Thursday, May 25, 2017
When people write in to this blog with queries (or expostulations!) about children’s behavior problems, it’s frequent for them to mention that their school-age children still wet themselves in the daytime or urinate in strange places, and that some even defecate in their pants or in some hidden place that is revealed only by the smell. Frustrated and angry, the parents often feel that the children are doing these things intentionally as hostile actions toward the adults (and often the parents think that such hostile actions would be a sign of an attachment disorder—but I don’t want to get into that today).
As it happens, a child clinical psychology listserv that I participate in has recently been having a discussion about exactly this. One member had written in to ask for suggestions about working with a ten-year-old girl who was defecating in her pants. An interesting discussion ensued, and I want to summarize some of what was said and elaborate on some of the ideas.
A most useful point made by several people was that many of the children with these behavioral elimination problems were never completely toilet-trained in the first place, and the behavior of those children is an indication of their lack of mastery rather than their hostile intentions.
Consider what happens when a functional, “normal” family toilet-trains a child. First, the fact is that the parents have been communicating to the child for many months that there is something special about elimination. It’s not like drooling or even like spitting up. There is an emotional response to urine or feces, a strong motivation to clean them up and get rid of them, that is communicated to the baby by attentive, engaged parents. They sniff the baby or peek down her diaper to see what needs to be done. When changing a dirty diaper, they pay attention to the diaper and not the baby, complaining quietly if the baby kicks and gets her heel into the mess. Caregivers talk to each other in front of the baby: “Did she poop?” “yes, and what a smelly mess it was!”. If the baby is just wet, the diaper change is much more relaxed and probably involves some smiling, talking, and playing. In all these ways, a well-cared-for family baby is learning for a long time that something about elimination is special and important, and that urine and feces are different.
Well-functioning families also pay attention to whether a baby seems ready to be trained, whether she seems to be aware of bowel or bladder pressure, and whether she has the words to ask for help. Caregivers “talk up” using the potty or toilet, with the reward of big-girl or big-boy underwear held out for encouragement. Once the child has some success in managing elimination, adults follow him around reminding him, asking if he needs to go, paying attention to cues like dancing the “potty dance” or passing gas that indicate elimination is about to happen. They give careful instruction on the use of toilet paper, and may give boys paper “targets” floating in the toilet to practice their aim. Toilet “accidents” may or may not be punished, but certainly adults tend to respond to them with some degree of exasperation once they think a child has mastered the basics and just needs to pay attention.
These common and effective methods of toilet-training only happen under certain circumstances: The child is being cared for by people who have the time and energy and motivation to do the job. The child is being cared for by people who know him or her well, understand the child’s language or other communication, and are not completely distracted by other needs or obligations. The caregivers are thus able to be consistent and to predict elimination, so the child is helped to understand what events are likely to follow certain internal sensations. After all, to be completely toilet-trained, a person must be able to recognize internal cues and to understand the time available to get to the toilet once certain sensations occur. A child is not completely toilet-trained if he has to depend on others to tell him when to go.
As you can see, all this work by caregivers is not so likely to happen if a child has been passed from foster home to foster home, has been in the custody of an adult who uses drugs or alcohol or who is physically or mentally ill or who lives in a frightening environment. Some adults in these circumstances will focus on punishment following inappropriate elimination as their main toilet-training strategy; this is not only emotionally problematic but would be difficult to do effectively even by a skilled user of aversive methods. In addition, caregivers who use punishment in this way often do it inconsistently and out of irritation—even when a child defecates in a recently clean diaper.
Although some children may become completely trained under those conditions, others will not. Later in their lives, in school or in an adoptive home, toilet “accidents” may occur repeatedly and even may appear to be intentional because children do not seem to feel guilty or concerned. By that time, negative attitudes of adults and of other children to the child himself or herself, not just to the toileting problems, may begin to have effects on the child’s mood and behavior, further complicating the difficulties.
So what to do when this situation has developed? The first consideration is about medical problems that may cause toileting difficulties. (As one participant in the listserv discussion I mentioned earlier said, the causes are often thought to be volitional, but they are probably biological.) Urinary tract infections may be involved. As for inappropriate defecation, strange as it may seem, these children are sometimes suffering from constipation, with hardened feces held in the intestines, but softer feces passing around the hardened part and being passed involuntarily or leaking. This problem may have developed because children are afraid to use the toilet or because it has been painful to pass hard stools and the child is actively resisting this. If constipation is a problem, children may need to be treated with stool softeners and with changes in diet that can return them to a healthier elimination pattern.
Behavioral treatments are also useful, especially if a child has found defecation painful and needs to be rewarded for sitting on the toilet at first and later for defecating there. Frequent reminders and rewards, given in an encouraging and nonpunitive way, are needed until the child has some success.
If urinary problems are not caused by medical issues, the problem may be that the child has not learned to associate the sense of a distended bladder with urination soon after. Encouraging the child to drink large amounts of fluids and then measuring the urinary output (with a bucket or some other device) can call his or her attention to the connection between the two.
Children who have toilet difficulties of these kinds may also have other mood or behavioral problems, including defiant, oppositional, or callous-unemotional behavior, but it is probably a mistake to assume that the toilet behavior is just another aspect of defiance or opposition. The two kinds of problems are likely to have different causes and to need to be treated differently.
Need I say that when children are locked in their rooms, or when door alarms are used so that they have no free access to toilet facilities but must use buckets to eliminate or wait as long as they can, difficulties in controlling elimination are likely to emerge even if they were not present before? Limiting foods, as in the peanut-butter-sandwich-and-milk routine advised at one time by Nancy Thomas, is likely to play into any tendencies to constipation. Incidentally, I understand that the said Nancy Thomas, now touring Russia to spread her beliefs, is recommending that children with poor bladder control must wash their clothes by hand with cold water and vinegar; this is not likely to accomplish anything but to increase anxiety and lessen the child’s ability to control urination.
Sunday, May 21, 2017
Readers of blogs and quasiprofessional websites will be familiar with the practice of calling children “psychopaths”. Readers of professional psychology and clinical social work will find this terminology strange and sensationalistic; they will be accustomed to the use of terms like “callous-unemotional (CU) behavior” or “conduct disorders”.
Many of the ideas associated with the “psychopath” label are zombie ideas: they are dead, but they won’t lie down—and they accomplish certain kinds of work for the people who use them. The current (June 2017) issue of the Atlantic magazine features an article full of zombie ideas about children’s aggressive and angry behavior and is entitled “When Your Child is a Psychopath” (https://www.theatlantic.com/magazine/archives/2017//06/when-your-child-is-a-psychopath/524502/). This article recounts frightening stories about children obsessed with anger, taking pleasure in hurting others, and becoming more dangerous as they grow. These children are different from others, it is stated, because their problems are genetically caused and cannot be treated (except, maybe, a certain residential treatment program might be a bit helpful).
“When Your Child is a Psychopath” is one of a large group of scary-exciting bedtime stories for adults; these focus on the Bad Seed concept, that children may only appear to be innocent, and that some of them are just waiting for the opportunity to do us in. For parents of quite well-behaved children, these tales are thrilling accounts of how bad other people’s lives are, a sort of inversion of the equally-loved stories of serious child abuse with torture and sex. The good parents know that they are okay when they read these things. They would never do such bad things, nor would their kids, and in their hearts they believe the problems are caused by the bad parents rather than by genetic factors.
For parents of sometimes-aggressive, occasionally-antisocial children (i.e., most of us), the Bad Seed stories provide a chance to think how bad things can be and to breathe a sigh of relief that ours are not as bad as that. In addition, the stories present the possibility that whatever problems the future holds, it may be genetics that cause them—these parents (most of us, again) are absolved from blame if that’s the case.
Parents of really callous-unemotional, antisocial children probably do not get much chance to read, but if they do read the stories, they can take comfort from the idea that they are not the only ones with these problems.
So, you see, the Bad Seed stories offer something gratifying for everyone. Of course, there’s a serious difficulty connected with the fact that they are probably not true. And there’s an even worse difficulty in the possibility that such beliefs will cause parents and practitioners to act in ways that will cause additional trouble for the children, for instance failing to seek treatment for the children and/or the parents because they accept the idea that antisocial behaviors are not treatable. The children can also be affected negatively by these ideas, perhaps assuming that they will never be able to control their impulses and that they will inevitably commit crimes and go to prison or worse. (There is quite a flavor of Attachment Therapy in this; it’s reminiscent of practitioners who tell children “unless you cooperate, you are gonna kill somebody some day!”)
As it happened, on the day I read the Atlantic article, I also opened a new issue of the journal Child Development Perspectives and found two useful articles commenting on antisocial behavior in childhood. The first article, by Dale Hay, had the title “The early development of human aggression” (CDP 2017, Vol. 11(2), pp. 102-106). Hay referred to genetic factors in aggressive behavior, but pointed out that aggressive tendencies resulted from a combination of genetic make-up and maternal sensitivity. Although all typically-developing children are capable of physical aggression by the second year, toddlers are more likely to develop increased aggressive behavior if their families live in poverty. Mothers who have been depressed during pregnancy, who have shown antisocial behavior themselves, and who react with hostility to their children’s displays of anger are more likely than others to have children who behave antisocially. Hay also noted that after age 2 years there are increasing differences between boys and girls in physical aggression. A group of factors acting together may make boys increasingly aggressive during early childhood. These would include the facts that girls mature more rapidly, that boys are more likely to have neurodevelopmental problems like ADHD, that parents treat boys and girls differently, and that young children prefer to play with peers of their own sex, which makes them likely to imitate and learn gender-related habits of aggression. Clearly environmental factors affect the development of angry, aggressive behavior, and when this is the case it should be possible for treatment to alter the pathway of development—contrary to the claims of the Atlantic article.
The second article in Child Development Perspectives was written by Rebecca Waller and Luke Hyde and entitled “Callous-unemotional behaviors in early childhood: Measurement, meaning, and the influence of parenting” (CDP 2017, Vol 11(2), pp. 120-126). Waller and Hyde pointed out that many children show early angry, aggressive behavior, but most stop this; the important question is why some continue and show long-term antisocial attitudes and behaviors. This is a complex question and the article is a complex one, but Waller and Hyde make some comments that I want to emphasize because of their relevance to the claims made in the Atlantic magazine. They noted that particular language about callous-unemotional (CU) traits (in which I would include the word “psychopath” as applied to children) “could have unintended consequences, especially given its origins as an extension of psychopathy in adulthood, which clinical lore (falsely) purports to be inborn (i.e., purely genetic) and even untreatable. Such notions are problematic when applied to young children, particularly when some children with high levels of CU traits benefit from treatment. Moreover, using the word traits [or other words like “psychopath”—JM] carries a risk that treatment providers, parents, or children may inadvertently receive iatrogenic messages about stability or untreatability, which become self-fulfilling prophesies”—as therapist and parents avoid treatment or seek it with no real expectation of benefit, and children understand themselves to be members of a special and dangerous group of human beings and follow the associated “script”.
It is unfortunate that the Atlantic chose to publish an article on an important and interesting topic, but did so without weeding out the zombies (excuse this mixed metaphor, I don’t know what you do to rid yourself of zombies). Let us hope that the effects of these ideas do not show that problems can be mediagenic as well as iatrogenic.
Tuesday, May 16, 2017
Quite a while ago, on March 18, 2012 to be exact, I posted on this blog a piece called “Attachment Therapy: Where Are the Testimonials From the Children?” I was hoping to hear from people who had experienced or observed various kinds of holding therapy as children and to learn what they remembered about what happened. I have had a few responses over the years, but not long ago, and again yesterday, I heard from someone who had experienced Martha Welch’s “holding time” version of this treatment and had seen and heard her autistic brother as he was put through a brutal form of holding. This correspondent made a suggestion that I had never thought of (doh!) and led me to look at the Amazon reviews of Welch’s 1989 book “Holding Time”, which recommended daily holding of screaming, resisting children, both as a treatment for autism and just for ordinary parenting purposes. Looking over those, I came upon a reference to a book I had never heard of, which amazingly turned out to be on the shelf in my town library.
Let me hear your voice: A family’s triumph over autism was published in 1993 by Catherine Maurice (I see elsewhere that this name was a pseudonym, so I am not at all sure how to reach her for further information—like what happened to her children later). Maurice had a typically-developing son, followed by a daughter and another son, both of whom began by developing typically and then showed many signs of the regressive type of autism. Both also recovered a typical developmental trajectory, a recovery that Maurice attributed to Applied Behavior Analysis (ABA), a behavior modification program that has research support.
This beautifully-written book is a candid account of the actions and feelings of parents dealing with first one, then another autistic child while trying to keep their daily lives somewhat intact. It includes an appendix with specific information about the treatment and gradual changes in each child. As such, it offers a great deal to parents who need some hope and understanding about how a treatment may proceed.
From my point of view, however, the great value of Maurice’s book is its exposure of Martha Welch’s proposed treatment for autistic children. Welch visited Evergreen, Colorado in the heyday of the town’s existence as home of the attachment therapy cottage industry. She absorbed the idea of physical restraint and the power of parental authority to force changes in children as the parent wished them to occur. However, in creating her own method, Welch added the seductive element of “mother love” as a cure for childhood mental illness. She proposed that all holding had to be done by a child’s mother, and indicated that this was a cure for all emotional problems of concern to parents—including aloofness or ingratitude in typically-developing children. In instructional videotapes, Welch presented her son Bram as an example of what could be achieved by daily holding of a resisting child until he or she relaxed and became accepting and affectionate. For many years, the great selling point for Welch’s method was her claim that it cured autistic children, but by 2006 she had altered this to presenting the treatment, now called Prolonged Parent-Child Embrace (PPCE) as a therapy for children with Reactive Attachment Disorder and oppositional behavior; autism was no longer a focus by that time.
Maurice openly admits how she “fell for” Welch’s approach and explanation of autism. Autism, according to Welch (and her mentors Elisabeth and Niko Tinbergen, the latter a Nobel laureate), was caused when a mother and child failed to “bond”. This failure caused the child to be terrified of the world and of people, whom he or she avoided. Inside each autistic child, according to this view, is a typically-developing child who is simply too frightened to speak or look at anyone. Holding therapy forces the child and mother to bond, the child loses his fears, and voila’, the concealed development is demonstrated to be there. Welch’s charm and air of authority convinced Maurice that she must be right, and indeed anyone who watches Welch’s instructional tapes can see how this attractive, warm, caring person would appear to answer the needs of any wretched, frightened, exhausted parent who saw a child deteriorating before their eyes. Of course, from a safe, objective distance, it is much easier to discern in Welch the deep conviction and enthusiasm of what Freud called the furor sanandi – the “lust for curing”.
With respect to holding therapy, Maurice’s story concentrates on how she and her husband responded to Welch. Catherine initially saw Welch as the savior she was looking for, although from the beginning she was concerned about the idea that something had happened to prevent a bond between her daughter and her self. Welch suggested that such an event could occur when a baby of a few months overheard her mother say something negative, or even when an unborn baby was in some way exposed to its mother’s thoughts and opinions. Catherine Maurice doubted this to begin with, and over the months began to question Welch’s views more seriously (although even after she broke with Welch, she seemed to feel that holding did something positive). Her husband was not pleased with Welch from the start, wanted information about the outcomes of the treatment which he did not get, but decided to go along with his wife’s wishes.
Speaking of encountering another mother who was devoted to Welch, Maurice noted: “In this woman, as in other holding therapy disciples, I was beginning to see something I didn’t like—something I recognized in myself: blind faith, idealization of human individual, unwillingness to admit we can make mistakes about what is right for our children….Before my relationship with Dr. Welch ended, I was to understand what it might be like to be seduced and drawn into a cult. To those who are frightened enough and desperate enough, it becomes harder and harder to hold onto sense and intelligence, reason and objectivity. Cast into an unknown land, uncertain of our bearings, we parents at the Mothering Center took enormous solace from the calm assurances, the sweet promises, of our savior.” However, over time Maurice realized that although she could see the positive results of the ABA treatment her daughter was also receiving, Welch consistently told her how harmful it was. She also came to understand that she had never seen any of the “cured” children Welch claimed to have come out of holding therapy. One case, published in Life magazine rather than in a professional journal, did not seem to Maurice to have had anything like the successful outcome claimed for it.
Maurice and her daughter visited a group in which holding therapy was being done by mothers with autistic children and were terrified by the screaming and the shouts of mothers “expressing” their rage that the children were not paying attention to them. Among other things, she saw a mother restraining her severely impaired three-year-old son; when the child accidentally bumped his head, the mother asked for ice, and an aide told her, “Mary… that bump is insignificant compared to the damage you will do if you don’t get a resolution from this child” – a resolution being a change in the child’s behavior from screaming resistance to cuddling. The aide went on to say that the reason she could not “get a resolution” was that her husband was not supportive enough. All these things were concerning to Maurice, but the final straw was that when she was asked to speak about holding for a BBC production on the treatment, her attempt at a balanced presentation, speaking of the various treatments that were being used for her daughter, was edited so that only holding was recommended.
Maurice’s discussion of her attraction to Welch’s method and her gradual loss of faith is a real, though sympathetic, object lesson to parents who find themselves devoted to an “alternative psychotherapy”. The impact of the misguided treatment on her family may have been as serious as the challenges presented by autistic children. At the time this book was written, Maurice’s children were still too young for their thoughts and memories to be articulated very well, so we really do not know how they experienced Welch’s treatment or any other treatment they received. I know Maurice has continued her concerns about autism, because, still using her pseudonym, she more recently co-edited a book with two well-known professionals in the field. Could she tell us now how her grown-up children are doing? Could the children tell us what they remember or think about their experiences? I wish she, and they, would round off the understanding she supplied in her 1993 book with that additional information.