Concerned About Unconventional Mental Health Interventions?

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

Saturday, April 22, 2017

What Are the Probable Earliest Signs of Autism?

Of the comments and queries I receive on this blog, the greatest number are from parents concerned that their babies are showing signs of autism. Of questions about autism, almost all of them focus on a lack of eye contact—the babies do not gaze at their parents’ faces as much as the parents expect them to.

Most parents, and certainly many Internet authors who discuss autism, assume that whatever are the signs and symptoms of autism in older children and adults, those will also be the signs and symptoms of autism in young infants. They know that social awkwardness and a lack of eye contact and other communicative gestures are common among older children with autism spectrum disorder (ASD), so they assume that infants who are fated for an ASD diagnosis will also lack eye contact. But in making this assumption they miss two important points.

The first point is that infants in the first two or three months are not easily attracted to pay attention to people. They will do it now and then, but often they respond only to quite dramatic adult facial expressions with wide open-mouthed smiles. Years ago, this developmental period was referred to as a stage of normal autism—the word “autism” deriving from the Greek word for “self”, and the babies being focused on themselves rather than the environment. Now that people are terrified about ASD, one doesn’t come across this expression, normal autism, any more, but that doesn’t mean that the stage no longer exists. What would be a symptom of ASD in an older child is a sign of perfectly normal development in a young infant. There is no point in expecting a baby of a few months to make extensive eye contact, any more than there would be any point in expecting her to build a tower of two blocks or to spoon-feed herself.

My second point is that earlier and later behavior patterns may be remarkably different in cases where there are developmental problems. A good example is the pattern shown in Williams syndrome, a genetic syndrome resulting from loss of certain parts of a chromosome. Williams syndrome is not terribly debilitating, but it does cause developmental changes that are rather different from typical development. Young babies with Williams syndrome are terribly colicky and cry frantically no matter what is done to soothe them. They are not interested in other people at that point. But when the colicky stage passes, they become extremely interested in people, stare at them intently, and appear to be “starved” for eye contact. We might expect them at this point to be very interested in communication and to speak early, but no; in fact, their speech is delayed by about a year. Once they do start to speak, they became chatty conversationalists. As adults, they are still talkative, with wonderful language abilities, and highly sociable—but socially awkward at the same time because they seem to lack the social anxiety that guides most of us. The screaming colic and delayed speech of the younger Williams syndrome individual are by no means symptoms of either the strengths or the weakness of the Williams adult—and it’s very possible that a similar situation holds for ASD people, whose later symptoms may not mirror the earlier ones (if there are any).

A possible conclusion from these two points is that the current preoccupation of parents with eye contact may be irrelevant to the diagnosis of autism. The fact that older ASD children may not use eye contact for communication very much does not mean that we can identify infants who will later be diagnosed with ASD by looking for them to make eye contact.

A recent paper on autism  provides some interesting insights into possible early symptoms of autism. (Thomas, M., Davis, R., Karmiloff-Smith, A., Knowland, V., & Charman, T. (2016). The over-pruning hypothesis of autism. Developmental Science, 19, 284-305.) This is a very complicated paper, and I am only going to refer to one of its points here.

The Thomas paper is one that discusses an idea about how ASD develops. The basic idea is that autism results when a particular problem occurs during early development. It is well known that during the first year, there is great overdevelopment of synapses or connections between neurons in the brain, followed by disappearance of many that are little used—a process sometimes called “pruning”. Although some authors have suggested that autism results from too little “pruning” of synapses, Thomas and his co-authors hypothesize that too much “pruning” could be the problem. They have tested this hypothesis by developing a neurocomputational model to allow them to predict what kinds of problems should result from excessive “pruning”.

Like all good scientists, Thomas and his colleagues are testing their model against some longitudinal studies of development of autistic children, and to some extent are finding that the longitudinal studies show the symptoms they predict on the basis of the timing of pruning events during early development. These do NOT include symptoms of social interaction problems. They do include difficulties with sensory development like over- or under-sensitivity to sound or touch stimulation, and difficulties with motor development. Motor development problems as a precursor to autism have been discussed since the 1980s, when studies of home videos were sought by researchers as a way to see the early development of children later diagnosed with ASD. Even before that, clinicians had noted that unusual movement patterns like crawling asymmetrically or always reaching with one hand during early childhood were related to a variety of later developmental problems. These sensory and motor problems in the first year or two may indicate that children will later show the social interaction problems often associated with autism—even though the children when younger do not show unusual social interactions.


The sensory and motor forerunners of autism are not yet clearly understood, so they cannot be used for accurate  identification of “pre-autistic” babies. In addition, many young children who are thought to be autistic at age 2 show normal development later. Much as we might like to have early identification and early intervention, we don’t have it yet. But if identification and intervention are ever going to work, they will have to be focused on development that is really not typical—and it is quite typical for babies in the first weeks and even months to look at things other than faces a good deal of the time.  

Wednesday, April 19, 2017

Qigong Parent Training (Believe It or Don't)

Today I received an email from a professional group I have respected in the past. They invited me to attend a session about qigong training for parents. I am somewhat startled about this, especially because this group, like others of its kind, is supposed to be alert to the evidentiary foundations of methods they recommend. They need not restrict themselves entirely to evidence-based treatments, because there may be perfectly good treatments that have not yet been thoroughly researched, but they should not be suggesting methods that are neither research-based nor plausible. They apparently don’t know this.

Qigong is a method that the National Center for Complementary and Alternative Medicine classes as a “putative energy therapy”. This classification indicates that qigong is said by its proponents to involve a field of energy (qi) that fills the body and surrounds it, but this energy is not electricity, light, or heat, and is not measurable by any physical means. Qi is thought not only to surround and fill the body, but to flow dynamically along meridians or pathways that connect body parts. If qi movement is blocked, there is resulting pain or distress. Of course, the distress experienced by the individual is the only thing that indicates to proponents that there is blockage of qi, or indeed that there is qi at all, since it cannot be measured.

Like many other “energy” methods, qigong is claimed to be an ancient tradition handed down for centuries. Although the practice does use traditional Chinese philosophical systems and meridian charts, the anthropologist David Palmer, in his 2007 book, dated current qigong practices to 1949. The method was created by a Chinese political functionary as a body training technique combining breathing techniques, meditation, and gymnastics—with the traditional belief systems omitted. In the 1950s, qigong became popular in China as political objections to foreign influences developed and there was new encouragement of Chinese traditions.

In the 1970s, however, a new group of qigong masters began to claim that they could “externalize” their qi , focus it on patients, and cure them, even at a great distance. Followers began to experience trances, “holy rolling”, and speaking in tongues, much as charismatic Christians sometimes do. Participants no longer needed to achieve skills  in qigong themselves, but could depend on a master to heal them. The Chinese government began to find these activities embarrassing and tried to suppress them, leading to emigration of qigong masters to the West.

There have been some attempts to demonstrate systematic evidence for the effectiveness of qigong (for example, a 2010 study by Oh et al). Unfortunately, like studies of other unconventional treatments I have mentioned on this blog, the research on qigong failed to isolate the variable being tested. For example, in the Oh study of the effect of qigong on fatigue and mood of cancer patients, patients were randomized either to a group that met twice a week for 90-minute qigong sessions, or to a “usual care” group that did not meet. This means that any differences between the groups may be due to social contact, to expectations, to the relationship with the leader, to effects on their qi, or to all these factors or many others.

The existence of qi, an undetectable entity, is not plausible, and attempts to manipulate qi have not received the appropriate testing that might or might not establish an evidentiary foundation for the practice. So—does that mean that training parents in qigong is a bad idea? It’s true that doing qigong will probably not hurt anyone directly, so in that sense the practice is a harmless one, however implausible. However, there are a number of problems associated with encouraging parents to believe unlikely methods or explanations. One is that parents who are convinced that they know the secret way to health for their child may reject conventional medical help when it is badly needed (yes, I’m talking about Christian Scientists too).  Another problem is that parents caught up in unconventional treatments may be unduly influenced by practitioners whom they admire, and may be unable to realize that they have been drawn into a cult that can have ill effects both on their children and on themselves. To state just one further point: of course, no one expects either conventional or unconventional practitioners to give their services for free, and parents involved with unconventional and ineffective treatments may find at the last that they have no resources to use for effective treatments.      


Netflix and Misunderstandings About Suicide

The recent release of 13 Reasons Why on Netflix is worrisome to mental health professionals and to parents who need to talk to their older children about the realities of suicide. Please go to this link for a very helpful approach to this problem:

https://700childrens.nationwidechildrens.org/13-reasons-parents-concerned-netflix-series/

If you are concerned about the issue, you may also want to see https://www.suicideinfo.ca/resources/

Keep in mind that talking about suicide does not cause suicide, and if your children are watching the Netfliz series talking to them may be one of the best things you can do.

Friday, March 24, 2017

Critical Thinking About Child Custody, Especially Parental Alienation Claims

I recently received a document relevant to decisions about a girl who prefers Parent A but has been sent to live with Parent B. She had been ordered to receive treatment for the “parental alienation” by Parent A  that is argued to be the reason for her preference for A over B. The girl, whom I will call Sophie, is 14; the parents have been apart and in high conflict since she was 11. Parent B has asked the court’s permission to move Sophie, along with Parent B and B’s romantic partner, to a neighboring state, where they are now living and where Sophie is attending school.

B has asked a proponent of a treatment for parental alienation  (let’s refer to him as Mr. P. Pat) to comment on Sophie’s present status and to support the argument that B, the partner, and Sophie should all remain together in the new state, and Parent A should be prohibited from all contact with Sophie. Mr. P. Pat argues that Sophie is doing much better now than she was at age 11, when the parental separation began. She is doing well at her school, studying music, and roller-skating This shows, Mr. P. Pat says, that Sophie has benefited greatly from 1. Separation from Parent A, and 2. Her experience of the Pat method of therapy for parental alienation effects. What’s more, Sophie’s improvement is evidence that the problem was indeed parental alienation. Mr. P. Pat also argues that Sophie must not have contact with Parent A because even the slightest contact will undo all the benefits she has received.

Let’s examine these arguments a bit (it won’t take much). Mr. P. Pat is taking advantage of the tendency most of us have to fall for the argument that post hoc  means propter hoc—that if one event follows another, the second one must be caused by the first. For example, if I eat a mango for the first time and I shortly develop a skin rash, post hoc reasoning suggests that the mango caused the rash—maybe I’m allergic, maybe it was contaminated by some agricultural chemical. But, of course, I could have a rash because I’ve contracted rubella, or because I’m allergic to something else I ate in the same meal with the mango, or because I put my arm on a table that had been polished with a furniture polish I’m sensitive to. All those things could have happened before the rash, but post hoc reasoning often chooses just one of the previous events and firmly assigns causation to the chosen possibility.

How does post hoc reasoning apply to Mr. P. Pat’s claims about Sophie? He states that she has received his treatment and that she is doing well (a claim made without any independent evaluation of Sophie, by the way) and that, therefore, the treatment must have caused her to do well (post hoc, ergo propter hoc). Let’s suppose, for the sake of argument, that Sophie is indeed doing well. What alternative hoc factors can we consider to be possible causes of Sophie’s status?

First, we need to think about maturational changes—changes in personality and behavior that normally accompany advances in chronological and developmental age, no matter what experiences the individual is having. The effect of maturation is one that is largely ignored by proponents of fringe beliefs about child development issues, and regrettably is also ignored by laws that classify humans from birth to age 18 as children, without further definition. Between age 11 and age 14, Sophie has passed through some important steps in development. Physically, this would have entailed puberty, with rapid physical growth and changes in appearance as well as reproductive maturation. Cognitively, Sophie would experience advances in executive function and in formal operational thinking, the capacity to think hypothetically and to separate variables from each other. Emotionally, she has moved through a phase of mercurial, “temperamental” responses, including unpredictable crying and anger, to a calmer responsiveness; she has also moved from a period of life in which family relationships are paramount to one in which peer relationships and school events take precedence emotionally. All of these make Sophie a different person than she was at age 11 and make her in many ways easier to deal with than she was a year or two ago.

Other changes have also taken place in Sophie’s life. One is that she and her parents and siblings have moved toward resolving their feelings about the parents’ divorce. To do this, Sophie had to disengage from the parents’ conflict and focus on her own life, a task that would be made much more difficult by insistence on the idea of parental alienation.

In Sophie’s case, her forced separation from Parent A has included separation from a sibling. She now lives alone with B and B’s romantic partner. This change has removed her from all the possible influences of her sibling for good or ill—the sibling may have encouraged or have discouraged Sophie from her positions about A and about B, may have provided comfort when Sophie was distressed about the family situation or may have acted to distress her further, and may or may not have provided a role model for a constructive response to both parents’ wishes.

Sophie has also moved away from a neighborhood and a school where most adults and many classmates were likely to have known about the parental conflict and to have weighed in on one side or the other. She is beginning high school and has much to get used to in a new school setting, distracting her from the family focus she probably had earlier.

This is enough of a laundry list to demonstrate my point that Sophie’s situation is post more than one hoc, yet Mr. P. Pat points to a single factor as the cause of any changes to be seen in Sophie. He has apparently failed to look for evidence for alternative rival hypotheses, either about the initial diagnosis of parental alienation or about the effects of the treatment.

An article by Dr. Madelyn Milchman discusses a better way to handle the task of understanding child or family problems in the context of child custody evaluations. (Milchman, M.S. (2015). The complementary roles of scientific and clinical thinking in child custody evaluations. Journal of Child Custody, 12, 97-128.) Dr. Milchman pointed out that scientific hypotheses are well-formulated only if they are falsifiable – only if it is possible for observable evidence to be used to reject the hypothesis. A hypothesis that appears to be supported by any possible observation is one that cannot be rejected and therefore is not useful for understanding events. In clinical work like child custody evaluation, practitioners are not doing scientific hypothesis testing in the usual sense, but they need to avoid their own biases and presumptions by testing their own preferred hypotheses and possible conclusions about a family. They do this by looking for consistency of evidence and pursuing issues of inconsistencies, and they also do it by formulating alternative hypotheses to see whether the evidence supports one or more alternatives better than it supports their preferred hypothesis.

Like scientists, clinicians cannot “prove” a hypothesis beyond the shadow of a doubt. The job is to try to disconfirm a hypothesis and to accept it only when the evidence does not disconfirm it.  For the clinician, this involves thinking about other causes that can explain evidence that is consistent with the preferred hypothesis. In Sophie’s case, the preferred hypothesis, that treatment has changed her behavior toward her parents, is weakened by the existence of a list of other factors that may have worked individually or together to alter her attitude. Clinicians also need to think about evidence that is inconsistent with a preferred hypothesis. In Sophie’s case, such evidence might be revealed by an assessment by a psychologist who has not been involved in her treatment (and ideally, one who is not committed to the idea of parental alienation). According to the documents I have seen, this possibility has been refused by Parent

Tuesday, March 14, 2017

I'll Get to Scotland Before Ye: "Parental Alienation" Again

I recently received several documents related to an accusation of “parental alienation” (defined by its advocates as the intentional persuasion of children by one, perhaps mentally ill, parent, that they should avoid and reject the other parent). Proponents of this idea assume that unless there has been demonstrated abusive treatment by the rejected parent, such rejection is prima facie evidence that the preferred parent has emotionally manipulated the children. Such manipulation, they claim, is in itself prima facie evidence that child abuse has occurred and that the children’s mental health is threatened, so they must be rescued from the preferred parent and given treatment that will restore their mental health and with it their affection for the currently rejected parent.

There’s a lot of prima-facie-ness here, it seems, and the implausibility of these claims extends to the documents I received.

Much as I hate to do this, I am not going to reveal the source of the documents, the name of the family they allude to, or the treatment program involved. I am afraid that the identification of the source of the documents would cause trouble for someone. I am not going to discuss family details, but will focus on some of the claims made by people who assessed the family and then proposed and carried out a treatment that closely resembles other “parental alienation” treatments. It abruptly removes children from their home, places them in close contact with the rejected parent, and uses videos, games, and some threats to try to change the children’s attitudes. How is such a serious proceeding initiated ? A court order is obtained, upon the recommendation of the treatment proponents, who have been hired by the rejected parent.

There is much to be said about this situation, and I have already said various things to the effect that I am sure it is possible for “parental alienation” (as defined above) to occur, but that I see no evidence that it occurs often even among high-conflict divorcing families. I have also noted that proponents of treatments for the supposed problem have given no real evidence that their methods are effective ways to change children’s attitudes—although I have no doubt that the inclusion of threats will change children’s behavior.

In this post, I want to touch on the issue of evidence for effectiveness of treatments. To the best of my knowledge, there have never been either randomized controlled trials of the treatments, or well-designed nonrandomized studies. Instead, one proponent of a treatment claims that he has evidence for the effectiveness of his treatment in the form of a single-subject ABA design. This research method looks at behavior during one set of circumstances, usually just everyday life with no treatment given (A); then creates a new condition, generally involving an intervention of some kind (B) and looks at behavior during that period; finally, the A situation is returned and behavior is again observed. Graphs or other displays show whether the change from A to B, and back again, is accompanied by a change in the behavior of interest (in the parental alienation case, of course, this would be rejection of one parent).

That proponent notes, in one of the documents I have, that this method is “one of only two research designs that can definitively determine causality, the other design being a randomize control experimental design”. There are several problems with this statement. One is that no research design “definitively” determines causality, as the results of psychological research are reported in terms of the probability that a given outcome has occurred by chance alone, and this probability may be close to 5 % in cases where a significant difference between groups is found. In addition, a textbook on research in education points out that ABA designs are weak in terms of external validity and require many replications followed by a randomized study before the conclusion that a treatment has a given effect can be drawn.

The proponent of the treatment runs into an additional problem when claiming that the treatment causes a change in the child’s behavior. ABA studies are normally careful to identify a single variable whose effect is to be tested and to hold constant other factors that could affect child behavior. The treatment in this case changes multiple factors between A and B, and between B and a return to A. A, the original situation, has the child in his or her own home, with normal opportunities for play and other preferred behaviors, and in the company of the preferred parent. The B situation abruptly removes the child from the familiar setting and places him in an unfamiliar place, in the company of the rejected parent and of a therapist who demands attention to videos and may make threats about the child’s uncomfortable placement elsewhere if he or she does not cooperate, or about continuing separation from the preferred parent. The return to A  returns the child to a familiar, unpressured social and physical environment. Are we surprised that behavior would be different in A and in B, particularly in the light of threats made in the B situation? The failure to isolate an independent variable makes this use of ABA ineffective as a research design.

There is a further important point about material in the document that makes claims about the conclusions drawn from a variant on the ABA design. The document states that “A single-case ABAB reversal design quickly and efficiently identifies the cause of the issues and restores the child’s healthy development as quickly as possible.” The results of either ABA or ABAB studies are irrelevant to this claim. If well done, such studies could show that a treatment was effective in changing a behavioral symptom. This, however, would not identify the cause of a problem; causes of problems are not being studied by this method. (As an example, let me point to applied behavior analysis as a treatment for autism, where the fact that an operant conditioning technique is helpful to the child does not mean that he was autistic because the parents used different methods in their child care routines.)  

It seems that the “parental alienation” proponents involved in these documents are inclined to fancy footwork rather than logical analysis as they put forward claims for their methods of assessment and treatment. Unfortunately, it would appear that judges and attorneys have in some cases fallen for this line of chat, and challenges have been few.

(Could it possibly be that people who have heard once or twice of applied behavior analysis—also called ABA—recognize that abbreviation and think “oh yeah, that’s a thing, I heard of it”? I hope not, but stranger things have occurred.  )



Sunday, March 5, 2017

Are You a Good Enough Parent? How Can You Tell?

A friend was telling me yesterday about some conversations she’s had with her niece, who is the mother of a one-year-old. The young mother seems to be in a sort of “mother’s arms” race with her friends, who vie to find the latest thing that absolutely must be done for the baby, the toy that must be bought, and the classes mother and child must be involved in. My friend’s niece is getting pretty exhausted but fears the consequences of giving up the competition. So, my friend, quoting me quoting Donald Winnicott, said, “all you have to do is be a Good Enough parent.” (Actually Winnicott talked about a Good Enough Mother, because this was before fathers became parents.)  

But the niece cut through all these fine words by asking, “How do I know whether I’m a Good Enough parent?” Friend and I were both stymied by this one, and I resolved to try to give it some thought.

The idea that you just have to be “good enough”, not perfect, in parenting is really derived from what we know about young children’s physical growth. If a child has a normal, “good enough” diet, he or she will grow to the height dictated by genetic characteristics. Giving the child an even better diet, with extra vitamins, protein, and so on, will not make the child grow taller than the limits set by heredity. On the other hand, a less than “good enough” diet will result in less adequate growth and diminished stature relative to genetic possibilities, in childhood and adulthood. This gives us a pretty good idea about what is a “good enough” diet, because we can see direct effects of diet on growth in height (and even more importantly, growth in head size).

All right—now we have a useful metaphor to guide us in thinking about being a “good enough” parent. You know a diet is “good enough” when the child grows as is typical, or that it isn’t “good enough” when growth is slowed. What can we look at in the child that will tell us whether the parenting is “good enough”? 

This is an answerable question, but like many points about development it depends: it depends on age. This may be chronological age for typically-developing children or developmental age for children with challenges, but it’s critical to understand that indicators of good development will be different for different ages. We would not expect a two-week-old to make eye contact with a parent, but we do expect that from a two-year-old. We would expect a two-week-old to show a strong startle reflex, but we would have reason to worry if a two-year-old still showed that reflex. It’s different strokes for different folks… of different ages.

Let’s look at what might be some good indicators of “good enough” parenting and resulting development for a one-year-old. These aren’t all the possibilities, but they are ones that come to mind as important and pretty easy to observe.

  • ·         Has the child’s growth, including growth in head size, been typical since birth, according to the growth chart kept by the pediatrician?( It is not important that everything be at the 99th percentile, but it is important that the child stay at or above the percentile that was indicated in the early months.)
  • ·         Is the child working on motor achievements like pulling to stand, bearing weight on the legs, or even independent walking? (It does not matter if the child has never crawled or if other motor achievements like rolling over have been delayed relative to “the book”; if the baby has been sleeping supine, they probably have been a bit delayed )
  • ·         Is the baby interested in familiar people? Does he or she explore your face, put a finger up your nose or in your mouth, grab for your glasses or earrings?
  • ·         Is the baby starting to feed himself, with finger foods or spoon, with bottle or cup?
  • ·         Does the baby play peek-a-boo, either by watching breathlessly as you hide your face or by covering her own face and then popping out joyously?
  • ·         Do the baby and a parent have at least ten minutes in a row of fun together at least once every day? (You can count games at feeding or bath time provided you both enjoy them.)
  • ·         Does the baby communicate by pointing, by facial expression or moving the head away from something, by vocalizing?
  • ·         Does the baby look where you look or pay attention to words you use by looking for an object?
  • ·         Does the baby look for an object you’ve hidden while she watched?
  • ·         Does the baby throw or drop things and watch what happens to them? (This includes food, full sippy cups, etc.)
  • ·         Is the baby very rarely apathetic, uninterested, disengaged, lethargic?
  • ·         Can you usually comfort the baby when he cries?
  • ·         Does the baby look or move to you when something scary happens?


If the answers to most or all of these questions are “yes”, you can figure that what you have been doing is Good Enough. Your baby’s development is showing you that you are providing the needed environment, so just keep on with what you’re doing.

 But please keep three things in mind. One is that you may have been doing an excellent parenting job, but if your baby is chronically sick, injured, or developmentally challenged in some way, the results of your good parenting may not be as obvious as you’d like. The second is that, once again, these questions are age related. A six-month-old will not do the same things as a one-year-old no matter how good the parenting is, and a two-year-old will have moved along in many ways. The third is that—just like what we saw about extra protein—extra toys, CDs, videos, classes, and toys will not make the baby’s development extra good; in fact, concentrating on those extras may rob a baby of the pleasant daily routines and fun that are the foundation of cognitive and emotional development.


Dr. Spock once said that bathing a feverish baby in cool water worked just as well as an alcohol rub, but it “didn’t smell so important”. Being a parent whose everyday caregiving is really “good enough” may not smell as important as chasing the latest toys and classes, but it may work even better than the fads do.

Thursday, March 2, 2017

Reactive Detachment Disorder is Fake News

Are you worried that your adopted, foster, or even biological child could have Reactive Detachment Disorder? Well, don’t be. There is no such thing.

Of course, that simple fact has not stopped various people from using the term Reactive Detachment Disorder. My first encounter with the expression was in about 2003, when I saw this expression used on a quite respectable Internet medical information site. I emailed them about it and they quickly admitted their mistake, apologized, and made the correction. Nevertheless, Reactive Detachment Disorder has remained a notional diagnosis, from the earliest example I can find, a 2002 discussion of the Hansen child starvation case in Utah, to the present day. A 2007 book by P.A. Potter, “Jekyll and Hyde: Arrested development and personality disorders”, refers to Reactive Detachment Disorder in adult criminals. Current websites like www.freedomfrommedom.com and www.health247.com come up in response to a Google search for Reactive Detachment Disorder (although some of these sites actually talk about Reactive Attachment Disorder). Reactive Detachment Disorder is referenced as associated with crime at www.archive.courierpress.com (“Defendant’s mental health scrutinized on first day of trial”) and given as a reason for judicial leniency at www.valleyjournal.net/article/17093/Negligent-homicide-case-headed-to-youth-court.

 In many of these cases, Reactive Detachment Disorder is said to be connected with antisocial behavior in adolescence or adulthood. This suggests that what the speakers/writers are really talking about is the equally notional “Attachment Disorder”, another faux diagnosis perpetrated by proponents of a belief system that attributes violent, aggressive behavior to past difficulties with emotional attachment. This is a view created by such luminaries as Foster Cline and Nancy Thomas. Recent information about the Institute for Attachment and Child Development in Colorado, to the effect that the Randolph Attachment Disorder Questionnaire (RADQ) is still used there, suggests that the IACD staff is committed to the same belief system, although they do not use the term Reactive Detachment Disorder.

What does it mean to say that there is no such thing as Reactive Detachment Disorder? This is not to deny that there is antisocial, disturbing behavior shown by both children and adults. It is, however, a denial, first, that this term is ever used among knowledgeable mental health professionals; second, that assumptions associated with the term (as in its connection with “Attachment Disorder”) are correct; and finally, that the term is among those listed in either of the two professionally-developed sets of mental health diagnoses, the International International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM).

The term Reactive ATTACHMENT Disorder does appear in both ICD and DSM.  It is not applicable to older children ,adults or adolescents. It does not involve aggressive behavior. Here are its symptoms:
 A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
      The child rarely or minimally seeks comfort when distressed.
      The child rarely or minimally responds to comfort when distressed.
B. A persistent social or emotional disturbance characterized by the following:
      Minimal social and emotional responsiveness to others
      Limited positive affect

Of course, this description of symptoms does not deny that some children show aggressive, disturbing, antisocial behavior, of the kind that the term Reactive Detachment Disorder seems to include. Such behavior is associated with the idea of callous-unemotional traits, with conduct disorder, and with oppositional defiant disorder—all legitimate diagnostic categories. I’ve discussed this before, at https://childmyths.blogspot.com/2016/11/conduct-problems-and-callous.html.

As I pointed out in that post, there is much confusion about Reactive Attachment Disorder, which is widely assumed by journalists and poorly-trained therapists to involve antisocial behavior and to be present in adolescents and adults as well as young children. The “RAD defense”, claiming that an attachment disorder caused a crime, has been around for a while—and disturbingly, this defense includes not only the idea that a person with RAD is likely to be a criminal, but the claim that a child with RAD may be so evil that an adult caregiver is forced to kill the child. Isn’t this enough confusion? Why bring the notional Reactive Detachment Disorder into the picture?

The use of the “detachment” term probably began as a simple mistake, but I would speculate that it would be a tempting thought for the Cline-Thomas mindset. A child is detached—how wrong! Children are supposed to be attached, and in the belief system in question that means that they are obedient, compliant, attentive and affectionate and grateful to parents. They are “respectful, responsible, and fun to be around”. They respond enthusiastically to parents’ offers of affection (“on the parents’ terms”) but they do not demand attention or affection on their own terms. In other words, they allow their parents to be detached, to be unresponsive and inattentive to the relationship except when in the mood; the ideal child in this mindset is always available and interested in emotional contact with the parent, is never angry or disappointed when ignored or rejected, and asks for nothing but what the parent wants to give. A child who doesn’t meet these standards must be mentally ill, or simply willful, and draconian methods are needed to make the child “attached” while still allowing the adults to be detached. However, the pathology here seems to be not so much in the child as in the parents or practitioners who promote these beliefs and practices.

In sum, there are a lot of really bad ideas implied by the term Reactive Detachment Disorder, and it does not provide any meaningful information for the use of parents, mental health practitioners, or the courts. It would be a step forward if journalists and others would stop using Reactive Detachment Disorder and seek a real—and appropriate—diagnostic category.



Wednesday, March 1, 2017

If You Have Queries About Infant Eye Contact

A number of people have brought up questions about infant eye contact on pages that are so full that no more comments can be published. It's really difficult for me to move those comments to other pages and to be sure you can see them!

If you have recently asked a question on this subject and have had no answer, please put your comment HERE on this page.

Friday, February 17, 2017

Children and Obedience: A Clinician's Perspective

A recent discussion on a child psychology listserv brought up once again some misunderstandings about Reactive Attachment Disorder. One correspondent, who spoke of a child who had been diagnosed with RAD, surprised me by offering the old holding-therapy-related symptom list, including “superficial charm” and “lack of cause-and-effect thinking”. I responded by pointing out that even now, when few practitioners do holding therapy, there are dangers in the associated authoritarian belief system—a system that considers disobedience a symptom of poor attachment and holds that once a command is given, a child must be made to comply with it. (This view was the one that led to the death of Candace Newmaker in a situation which was not in itself dangerous unless pushed much too far.)

 During the ensuing discussion, some really valuable comments about obedience were made by Dr. Bradley White, a clinical child psychologist at Virginia Tech, and I asked him whether I could summarize and quote some of what he said for this blog. In his very nice message of agreement, Dr. White commented on how much he has learned about these issues from his own children, but I want to point out that he learned from them because he was paying attention, not because he just happened to be in the same house with them!

Dr. White’s remarks stressed what early-childhood educators call developmentally appropriate practice: the understanding that an action can have different motives and meaning when performed by a child at different times in his or her life. When belief systems or associated treatments assume that all disobedience or noncompliance is pathological, they fail to take developmental changes into account and therefore lack real understanding of what the child’s behavior means from his or her own perspective. These mistakes lead to behavior that fails to provide an adequate model for the child—often at the same time that the adult is expressing concern about the child’s lack of empathy.

Dr. White commented: “If one sees noncompliance as developmentally appropriate and expected, it may simply be accepted and either ignored or redirected. If it is seen as problematic but functional or reflecting a skills or knowledge deficit, it may be helpfully viewed as a learning opportunity requiring extra support including gentle exploration, guidance, and rehearsal of alternatives.” (When adoptive or foster children have had few opportunities for leaning about social behavior and social relations, this viewpoint may be especially helpful. JM) Dr. White pointed out that when child behavior is always interpreted as provocative or manipulative, parents may see punishment as the only suitable  response—potentially damaging the child’s attachment relationship with the adults as well as teaching the child coercive methods for solving problems. Parents’ interpretation of child behavior helps determine how, and how effectively, they respond to the behavior.

Commenting that becoming socialized (understanding social rules and taking the perspectives of other people) takes many years and progresses slowly, Dr. White also made this important statement: “I think we adults are … often impaired at seeing the world through the eyes of a child or adolescent, since it calls for empathic sensitivity and perspective taking, which often don’t come automatically but require effortful focus. Yet from a child’s point of view caregivers are often overly demanding and distracted due to their over-involvement in boring, confusing, or simply weird and senseless adult-level responsibilities e.g. getting the kids to school on time, holding down a job, maintaining order and organization), in contrast to the things  perfectly reasonable kids care about (e.g., eating sweets, sleeping in, grabbing others’ attention with gross/silly/provocative acts, having fun now, and exploring how the world works by pushing and pulling on it and tossing it all around the house and yard, etc.).” In addition, Dr. White pointed out, it’s hard to cope with adult demands when tired, hungry, excited, and so on—“which arguably summarizes at least half of the day of an average healthy young child.”

Neither Dr. White nor I wants to argue that children don’t need to comply with rules and adult requests. Safety alone demands a certain level of obedience and cooperation, because adults often are able to foresee dangers that children know nothing about. The point here is that there are many reasons why a developing  child may sometimes--  perhaps often—fail to comply with adult rules, ranging from the limited abilities of the young child to the budding negotiating powers of the preschooler to the growing autonomy of older children and adolescents.


 From a practical point of view, a partial solution to this problem may be to have few rules and make few demands, but to follow through carefully on the ones you have. A corollary of this would be never to institute a rule or make a demand that cannot be enforced, especially if the issue is that a child is not capable of obeying.  And, of course, working toward a good, mutually supportive and cooperative relationship between adult and child will do more good than all the exertion of authority in the world.


It is a huge mistake to define obedience or disobedience as indications of mental illness or as related to emotional attachment. Thinking in those terms increases parents’ anxiety and makes them feel that there is a crisis that must be addressed every time a child fails to comply. Such anxiety limits the parents’ ability to use the “effortful focus” Dr. White mentioned. It also makes the parents vulnerable to unconventional and potentially harmful ideas about children’s mental health. 

Thursday, February 2, 2017

Is Psychological Treatment the Same Thing as Education? (Not Really!)

On the whole, it’s pretty easy to tell whether a method of working with people should be labeled psychotherapy, or should be considered as an educational approach. Psychotherapies usually have as their primary goal some changes in a client’s moods and the behaviors related to those moods, and although there may be associated cognitive changes, the latter are not the major concern of the treatment. Education is ordinarily thought of as involving cognitive change and the mastery of new information and skills; the information and skills may have to do with social or emotional concerns, and a person may feel happier because of mastery, but these latter  are relatively minor points.

What do these differences have to do with the price of beans, or anything else? I am bringing them up here because I see that to an increasing extent, practitioners whose goal is mood and behavior change are claiming that what they do is not psychotherapy, but is education. It is certainly true that education can play an important role in psychotherapy, as clients or their families learn useful information about the nature of mental or behavioral disorders and come to understand better what is happening in their lives. (This is what is usually meant by the term “psychoeducation”.)  However, psychological treatment has different goals and principles from education.

Why would practitioners of one approach claim to be doing the other? The answer may be a simple one: psychologists’ work is regulated by state professional licensing boards to a much greater extent than educators experience. As a result, a person who is not licensed as a psychologist may be punished for claiming to provide psychological treatment, but almost any person may freely present himself or herself as providing education, “family life coaching”, or “parenting coaching”.  To be hired as an educator in a public school, an individual must have appropriate state certification as a teacher, but no such certification is required for “coaches”, teachers in independent schools, or tutors. If a person wants to provide services focused on mood and behavior change, but is not licensed as a psychologist (or other mental health professional), the easiest solution to the lack of licensure is to redefine the treatment as education. 

Let’s look at some examples of this problem. I recently posted an account given by a young woman who had experienced a program that claimed to alter her relationship with her mother (http://childmyths.blogspot.com/2016/09/when-threats-substitute-for-therapy.html). She and her sister were taken against their will by youth transportation service workers and transported to another state, where they were confined to a hotel room and forced into interaction with the mother and her boyfriend. They were shown videos of the kind often used in introductory psychology courses, but in addition they were threatened with disturbing options if they did not cooperate—placement in residential treatment centers or wilderness programs where they would be unable to communicate with anyone outside, and where escape would be difficult or even dangerous. A psychologist in charge of this treatment had already had his license to practice psychology suspended, but he argued, so far successfully, that what he was doing was not psychotherapy but was simply education, and that the state psychology licensing board could therefore not discipline him.

A New York Times article (“Weak support for treatment tied to De Vos”, 1/31/2017, A1, A21) yesterday discussed similar issues with respect to the company Neurocore, which has called itself an educational organization in the course of a trademark dispute. Neurocore employs neurofeedback methods, recording brain wave patterns that indicate attention or inattention and manipulating interesting material clients are watching, so that indications of inattention cause a video to freeze. The method is used for both children and adults with autism, anxiety, ADHD, depression, and so on, and there are plans for marketing the approach to elderly people with cognitive problems. Unfortunately, however, evidence that this method effectively treats any of the listed disorders is missing. If Neurocore called itself a purveyor of psychotherapy, regulation would be possible (although professional psychology licensing boards do not usually concern themselves much with the use of ineffective treatments), but as long as the treatment is “education”, it is not.  Yet it seems that that the purpose of the Neurocore treatment is to alter mood and behavior, not to effect cognitive changes, so classifying this approach as educational rather than psychotherapeutic does not make sense—except from the financial and regulatory perspectives.

A third example of calling a psychological treatment “education”  under questionable circumstances comes from the history of the Miracle Meadows School in West Virginia, which I discussed some time ago in this blog (http://childmyths.blogspot.com/2014/09/more-mistakes-about-RAD-time-to-mow-hay.html). Miracle Meadows, which was closed down some months ago, was a Seventh Day Adventist-sponsored institution that focused on emotional and behavior problems of teenagers, many of them adopted from other countries. In one case, a child was sent to Miracle Meadows from another state when her adoptive parents were under investigation for abusive treatment. In another, children in a Tennessee residential treatment program that has been accused of child abuse were threatened with being sent to Miracle Meadows if they did not cooperate. Miracle Meadows had been investigated several times for abusive treatment of residents, but had successfully argued in court that staff need not comply with guidelines about the use of physical restraint and seclusion with children, because as an educational institution they were not required to follow guidelines that were intended for residential treatment centers dealing with psychological problems. More recently, a series of complaints and investigations of staff actions led to the closing of Miracle Meadows, as the argument that abusive practices could be classed as “education” could no longer be sustained.

The moral of this story? When choosing a treatment for mood, emotional, or behavioral problems, especially one for children, watch out for those programs that call themselves “education” but claim to help non-cognitive problems. They are not well-regulated and may present themselves as educational only to avoid compliance with guidelines for mental health practices. If you like the idea of an “education” approach because you dread the stigma of mental health treatment, do think carefully about your choices—by avoiding the idea of emotional disturbance, you may be placing your child in treatment that is not only ineffective but potentially harmful.



Thursday, January 12, 2017

A Mother Tells It Better Than I Can (About Those Autism Fears)



Every now and then I get a comment that I think really
 needs to be read by a lot of people, so although this 
and  some other comments by this mother and  by me 
are posted  at https://childmyths.blogspot.com/2016/02/
eye-contact-with-babies-part-2.html, I want to put her
 important remarks out where it's easier for people to
 see them. If you are worried  about developmental
 problems,please read what she has to say 
about "milestones" and about mood disorders.

Please forgive the slightly cut-off word endings-- when
 I moved this here from my gmail account it seems to
 have established a format that I can't correct.



"First, I am specifically writing to tell you thank you
for your work to help parents feel less burdened by
 the weight of our own anxieties, often brought about
 by what we don't know, and what the  internet tells us
 when we google our fears at 3am.
 I was just that new mama! My daughter who will be
 20 weeks this Friday, and is the absolute joy of my life,
 has blossomed over the past month. Before this, I was
 sick with worry that she had autism or any other number
 of developmental delays as many parents in your comment
 sections also worry about. I was so busy comparing her 
to other babies her age. A friend of mine oncetold me,
 "Comparison is the thief of joy." This was profoundly true
 for me. I could not fully enjoy my daughter just the way 
she was. And what she was, and is, is a little girl who
 has developed  and met milestones in her own time.

She would give a passing glance around 11 weeks, but
 even then I had to really work for it and it was only 
if you were a certain distance from her face. She gave
 her first smile around this time as well, but again, I had
 to REALLY work for it. She seemed rather disengaged
 and not very interested in socializing. She also would
 not bat at or grasp at toys, she actually ignored them
 even when held right in her line of sight. She seemed to
 be at a standstill in making progress in this area until
 week 16 when she really blossomed. She began making
 eye contact very effectively, started smiling on 
her own without me making an effort to get her to do so. 
She found her first chuckle at 17 weeks and her first belly 
laugh at 18 weeks. She discovered her hands around week
 17 as well and now  grasps at and bats at her toys to her
 great amusement. I'm detailing this to show that it really
 can take our little ones time to learn how to socialize and
 learn. She, I believe, chose to observe and absorb her
 new world as long as she needed to (which was longer
 than every  development milestone book/blog/website ect.,
 listed it should
 take) before she was really to actively engage in it. 

Additionally, I, like some of your readers, struggled with
post-partum anxiety. My daughter’s pediatrician referred me to 
get help, which I did. Incidentally, once I had begun taking
 anxiety medication and seeing  a therapist and started feeling
 considerably better, my daughter also
 began to blossom. Whether my emotions had an effect on her
 or not,
 I'm not sure, but I think it's worth being aware of.

Anyhow, thanks again for your blog! I actually found it
while I was googling "8 week old not making eye contact" 
and came across several  “red flags about autism” sites and
 forums full of anxious moms worrying  about the same thing.
 One mom posted a link to your blog and how
 much it helped to relieve her excessive worry and I'm forever
 grateful
 to have found you through her!"



As I mentioned above, we had a further discussion in the
 comments at the link given above. (I don't seem to be able
 to move her other comments
 here, for some reason, but do look at them--I think many
 people will find 
them helpful.)