused on managing his behavior with effective commands, positive reinforcement, and immediate consequences for his behavior. They gave or took away points for complying or failing to comply, and he could use the points to buy free time at noon and privileges like screen time at home. In addition, a daily report card helped to determine whether Juan could participate in a “fun field trip” on Fridays. The focus for Juan’s behavior therapy was on his tendency to interrupt other people, to violate classroom rules, and to tease his classmates. Juan’s behavior did change in response to this regimen, and he did best when the behavior change he was asked to perform was clearly stated – not just that he should interrupt less, but how little he had to interrupt in order to be rewarded.

Waschbusch and his co-authors mentioned that there has been less research on the effective use of punishment in behavior therapy than on the effective use of reward. They noted that it seems plausible that effective punishment must be mild, consistent, and predictable, but parents of children with conduct problems often do not manage this. Instead, they ignore bad behavior for some time, then unpredictably use serious punishment, which does not seem effective in changing behavior. Waschbusch and his colleagues also noted how little is known about the use of aversive events as punishments rather than punishment by taking away points or privileges.

Although there is much still to be understood about treatment of children with CPCU, these unwanted behaviors are apparently not related to attachment or any version of RAD. Also, they are treatable with standard treatments and need not destine a child for the school-to-prison pipeline. Treatment both at school and at home seems to be a key to success, and effective treatment requires changes in both teacher and parent behavior.    

Tuesday, November 8, 2016

Blinding Them with Science: The Epigenetics Issue

The idea of epigenetic factors—events that shape the ways genetic material is expressed in the developing individual—goes back a long way. For example, the geneticist Waddington suggested what he called an “epigenetic landscape”, in which factors like exposure to infection could push development into a different pathway from what might otherwise have been. These different pathways, once entered on, would further direct the course of development and might take the individual farther and farther from the developmental outcome that would have occurred without the infection.

Within the last half-century, it has become apparent that a range of factors can change the ways in which genes are expressed in individual development. One of these factors, a biochemical change called methylation, alters matters like the number of repeats of a genetic pattern in the individual genome. The very interesting thing about methylation is that this genetic change sometimes is, and sometimes is not, apparent in an individual’s developmental outcomes. For example, the gene responsible for Fragile X syndrome (a problem characterized by mental retardation and behavior problems) has already begun to change several generations before any developmental problems are apparent. A Fragile X patient’s mother and grandmother already had genetic changes at work, but these had not advanced to the point where development became atypical. (Note, by the way, that when genetic problems of this kind occur, some, like Fragile X, develop only in the maternal line, while others develop only in the father’s and  grandfather’s genomes.)

Fast forward now to 2004, when researchers reported that rat pups whose mothers licked them more (as well as showing more of other maternal behavior) had fewer genetic methylation events than those with less attentive mothers, that this situation persisted into adulthood, and that the less-mothered pups had worse reactions to stress in adulthood. The researchers, Szyf and Meaney, also that by cross-fostering pups (temporarily giving the less-mothered pups to more attentive mothers, and trading those mothers’ original pups to the inattentive mothers) they could actually reverse the differences between the groups, thus showing that the pups’ original genetic make-ups had not caused the differences between groups. As far as I can see, these researchers assumed that all effects had to do with the attentive and inattentive mothers’ behavior; they do not seem to have analyzed the milk of each mother for differences that might influence genetic material and development of the pups.

Very quickly, a rush to apply the rat studies to human beings began. Look, people said, early bad experiences change individuals, and what’s more we can fix them! For example, at, where attentive rat mothers are anthropomorphized as “conscientious”,  Arthur Becker-Weidman uses epigenetic studies to make the following claim:

“One clear implication of this research is that the Attachment-Facilitating Parenting with Attachment-Focused Psychotherapy can be instrumental in demethylating important genes and, therefore, ‘resetting’ the stress response system to be within a more normal range. It is clear that harsh parenting methods, methods that are shaming, blaming, and critical only serve to reinforce negative expectations and the unresponsive stress-response system’s reset mechanism [N.B. I do not claim to understand this last bit; I’m just reporting the news here. J.M.]. Parenting methods that are grounded in a focus on relationships and connection of an emotionally meaningful and joyful nature may reset the stress response system by its [sic] effects.”   

Let’s examine this claim under a couple of strong lights. The first has to do with extrapolation from rats to human beings (or even from a particular strain of rats to other strains of rats). As I pointed out on this blog some years ago, if Harry Harlow had used a different type of monkey, the results of his work, and their capacity to support Bowlby’s attachment theory, might have been quite different ( Generalization from one species to another takes careful work to substantiate it, especially when the species are so different, with much different life spans and times to reach reproductive maturity. Rats take about 30 days from birth to reproductive age, as opposed to 12-14 years for human beings, so how do we decide which part of a rat’s early development is parallel to any part of human development? In addition, the work of rat mothers involves building a nest, licking the young, positioning herself so they can nurse, and retrieving them in response to their squeaks if they manage to get out of the nest. If disturbed by noises or other animals, the rat mother may well eat the babies (and although I suppose this may have happened among humans, even Greek myths usually concentrate on mothers who serve the kids up to their fathers for dinner). I leave it to readers to think about parallels to human infant care, but want to point out that humans typically have one baby at a time and concentrate on that baby’s care, with at least a year ordinarily intervening before a new baby arrives—humans are not caring for a litter of young ones as rats do.

To go on, let’s look at the statement that a kind of intervention can be instrumental in methylating certain genes. This is a rather staggering leap of logic. For one thing, it suggests that  behavioral change through psychotherapy results from change at the genetic level, caused by the therapy. As we have yet to understand any specific relationships between human genes and human behavior, the suggestion that changed genes mean changed behavior, and vice versa, is far from warranted. Unless we are to assume that all learning results from genetic change (which would be absurd), this cannot be a correct connection to make. Even if we were to have evidence that some intervention changed some genetic material, which we do not, it would be necessary to show systematic evidence supporting the claim that any other intervention had the same effect.

In addition, in this particular case of generalization, there seems to be a questionable assumption that human beings can at any point in their development be influenced in their genes and behavior by treatment, in ways parallel to the effects of cross-fostering on rat pups very early in their development. It’s curious, too, that on an Internet site so devoted to the ill effects of adoption on development, the comparison is made to cross-fostering and reversal—these rat pups were reported to do better with “good” mothers rather than to suffer from separation from the birth mother.

 Unfortunately, it is becoming all too common to see claims that because established research evidence supports part of an idea or a practice, it can then be assumed that the whole idea or practice is equally evidence-based.  When this approach is applied to epigenetics, some wild conclusions can be drawn in the course of attempts to translate lab findings into social recommendations (as Juengst et al noted in Trends in Genetics,    
(My thanks to Yulia Massino for suggesting this source.)

The lessons of “blinding with science” are applicable not only to epigenetics, but to a variety of other attempts to bring scientific concepts to bear on what are essentially pseudoscientific ideas and practices. One example is the effort to bring quantum mechanics into explanations of various “energy therapies”. Another is the enormous proliferation of supposedly brain-based educational interventions that emerged from the “split-brain” work of Roger Sperry (for an account of this, see Michael Staub, “The other side of the brain: The politics of split-brain research in the 1970s-1980s”. History of Psychology, 19(4), 259-273).

Moral: Before hurrying to conclusions about application of research findings to the more complicated world outside the lab, we need to ask ourselves—“exactly what does the research have to do with the practical problem we’re worried about?” Often the answer will be “Nothing—yet.” Realizing that can help keep us from treatment scams of which there are so many looking for suckers.


Saturday, November 5, 2016

More Parental Alienation: What Are the Characteristics of Rejected Parents?

Internet sites focused on “parental alienation” (PA) during high-conflict divorces give vivid descriptions of the behavior and moods of children who unreasonably reject and avoid one of the parents, while preferring and seeking the other one. Some such sites also describe the preferred (or “alienating”) parents as suffering from personality disorders like narcissism, which drive them to brainwash children and to make false accusations against the rejected parent. These descriptions are questionable and concerning because in most cases the preferred parent has not been seen by the practitioner who suggests these diagnoses.

There seems to be much less discussion of the characteristics of the rejected parent. Does rejection take place “at random”, so anyone involved in a high-conflict divorce is as likely to be rejected as anyone else in a similar situation? Or are there characteristics and behaviors—other than actual abusive treatment-- that make a parent more likely to be rejected by his or her child? Given that human relationships are ordinarily transactional, or influenced both by characteristics of all members and by time and experience of interaction, it seems most likely that everyone in the conflict contributes something to what happens, whether for good or ill.

Not surprisingly, and quite humanly, rejected parents tend to feel that they have done and said nothing that would make the children reject them. But as it turns out, there have been a few comments on how characteristics of rejected parents may help to drive the process of rejection. These suggestions are not based on careful empirical work with large numbers of cases and so should be considered with some caution, but I think they are worth a look.

Descriptions of characteristics of rejected parents have been given by Barbara Jo Fidler, Nicholas  Bala, and Michael Saini in their 2013 Oxford University Press book Children who resist postseparation parental contact, and were further discussed by Nicholas Bala and Katie Hunter in a 2015 Queen’s University Faculty of Law research paper (“Children resisting contact & parental alienation: Context, challenges, & recent Ontario cases”; 2015-056).

Here are some of the characteristics suggested as more likely to belong to parents rejected by their children in the course of a high-conflict separation and divorce, as described by Bala and Hunter:

·         Harsh, rigid and punitive parenting style
·         Outrage at child's challenge to his/her authority
·          Passivity or withdrawal in face of conflict
·          Immature, self-centered in relation to child
·          Loses temper, angry, demanding, intimidating character traits, but not to level of
abuse (an important point, as a parent may not perceive this “permissible” behavior as problematic—JM)
·          Counter-rejecting behavior (the parent responds to the child’s rejection with coldness and hostility—JM)
·          Lacks empathic connection to child
·         Inept and unempathetic pursuit of child, pushes calls and letters, unannounced or
      embarrassing visits

·          Challenges child's beliefs and/or attitudes and tries to convince them otherwise
·          Dismissive of child's feelings and negative attitudes
·          Induces guilt
·          May use force to reassert parental position (this, of course, may be easier when a court has been persuaded to order treatment including an abrupt custody change, or transport of the child to a treatment facility by hired “transport staff”—JM)
·          Vents rage, blames alienating parent for brainwashing child and takes no

I would add to these points a term that I have not heard used for some years, but which I think describes an important consideration in both high-conflict and other divorces. The term “funneling” has been employed to describe situations where a noncustodial parent  
continues to treat a visiting child just as he or she did when last sharing a home with the child—for example, if the separation occurred when the child was three years old, the parent may continue to read the bedtime stories the child liked then, even if five years have passed, or may continue to come into the bathroom at will even when the child is nearing puberty. These are not abusive behaviors, but certainly demonstrate a lack of empathy and therefore (when combined with other factors) may be part of the picture when the child rejects and avoids the parent.

My point in this post is not to attack or defame rejected parents, but simply to say that because human relationships are largely bidirectional and transactional, it would be surprising if child custody issues did not share those characteristics. Therefore, we could hardly expect rejection of a parent to be due entirely to the character traits and actions of the preferred parent, or even to those of preferred parent and child combined. Neither could we expect genuine changes in relationships to be brought about simply by custody change without serious work to alter the factors the rejected parent brings to the situation.

However, I want to emphasize the fact that none of the descriptions of either preferred parent or rejected parent characteristics are at this point supported by systematic investigation of a large number of cases.