Child Psychology Blogs

Concerned About Unconventional Mental Health Interventions?

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

Thursday, November 30, 2017

"A Generally Accepted Record of Efficacy": States' Religious Exemptions for Caregivers Who Neglect or Harm Children

Some readers will be aware that in many states of the U.S., parents who refuse to immunize their children against contagious diseases may suffer no penalty if they can argue that their decisions were made on the basis of religious beliefs or philosophical principles. One of the reasons that the parents can do this is that state laws are affected by the requirements of the Federal law CAPTA (Child Abuse Prevention and Treatment Act, which from 1996 onward demanded this policy on First Amendment grounds, and because of lobbying by groups like Christian Scientists).

It’s likely that fewer people know that some states allow religious exemptions for crimes against children as serious as murder, as is shown at childrensheathcare.org. While outrageous indeed, this fact is not quite as outrageous as it appears at first glance—the issue has to do in many cases with legal definitions of murder and other crimes. (No one is saying that a parent could get away with arguing that his religion requires him to chop up his child with an axe.)

For example, the Arkansas code protects a person from being charged with capital murder if his or her child dies because of the withholding of medical or surgical treatment due to the parent’s beliefs in the tenets of a recognized religious group. In Delaware, unless a child dies or is seriously injured physically, a religious exemption protects the parent from a charge of child endangerment. In Idaho, parents withholding medical care for religious reasons cannot be charged with manslaughter, as this charge requires the performance of an illegal act, and using spiritual healing techniques alone is legal under the Idaho code.

A number of other states’ laws are discussed at childrenshealthcare.org, but the one that intrigues me most belongs to Texas. This law protects a parent who has withheld medical care and used spiritual techniques from charges of criminal injury to a child, provided that  “the act or omission was based on treatment in accordance with the tenets of a recognized religious method of healing with a generally accepted record of efficacy.” I am not at all sure what the Texas legislators thought they were talking about when they wrote this language, but the word “efficacy” certainly has a “generally accepted” meaning.

The term “efficacy” refers to the extent to which an intervention causes statistically significant improvement in the problems for which it is used. The use of interventions of high demonstrated efficacy is called “evidence-based practice” and is strongly encouraged by both private and public funding sources that cover either physical or mental health treatment.  Conclusions about efficacy are not based on studies of whether parents of treated children approved of the treatment, but on measurable changes in a child’s condition. Efficacy is considered to be demonstrated only by demanding research designs, and this generally requires either randomized trials, or well-managed nonrandomized trials, because when designs are weak, other factors may be “confounded” or confused with the effect of the intervention, and it may be wrongly concluded that the intervention caused any changes that occurred. In addition, conclusions about efficacy are not based on any single study, but require more than one independent investigation showing that a treatment has had a significant positive effect. By these standards, there are no “recognized religious method[s] of healing with a generally accepted record of efficacy”, although there are claims of efficacy (e.g., for prayer of different kinds).

The Texas example suggests that states’ legislation, often created hastily to be in line with CAPTA, has not been thought through very well. Whether one agrees with the thrust of these religious exemptions or not (and I don’t), they should more clearly balance the needs of children, the religious freedom of parents, and the states’ interests in supporting public health. The reports of childrenshealthcare,org on events in Idaho, where children of a religious group who died in unusual circumstances are not autopsied, is an example of public health risks, as well as children’s needs, being ignored, as the greatest weight is given to issues of religious freedom.

For obvious reasons, concerns about religious exemptions to liability for actions with ill effects on children are usually focused on medical and surgical treatments, which may if withheld contribute to serious illness or death. But religious exemptions have come to apply in other areas as well. For instance, although state laws uniformly require education of children after some minimum age, and although education other than through the public schools has long been an option for families who wanted it, “home-schooling” with few constraints or requirements has in the present generation become a choice for religious reasons--  parents essentially demand a form of religious exemption from laws that consider the failure to educate as a type of child abuse and neglect. Whereas parents in the past sought exemption from school attendance because of travel issues or because they felt the available public schools did not provide a good enough education, the current generation of parents often chooses home-schooling so their children will not learn about a number of topics, ranging from human sexuality to evolution. Permitting these choices, for these reasons, is a form of religious exemption.

Can the idea of religious exemptions also be applied to the use of some forms of psychological treatment that are popular with the religious right? Consideration of this issue requires the awareness that not all forms of psychotherapy are effective, and that some of them are potentially harmful to children. In rare cases, children have been injured or died as a result of holding therapy or because of parental actions related to associated beliefs. One assumption associated with holding therapy is the idea that children who do not comply with parental demands do so because of intentional, willful resistance, not because they are unable to comply. This assumption has even been applied to vomiting and defecation, opening the door to withholding of medical care when symptoms of illness are perceived as defiant acts.

The question of psychological rather than medical harm resulting from some forms of psychological treatment is largely unanswered, but some anecdotal information suggests that anxiety disorders, including PTSD, may result from some kinds of treatment offered for children. Some such treatments, for example “conversion therapy” to attempt to alter sexual orientation, are strongly related to religious beliefs. As several states have passed legislation forbidding psychologists to use “conversion therapy”, members of the clergy have continued to be allowed to use the treatment methods.

If parents whose children have been injured physically or mentally by psychological treatments are charged with abuse or neglect because of their treatment choices, can they claim religious or philosophical exemptions from the charges? So far, this issue does not seem to have been addressed in any U.S. court, but then, even the idea that psychological treatments can be potentially harmful is a very recent one.

Wednesday, November 29, 2017

Referencing John Bowlby: Not Your Grandpa's Attachment Theory Any More

Thousands and thousands of articles on attachment theory and research have been published over the last 40 years or so. This topic, with its emphasis on early experiences and social-emotional outcomes, has fascinated many readers and received faddish attention and emphasis both within the field of psychology and outside it. Unfortunately, not everyone who writes about attachment theory is on the same page; there is a mainstream view of attachment, developed through decades of discussion and research analysis, and there is an alternative attachment theory that has given rise to the use of holding therapy and similar non-evidence-based treatments.

How do you tell the difference between these when reading Internet articles? One way is to notice that the alternative attachment theorists quote John Bowlby, the “father of attachment theory”, to the exclusion of any more modern work. This practice is problematic, because some strongly-held tenets of Bowlby’s theory are much at odds with modern empirically-based work.

I am going to comment on some of Bowlby’s ideas that no longer appear credible. Please understand that this critique is not an attack on Bowlby himself or on attachment theory in general. John Bowlby was a man of his time, and his formulation of attachment theory was influenced by other ideas current during his professional lifetime. In addition, his thinking changed and developed over a long professional life, with relevant experiences in both wartime and peace. These statements about changing ideas are true of any influential theorist, in psychology or any other discipline—for example, asking what Freud thought about something really makes sense only if we say whether we are asking about his thoughts in 1900 or in 1935.  

References of alternative attachment theorists to John Bowlby’s work often take their information from Bowlby’s report to the World Health Organization in 1951 on maternal care and mental health (later published by Schocken in 1966 in a volume including responses of both supporters and critics to the original report). Here are some ideas rom that volume that no longer seem credible to mainstream attachment theorists and researchers:

1.    1.   Genetic factors play little or no role in the development of mental illness; early experiences, especially separation from the mother or deprivation of maternal care, are the primary causes of later mental illness and/or criminality. [This stress on experiential rather than biological factors was characteristic of Bowlby’s time and can be seen in the work of researchers working on juvenile delinquency like Glueck and Glueck. It is an optimistic view of mental and behavioral problems, because it implies that new, appropriate experiences may be able to correct the effects of early, bad experiences.]

2.     2.  Infants form attachments to a single person rather than to several caregivers and have a great deal of difficulty in forming new attachments if separated. Because of this tendency, called monotropy, the great preponderance of infant attachments are to the mother. [ During the Victorian period and later, emphasis on the powerful importance of mothers was generally assumed to be correct. By the 1940s, mothers were both praised for their benign influences and blamed  for their potential harmfulness—for example, the attribution of autism to “refrigerator mothers”.]

3.     3.  Attachment and attachment behavior are characteristic of the human species and are parallel to the rapid learning to follow other ducks shown by ducklings (called imprinting). When imprinting “goes wrong” (for instance, when a duckling imprints on a human being rather than another duck, and in adulthood tries to court the human rather than mating with another duck), it is very difficult to correct the problem, so attachment difficulties are also likely to cause serious adult problems that are hard to treat. [This ethological approach to human behavior was an outgrowth of comparative studies of  animal behavior that were a feature of psychological work from the 1930s to about 1980. We see little of this time-consuming observational research today and most people do not think of it as part of psychology, but it was of serious interest in the past, when undergraduate psychology curricula normally included a “comparative psych” course.]

4.      4. When children have been separated from their mothers or have otherwise been deprived of maternal care, encouraging regression by bottle-feeding and other “babying” can be an effective way to treat older children who have behavior problems. [ Bowlby included this idea in his 1951 report because such treatment was being used in Sweden, for example, in the care of children who had suffered severe deprivation and separation during World War II. The effect of the war, the number of orphans to be cared for, the evacuation of British children from cities that were being bombed, and so on, cannot be underestimated as a factor in Bowlby’s thinking.]

5.      5. Separation from their mothers causes psychological trauma in young children. [Bowlby based this view on observations of separated, evacuated British children, European Jewish children sent to England by their parents as Hitler came to power, and children being treated in hospitals where their parents might not be allowed to visit them for weeks.]

Much further thinking about attachment, and empirical research on the topic, have allowed us to reject these early assumptions of Bowlby’s while keeping some important tenets of attachment theory. (A paper by Michael Rutter in 1995 stated this very clearly and can be considered a beginning for a more advanced form of attachment theory, in which I do not include Schore’s so-called “modern attachment theory”.) Here are some reasons for rejecting the tenets listed above:

1.    1.  Genetic factors have been clearly shown to play important roles in the development of both mental illness (such as autism) and criminal behavior. Experiences are also important, but individuals with different genetic make-ups may respond to experience differently.

2.     2.  The research evidence indicates that infants commonly have attachments to several different caregivers, none of whom need be the mother.

3.     3.  Although human beings show many characteristic behaviors related to attachment, both in terms of seeking and of giving social interaction with others, it is deceptive to think of these as parallel with imprinting. From an evolutionary point of view, it would seem maladaptive for human beings, with their long childhoods and the relatively high chance of death of a parent (especially a mother) during that time, to have an unbreakable emotional connection with any individual and to have development badly distorted by separation from a single person.

4.    4.   Treatment of childhood mental illness by regression methods has never been shown to be effective. Parenting methods that demand a reasonable level of maturity are advantageous, so it would be surprising if the opposite treatment for mental illness worked.

5.     5.  Older infants (more than about 6 months old) and young children show great immediate distress in response to separation and continuing distress over weeks or months in cases where they receive little comforting attention and care. However, as John Bowlby’s colleague John Robertson showed in an observational study, plenty of responsive care from a small number of concerned adults reduces this distress a great deal. It would appear that it is the withdrawal of sufficient concerned care from adults that is potentially traumatic, not the separation itself. (It should be noted that the youngest infants, before about 6 months, do not appear to show distress about separation, and this is certainly true of newborns, despite some alternative theorists' claims to the contrary.)

Once again, this post is not an attack on John Bowlby or on the essentials of attachment theory. It is simply a statement that some of Bowlby’s ideas have not stood up to continuing thought and research. When advocates of alternative attachment theories and treatments for children cite  some of Bowlby’s original ideas as received knowledge or “scripture”, readers should see this practice as evidence that these people do not understand evidence-based concepts of attachment, and their other pronouncements should be approached warily.

Incidentally, material that invokes the name of Sir Richard Bowlby should be regarded with suspicion. Richard Bowlby, John Bowlby’s oldest son, has been a medical photographer. He inherited his title from his baronet uncle (John Bowlby was a younger son and not in line for the title.) There was a period of time when Sir Richard was invited to speak at conferences of alternative attachment theory proponents, presumably because of the magic Bowlby name and the magic baronetcy.  However, he did not know very much about attachment. He still has a website, though. 

Tuesday, November 28, 2017

Jumping to Conclusions About Child Custody (Lawyers, Please Read)

The Monitor on Psychology, a publication for members of the American Psychological Association, has an “in brief” section where summaries of interesting research are presented. I have often had a beef or beeves with “in brief” summaries involving child care and parenting, which too frequently suggest a cause and effect relationship where none has been shown to exist. I am really disturbed by this in cases where people who assume that one thing causes a particular outcome for children may want to argue in court for particular orders about child custody or treatment, and may cite research as a support for their arguments even when the research does not actually provide the evidence they imply.

A recent case in point: in the “in brief” section, and under the headline “Shared Custody Matters” , the Monitor (December, 2017, p. 13) reports a Swedish study that compared psychological problems of preschool children in the joint custody of divorced parents with the problems of those who spent all or most of their time with one parent, and with those of preschoolers in intact families. (This study is summarized at DOI:10.1111/apa.140014. The article is by Bergstrom, Fransson, Fabian, Hjern, Sarkadi, & Salari – “Preschool children living in joint physical custody show less psychological symptoms than those living mostly or only with one parent”, Acta Paediatrica , 2017).  The researchers reported that children in intact families had the smallest number of psychological problems, followed by those in joint custody, and those in the care of only one parent had the most problems.

There are a number of Internet references to this study that suggest that shared custody has thus been shown to help children psychologically, and some of them use language like “children of divorce” that encourages readers to ignore the ages of the preschool children in the study and to generalize from this study’s results to conclusions about children of all ages.

So what’s my problem with this? Does the article not show that shared custody is better for children? No, actually it does not, and it can only be interpreted as doing so if the reader ignores the multiple factors that affect child psychological outcomes, as well as the bidirectional influences of parents on children and vice versa. Such an interpretation also avoids the fact that the groups of families studied may have had many important differences that directly affected their custody arrangements.

Given that many divorcing families choose joint custody (in the U.S. this is the default position of most judges, as well), why do some not follow this pattern? How are families with joint custody potentially different from those without it? The list of differences is substantial.
High-conflict parents may avoid shared custody, and exposure to conflict may cause psychological problems for children. Parents who have serious physical or mental illnesses may be less likely to be able to share custody, and children may be affected by the parents’ disorders. Children with existing physical or mental problems that make them challenging to care for may be avoided by one parent, who will be unwilling to share custody, whereas the same parents might be quite ready to care for healthier or “easier” children. Parents who have the assistance of their own parents or other family members may spend more time caring for their children than those who do not have such assistance, and depending on the family circumstances, this may or may not affect the children’s psychological health. Parents who have committed domestic violence may be regarded warily by co-parents, who may try to reduce the time the abusive person spends with the children – either the domestic violence of the past or the present fears of  one parent can affect the children psychologically.

Being able to name alternative causes is not the same thing as showing evidence that one or all of them are at work, but this exercise does underline the fact that a nonrandomized study of naturally-occurring events cannot be used to conclude that a single factor caused an outcome. I don’t say the original authors did this, but other interpreters of the research seem to have done so.

I’d like to touch on another point about the Bergstrom et al study. The children were preschoolers, ages 3-5 years, but some Internet references speak of them as “children of divorce” in a general way. There are real problems about generalizing from preschoolers to older children, or vice versa, as their developmental strengths and vulnerabilities may influence the ways they react to experiences. In addition, if all the children in a study are preschoolers, this means that the divorce took place no more than 5 years ago, and in many cases is likely to have been much more recent. These families are still working out new roles and functions in the wake of the divorce and may take two years or more to manage these tasks and arrive at a calmer period of their lives. “Children of divorce”, taken across the developmental range, are in many cases past the early chaos of post-divorce adjustment and have established relatively successful ways to function. For children in those later years, who are also more mature cognitively and emotionally than preschoolers are, psychological responses to care arrangements will not necessarily be the same as those of younger children.

I would hate to see the Bergstrom et al study dragged into the courtroom as an argument in child custody cases where there is a real concern about the children’s contact with one of the parents. Having plenty of contact with each of two “good” parents is beneficial for children, but plenty of contact with a “bad” parent is not necessarily desirable and may even be harmful. The Bergstrom study does not adequately support the claim that joint custody is superior across the board to single-parent custody, with respect to children’s psychological development. Let’s hope that lawyers and judges understand this and don’t jump to conclusions.

Friday, November 17, 2017

Martha Welch Meets Bruno Bettelheim, Edgar Cayce, and the Rules of Research Design

I’ve devoted several posts and parts of some publications to the claims of Martha Welch, a New York psychiatrist, who used to claim that she could cure autism and now says she can prevent it. Welch has, inexplicably, the support of Columbia University, which has appointed her a sort of peripheral non-teaching faculty member with certain faculty privileges, and which not long ago gave her an award as a distinguished alumna.

In the 1980s, Welch visited Evergreen, Colorado, home of Holding Therapy as practiced on adopted children who were said to have attachment disorders. I have no idea exactly what happened there, but after her visit Welch decided that autism must be a form of attachment disorder, curable by facilitating emotional attachment to the child’s mother. She developed a new form of treatment that she named Holding Time. Rather than the Holding Therapy methods, which usually restrained the child in the therapist’s lap and used intrusive and painful shouting and poking to intimidate the child, Welch proposed that smaller children be held face-to-face with the seated mother and embraced so they were pressed belly to belly with her. This hold was to be maintained for an hour or more at a time, every day, as the child screamed and fought for release and eventually gave in and relaxed in the  mother’s arms. Older children were to lie on their backs while the mothers lay prone above them, partly supported on their arms. In both cases the mothers were to speak to the children, communicating all of their negative and positive feelings; the children too communicated a good deal of negative emotion.

Welch’s approach would probably have remained among the various obscure “complemetarty and alternative” approaches to autism, except that in the 1980s she made a connection with Elisabeth Tinbergen, a special education advocate and the wife of the Nobel laureate in medicine Nikolaas Tinbergen. Niko Tinbergen was a specialist in ethology, the study of innate, species-specific behavior patterns; although ethology had focused largely on insects, fish, and birds, the 1960s and ‘70s were a time when studies were attempting to find such species-specific behaviors occurring independently of culture and learning in human beings. The Tinbergens saw parallels between what Welch was doing and the occurrence of “imprinting” connections to other animals in ducks. They enthusiastically wrote a book declaring “hope” for autistic children in Holding Time methods, and included a long appendix written and illustrated by Welch. The Tinbergen book led to the publication of Welch’s 1989 Holding Time and an extensive book tour in Europe during which Welch presided over roomsfull of mothers holding tightly to screaming autistic children. (The Tinbergens also encouraged the promulgation of similar methods by Jirina Prekopova, a Czech psychologist working in Germany.) However, little was made of a point clearly stated in the Tinbergens’ book: that there was no empirical evidence to support the effectiveness of Holding Time.

I’ll leave this brief summary now because there is much more to say about Welch’s current activity. She is now running a program called Family Nurture Intervention and claims that physical contacts between premature babies and their mothers can reduce the frequency of autism, which occurs more frequently in premature than in full-term babies. You can see a demonstration and discussion of this method at https://www.youtube.com/watch?v=DIXAMaIOK64
 (my thanks to Yulia Massino for calling my attention to this video; for some reason I cannot create a link here). Welch is carrying out a research project on the effectiveness of Family Nurture Intervention as a prevention of autism and has described the research plan, a randomized controlled trial, at https://bmcpediatr.biomedcentral.com/articles/10.1186/1471-2431-12-14. Among other things, Welch proposes that autism is related to the presence of abnormal levels of peptides released from the gut, for example secretin and oxytocin (both popular suggestions for treatment of autism in CAM circles).

I want to comment on three aspects of Welch’s theory and research. First, her assumption that babies become autistic because they miss experiences of physical contact, exchange of odors, and so on with their mothers is a direct reflection of the very much outmoded “refrigerator mother” theory put forward by people like Bruno Bettelheim (an art historian who became focused on child mental health). Bettelheim claimed, without evidence, that cold, unemotional mothers caused autism by their failure to engage physically and emotionally with their children. He did not mention premature babies, but those babies can certainly be included in this hypothesis because their medical care makes it difficult for parents to touch or engage with them in pleasurable ways, and even the most loving parents of premature babies will not be able to care for them as they would normally want to do. In the video mentioned above, a scientist who works for Autism Speaks points out this problem of Welch’s approach—that she is accepting something like the “refrigerator mother” theory in spite of decades of evidence that genetic factors rather than experiences cause autism.

Second, Welch’s emphasis on literal “gut responses”, the production of peptides and their effect on the brain, is an example of an old theme in American CAM. Edgar Cayce, an early- 20th-century “prophet and seer”, emphasized the work of the “enteric brain” as a source of emotion. The Meridian Institute of Virginia Beach, VA has continued to promulgate Cayce’s ideas, which are still part of many CAM approaches. For example, Andrew Wakefield, the disgraced physician who started the claims that immunization caused autism, looked to gut contents as evidence that materials of immunization remained in the body, and, presently working in America, he continues to focus on digestive tract issues as causes of autism and ways to treat it, in contradiction to all that is known about autism.

Now, the fact that Welch’s Family Nurture Intervention smacks loudly of outmoded and CAM beliefs is not enough to condemn it. It would be very reasonable to say, “who cares if it’s based on wrong ideas? If it works, that’s what’s important.” And Welch has reported some preliminary positive results—but this leads us to the third problem about Family Nurture Intervention studies.

Welch and her colleagues state proudly that they are carrying out a randomized controlled trial, and most certainly it is randomized, with families assigned randomly to one of two treatment groups. The problem is that it is not controlled, despite the presence of a putative comparison (control) group. Here is the trouble: according to the BMCpediatrics article mentioned earlier, the two groups are receiving treatments that are different in a number of ways other than the Family Nurture Intervention itself. In the FNI treatment group, mothers have 4 1-hour intervention sessions per week, or more, plus standard care. The comparison group has no specified treatment, standard care, and 1 meeting a week with research staff in the hospital. In other words, the FNI treatment groups is experiencing 4 or more times the socially-supported time with their babies as the comparison group receives. Such social support is well-known to improve mother’s moods and therefore to help them interact more patiently and warmly with their babies.

The point of randomization is to help isolate a variable, which is the crux of all experimental work. Randomizing families to conditions means that no special characteristic of the people (like knowing about and wanting a treatment) can interfere with finding the effects of the treatment itself, which should be isolated from any other possible effects on the outcome. But randomization alone cannot isolate the effects of the treatment unless the rest of the design and implementation of the study are correct. The time spent in treatments is clearly a factor that needs to be controlled, as it is common for more of a treatment to have a greater effect on outcomes than less does. When a treatment involves social support for people in a stressful situation, the time spent and the attitudes of staff are important factors. This study should have provided 4 or more sessions per week for the comparison group, devoting them perhaps to supportive interviews and motivational discussions with the mothers. Otherwise, we can only conclude that having more sessions has a better outcome--  we can’t conclude that the Family Nurture Intervention itself is supported.

A 2015 publication by Amie Hane et al (with Welch as a co-author), https://psychology.williams.edu/files/Hane-et-al-15-JDBP.pdf, concluded that mothers’ care for babies in the NICU was improved by experience of the Family Nurture Intervention. However, this article very properly stated some limitations of the study.  “The control group received standard care (SC) (i.e., usual care) as part of our randomized controlled trial that included holding and skin-to-skin care if the mothers chose to engage in these activities. But, there were not corresponding control conditions for each of the specific activities of FNI. For instance, SC mothers did not exchange sham odor cloths with their infants (cloths that were not exposed to mothers and/or infants). The effectiveness of FNI should thus be interpreted as a function of a comprehensive and integrative intervention, since during this preliminary trial of the intervention control manipulations of FNI activities were not entirely possible.” (p. 194). In other words, mothers in the comparison group may or may not have carried out some of the activities used for the FNI treatment group, but they did not share any version of some parts of the treatment, including the length of time per week (this last not mentioned as a limitation by Hane et al.). The standard care comparison group did not receive a family support session before discharge as the FNI group did.

Martha Welch has spent many years arguing in favor of alternatives to evidence-based conclusions about causes of autism and effective treatments for the disorder. Her connection with Tinbergen was apparently sufficient years ago to earn publication of a popular book and the support of Columbia University. The Columbia IRB approved her research design, weak as it is, although even non-harmful treatments can be considered as a harmful waste of time and resources if improper design and implementation of research can lead to incorrect conclusions. What is this all about? I would like very much to know.

N.B. Nothing in this post should be taken as rejection of the extensive legitimate research on neural factors in gastric and endocrine functioning; my point is that the existence of such physiological factors is not in itself evidence that supports any statement about autism.