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Concerned About Unconventional Mental Health Interventions?

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

Thursday, October 18, 2018

How Not to Get Any Help for Children That You Think Have Reactive Attachment Disorder


Have you, or has someone else, decided that your child has Reactive Attachment Disorder? Has this diagnosis been made because the child is aloof, aggressive, sneaky, and avoids being affectionate on your terms? I know there are a lot of you out there, and many of you feel pretty desperate—you don’t even like the child any more, and that disturbs you as much as the child’s behavior does. You and the child need the help of knowledgeable professionals, or it seems that the least awful thing that could happen is disrupting the adoption or putting the child in residential treatment until age 18.

I’m going to tell you how NOT to get any help for your family. Part of my instructions will be drawn from a book by Keri Willimas, “Reactive Attachment Disorder (RAD): The essential guide for parents”, a self-published book available on Amazon.

1.     1.  Get into an argument with any available professional about whether your child’s behavior problems and your emotional distress are caused by Reactive Attachment Disorder. Insist that no matter what the mental health professional shows you in DSM-5, the problems that concern you are indicative of an attachment disorder and nothing else. Stay focused on the name that’s used, not on a discussion of the mood and behavior problems of the child and others in the family. If the professional tells you the name is not important, leave and do not make another appointment. This will ensure that your family does not get any help in thinking about the many sources of behavior problems and various effective ways of treating them.

2.      2. Go immediately back to your on line support groups and have them reinforce your beliefs that attachment and attachment disorders in the child are at the root of all family problems. Ask them to recommend practitioners who will accept your diagnosis and start doing attachment therapy of some kind. This will guarantee that you will not risk encountering any professional psychologists or clinical social workers who are trained in work with children’s behavior problems.

3.    3.   If you lose faith and call a mental health professional with advanced training, or a clinic that employs such people, be sure you demand immediately to know whether they treat Reactive Attachment Disorder (or simply, attachment disorders). If they hesitate or ask you to be more specific about the problem, hang up--  they obviously are not RAD specialists. This way you won’t accidentally connect with anyone who might have the training to help your family.

4.    4.   If you locate some mental health professionals that you might use, be sure to choose the one with the lowest level of training and licensure; with any luck you could find someone who is operating under another person’s license. The less trained the people are, the nicer they are, and the more likely they are to listen to you unquestioningly. If you do this, you can be almost sure that you will not run up against a practitioner who knows more than you and your support groups do and might actually be of help.

5.     5.  Always assume that only other people who have lived with a child with behavior problems can understand or be of any help to you. This will assist you in avoiding mental health professionals who are trained in working with many kinds of families and many overlapping problems.

6.      6. Be sure not to use any evidence-based programs like Parent-Child Interaction Therapy that ask you to learn new things or to work with your child in new ways. Insist that the child be fixed and that no other family changes take place. Generally, this will avoid any beneficial changes.

7.    7.   It’s wise to choose only treatments that assume one single factor, like RAD, as the cause of any of the problems you are experiencing. Most problems have multiple causes, so focusing on a single one can help you avoid any benefits of treatment that you might otherwise get.

8.      If you choose a treatment program, make sure it’s trademarked. That will mean that nobody can get at evidence to test whether it is both safe and effective. The proprietors will be able to make all sorts of claims and have their statements protected as commercial speech. You won’t have to worry about understanding empirical research or asking any of the right questions, which will be much more comfortable for you although not very likely to be of any help to your family.

9.      Always follow the recommendations made by Keri Williams in her book (mentioned above). She certainly knows how to prevent even the best-qualified mental health professional from helping your family. For instance, she advises parents, “Be very cautious about sharing sensitive information about yourself with your child’s therapist. It’s easy to think of them as objective. They’re not. If it comes to taking sides, they’re on your child’s side. Don’t blurt out that you don’t feel affectionate towards your children, that you are frustrated, or that you are angry. If you do, that’s almost certainly the only thing they’ll focus on going forward. They’ll conclude that your feelings and actions, not RAD, are the cause of your child’s behaviors. If the therapist focuses on ‘fixing’ you, your child will not get the help they so desperately need.” This approach, akin to treating repeated illness with antibiotics rather than considering what environmental factors are causing it, will certainly make sure that your family avoids help but is instead encouraged to find residential placement for a child and “love her at a distance”--- and all your friends will say how brave you are and how sad it is that your child was so damaged that no one could help. (How about suing the adoption agency too?)

You see, it’s pretty easy when you know how. You can be sure your aggressive or behaviorally disturbed child never gets any help, while at the same time claiming the moral high ground as the victim and sufferer who has only been trying to do the best thing for everyone. Just don’t forget to talk about RAD a lot.

Friday, October 12, 2018

What Bowlby Really Said, or, More Fun with Parental Alienation


I don’t usually watch to see what Craig Childress says on Facebook, but a lawyer colleague has called my attention to his recent comments about attachment and its implications for children who avoid one of their divorced parents. He attributes his own ideas to John Bowlby, Mary D.S. Ainsworth, and Otto Kernberg, not to mention Sal Minuchin, and describes these people with a novel collective noun as a “pantheon of kahunas”.

The problem is that Childress either doesn’t know or doesn’t understand what Bowlby actually said about attachment, or that attachment theory has changed a good deal in the course of decades of research and discussion. (I published an article in 2010 in Theory & Psychology, titled “Attachment theory and its vicissitudes”—and there have been many vicissitudes.)

Bowlby’s work was focused on trying to find explanations for some common and obvious toddler behaviors. These were of course not newly discovered but had been described for centuries, even mentioned in the Iliad. The two basic kinds of behavior Bowlby was looking were, first, the tendency of toddlers to stay close to familiar people under some circumstances, to avoid strangers and strange events, and to show severe and lasting distress when separated from familiar people, and, second, the tendency of toddlers to be curious and explore the environment under some circumstances. They stay near and they go away, with apparently contradictory motives. Why does this happen? Attachment theory began as an attempt to answer this question and built from there.

However, Bowlby’s original concern was with the way toddlers try to stay near familiar people, especially if they (the toddlers) are sick, injured, frightened, or in a strange place. He saw children hospitalized in England in the ‘30s and ‘40s, when parents were not allowed to visit and surgeries like tonsillectomies were common. Those children were terribly distressed and for months after would cling to a parent as they had not done before. Bowlby also saw European children brought to England by the Kindertransports when their families were threatened by the Nazis—suddenly packed up and sent off with strange caregivers and large groups of other children and suffering from separation, fear, and often physical distress as well. In addition, Bowlby observed English children evacuated to the countryside when London was being bombed nightly.

In all these cases the young children were badly distressed both short-term and long-term in ways that were not the same for children of school age or older. Bowlby prepared two reports for the World Health Organization, entitled “Maternal Care and Mental Health” and “Deprivation of Maternal Care”. In other words—Bowlby attributed the children’s problems to loss of the mother. He believed that human beings in early childhood were able to form an attachment to only one person, and that one was the mother. Bowlby called this tenet of his early theory monotropy. As we can see in his film “Nine Days in a Residential Nursery”, about a toddler left at a residential child care facility while his mother has another baby, fathers were not considered by Bowlby at this point to be attachment figures, and the lonely, frightened little boy in the film does not respond much to his father’s occasional visits.

Nowadays, we assume that fathers, mothers, grandparents, sisters, brothers, and babysitters can all be attachment figures for young children. Bowlby clearly did not think so—and would not have supported Childress’s view that children’s attachment to their fathers is a critical issue. It was all about mothers at that early stage in attachment theory. Why? Well, two reasons. One is that parenting behaviors have changed, with fathers given (and taking) more responsibility for child care, at least in educated middle-class groups. Bowlby would have been astonished at the idea of fathers in the delivery room (remember, even Dr. Spock said that the best thing a father could do for the child is to love the mother). But in addition to that matter, Bowlby focused on mother-baby relationships because he was searching for an explanation of toddler behavior in the lives of animals. He attributed the child’s desire to stay close to mother to evolutionary processes such that children of our remote ancestors were more likely to survive and reproduce if they fled to mother when something strange happened. Genetically-controlled behaviors of that kind are easily observed in some animals and were being studied by ethologists like Nikolaas Tinbergen. Whether human beings also showed such “fixed action patterns” was a major question, and Bowlby argued that toddler behavior toward familiar people was an example of what is sometimes described as “instinct”. Because most animals that show the tendency to stay near an adult do this with their mothers, Bowlby looked to behavior toward the mother as the foundation of social and emotional development, or attachment.

By 1995, Michael Rutter, one of the most important figures in the modernization of attachment theory, had marked a number of changes in the way the theory was developing. He ruled out monotropy (the exclusive attachment to the mother), as all the evidence was that toddlers usually have multiple attachments. Writing in the journal Child Development in 2002, Rutter referred to the overuse of the attachment concept as “evangelism”, and said “[It] is clear that parental loss or separation carries quite mild risks unless the loss leads to impaired parenting or other forms of family adaptation.” Presumably Childress would claim that lack of contact with one parent, as desired by the child, would be “family maladaptation”, but this claim cannot be derived from Bowlby (unless it’s the mother who is missing!) or from the more recent version of attachment theory as discussed by Rutter.

There’s a lot more to be said here, with respect to Bowlby and attachment theory. As the years passed, Bowlby dropped his ethological view and began to think of early attachment behavior as the foundation of an internal working model of social relationships, like the mental models  earlier suggested by Kenneth Craik. These models helped to determine social expectations and social behaviors and were “goal-corrected”, altering with time and social interaction, so that the original “attachment system” did not last for very long. (By the way, almost nobody ever talks about the exploratory system, which acts in cooperation with the attachment system and in Bowlby’s original formulation keeps a balance with attachment.) The attachment system of any individual turns into  an internal working model in the course of development, so it cannot become “deactivated” any longer, or contribute to pathological mourning if the child experiences separation in the school years or adolescence, as is the case for most of the families Childress attempts to describe.

One last thing here: Kernberg and narcissism as associated with broken attachment. Sorry, this is not what people think today. Narcissism in adolescents is connected with “overparenting”, “helicopter parenting”, but especially with excessive psychological control of children by their parents. Psychological control involves strenuous efforts to change children’s beliefs, attitudes, and emotions to those that are preferred by one or both parents. How better could we describe some of the interventions offered for “parental alienation”!



Tuesday, October 9, 2018

Separating Migrant Children from Their Parents

I don't seem to be able to overcome the format of the material I copied and 
pasted here, so you may not be able to read everything-- but the journal links should work anyway.
I'm sure that some readers are very interested in the outcomes for migrant children of the practice of 
separating them from their families. 
Here are some things you might want to read about this, especially if you work directly
 with children or with their families. 

The first piece, from the NYT, is a description of the changed behavior of some children who have
 gone through separation and then
 been reunited with their families. It shows clearly that the problems are not
 over when reunion has occurred.
 https://www.nytimes.com/2018/07/31/migrant-children-separation-anxiety.html


Here are a number of free articles from a professional journal, addressing a variety of problems related to early childhood trauma 
resulting from violence and separation.
As the leading publication for pediatric mental health, the Journal of the American Academy of Child and Adolescent Psychiatry has
 published many articles demonstrating the damaging effects of early childhood trauma on later development, the role of parental stress in the
 intergenerational transmission of both psychiatric and other medical outcomes, and the positive role of parents in promoting child and 
adolescent mental health.
We oppose the practice of separating immigrant children from their families.
In collaboration with our publisher, Elsevier, we have created a free collection of articles published in JAACAP on the effects of separation,
 early life trauma, and related topics, and will maintain and update it until this practice is no longer the norm.
Select articles from this collection include:
View the full collection of articles on the JAACAP.org website under the collections tab in the menu.

Monday, October 8, 2018

The Demand for Obedience: How Two Alternative Psychotherapies for Children Resemble Each Other


Discussions of non-evidence-based medical treatments often use the term CAM—complementary and alternative medicine. The idea is that such treatments can be used in two ways. They may be complementary to evidence-based medicine, as when yoga or nutritional components are added to conventional cancer treatment. Or, they may be used as alternatives and substituted for evidence-based treatments, as when substances made from apricot pits are used to treat cancer rather than radiation or chemotherapy.

Non-evidence-based treatments also exist in psychotherapy, but they are usually used as alternatives rather than as complementary additions to evidence-based treatments. Because of that, I usually call them alternative psychotherapies (APs) rather than using CAM or CAP to describe them. APs are not just treatments that lack a good evidentiary foundation; there are psychotherapies that are still in the process of data collection that are not APs in spite of their relatively small evidentiary support. APs are different in that they are not plausible, because they employ faulty logic or because they are not congruent with things we know about human beings. APs for children and adolescents are noticeably out of step with established information about child development, for instance. APs also have potentials for causing harm to clients, sometimes serious harm, sometimes harm in the form of opportunity costs as families expend resources on ineffective treatments.

APs for children and adolescents may resemble each other even though the theories behind them and the practices they employ are quite different. This is especially the case when the focus of the treatment is on compliance and obedience to adults. 

My original interest in APs involved Attachment Therapy, a treatment for children that stresses obedience and considers compliance to be the indicator that children have formed emotional attachments to adults. This is implausible for many reasons, but especially because it assumes a single factor at work to determine complex behaviors that are based on both maturation and experience. Advocates of Attachment Therapy have published descriptions of their practices and discussions of their rationales for limiting children’s diets, requiring tedious and difficult manual labor, and threatening children that they will never go home if they do not cooperate. Members of groups like the Facebook closed group Attachment Therapy Is Wrong have disclosed their experiences in this form of AP.

More recently, I have identified some treatments for “parental alienation” as APs. These treatments purport to correct children of divorced parents who strongly prefer one parent and resist visiting the non-preferred parent. The children are thus disobedient to the non-preferred parent, and if they have been ordered by a court to visit they may also be failing in compliance to the court and its officers. Parental alienation treatments have been described by their advocates as involving multiday workshops in which children may not contact the preferred parent, must spend time with the non-preferred parent, and must watch educational videos and engage in “fun” activities followed by a required vacation with the non-preferred parent. Some of the programs maintain separation from the preferred parent for 90 days or more and make communication with that parent contingent on complying with rules for desired behavior toward the non-preferred parent. The children have no money or phone allowed to them and are often a great distance from home.

 Although as far as I know there is no social media site where adolescents or young adults have described their past experiences with parental alienation treatments, over the last year I have seen a number of accounts of the proceedings as experienced and recalled by those who have been through them. These accounts have some details in common. One is that the children (I am going to include adolescents in this category) were taken from school or home to the place of treatment by youth transport services workers. The transporters in some cases applied handcuffs to the children before transporting them by car or plane. Money and phones were taken away, so although some children were told that they could leave the treatment rooms if they liked, and that they were not being forced to do anything, in reality they had little choice except to find themselves alone on the streets of a strange city. Cooperation was also obtained  by means of threats—for example, if a child would not eat when given food, he or she might be told that this was very unhealthy and it would be necessary to place the child in residential treatment for his or her own good. Wilderness therapy programs were often mentioned, with emphasis on the impossibility of escaping or communicating with anyone on the outside. Other threats involved manipulation of concerns about the preferred parent, for example that he or she would go to jail or be fined a large amount if the child did not cooperate, watch the videos, play the games, and talk to and make eye contact with the non-preferred parent.

The common themes of Attachment Therapy practices and those of parental alienation interventions are evident. The children are essentially held captive by practitioners. They have in many cases experienced physical restraint—handcuffs for the parental alienation cases, “take-downs” for the Attachment Therapy situations. Although in theory they may be able to leave the premises, in practice this would mean going into a frightening milieu that they are not prepared to handle. In both cases, descriptions by victims include constant intrusive supervision and demands for compliance with unnecessary assignments, whether cutting the grass with nail scissors in one case or watching videos and discussing them in the other. Victims of both methods have reported practitioners’ laughter at the children’s discomfiture. Threats of abandonment or of more intense seclusion and isolation are in both case used to manipulate children’s behavior. In both therapies, children learn to comply to whatever extent they are able  in order to escape from the pressure and constant demands they experience. Only children who for physical or mental reasons cannot comply will not show the temporary behavior changes required of them, and as a result advocates of both methods claim that their treatments are effective.

I don’t discount the importance of some degree of obedience and compliance in children and adolescents. Their own safety may well depend on established habits of attending to adult advice. However, when a psychotherapy focuses entirely on compliance as an indication of mental health, and especially on compliance to an adult’s demands for affection and gratitude, a mistake is being made. This is particularly true when an intrusive treatment is directed toward older school-age children and young adolescents, whose normal developmental trajectory is moving them away from their relationships with parents and toward relationships with peers, romantic connections for the future, and cooperation with friends, teachers, and employers.

Finally, I want to point out that treatments involving parent-child relationships need to involve changes in both child and adult, without which the relationship itself cannot really change. In infant mental health circles, one important principle is that treatment must be treatment of the dyad, and this is true in a more complicated way of relationships between parents and older children too. Yet the APs discussed in this post focus on making the child change. Why? Presumably this is because a) the child can’t get away, and b) the adult is paying the bill. It’s certainly not because there is evidence that this approach is effective, or even that it is consistent with the ideas of family systems that are so often and so nonchalantly invoked.

Monday, October 1, 2018

A New Book About Crime and Children


Children and crime can be connected in a lot of different ways. Children can commit crimes, sometimes starting when very young as “runners” for older criminals. If caught, they may receive various penalties considered as interventions, from placement in foster care to imprisonment (sometimes with life sentences!) as juveniles. They can be victims of crime, too, and some would even argue that in having been brought into criminal activity they have already been victimized. Arguments about children’s rights and the reasons children become criminals—or victims of crimes like child abuse and neglect—are intense, and reflect the ongoing culture wars of the United States and their associated differences on child-rearing and treatment of adult criminals.

Clearly it is a complicated task to discuss the many topics we can categorize as “children and crime”. There are plenty of books out there that focus on some single topic like child maltreatment or juvenile justice. But a new book by Dr. Connie Tang brings all these topics together in a coherent way. Children and crime (Rowman & Littlefield, 2019) is an unusual and valuable contribution that can be used with benefit by the general public as well as by undergraduate and graduate students in psychology, sociology, social work, and criminology. (And if you belong to the general public you don’t have to  worry about the learning objectives and thought questions in each chapter, but just dip in to what catches your attention!)

Children and crime emphasizes the need for critical thinking about complex problems by discussing the real problems of research design that must be addressed when it is impossible to do experimental work that separates possible causes and effects in a meaningful way. This is the part of the book that most psychologists and psychology students will find most useful. But in addition Dr. Tang expresses a deep compassion and sympathy for children caught in the toils of crime, a practical concern reflecting her early training as asocial worker. A third factor that makes this book unique is Dr. Tang’s awareness of cultural differences, born of her own upbringing in China and adult life and parenthood in the United States (which, full disclosure, she and I have discussed many times).

Like any other serious work on the events of childhood, Children and crime has to deal with the fact that although laws are written as if every person from birth to age 18 has the same needs and abilities, this is actually far from true. Dr. Tang shows three graphs early in the book that demonstrate this fact clearly with respect to children and their involvement with crime. The first graph shows that almost 50% of child victims of  homicide are under 6 years of age; 10% are between 6 and 11; perhaps 7% are 12-14; and more than 35% are 15-17. In other words, young children are most often killed, school-age children and young adolescents quite rarely, and older adolescents with increasing frequency. In a second graph, the child homicide victim’s relationship with the killer is shown. Almost 60% of victims under 6 are killed by family member, another 20% by acquaintances, very few by strangers, and almost 20% by unknown persons.  Child victims between 6 and 11 are killed with about the same frequency by family and unknown persons (about 40% each), and less than 10% of the time by both acquaintances and strangers. By ages 12-14, family killers are reduced to 10% and stranger killings to about 15%, while acquaintances are the killers 25% of the time and killers are unknown in about 50% of cases. These developmental changes proceed with victims aged 15-17, who are rarely killed by family, somewhat more often by strangers, but nearly 40% of the time by acquaintances and 55% of the time by unknown persons. A third graph shows victim age differences in weapons used in the killing: for the youngest children, knives or objects are rarely used, firearms in only about 15% of cases, and the most common method of killing (50%) is “personal”--  that is, the child is killed by beating, strangulation, or similar methods. By ages 6-11, firearms have become the method of killing 50% of the time and “personal” methods have shrunk to 5%. By ages 12-14, 65% of the child victims are killed by firearms, and by ages 15-17 this has increased to 85%.

These developmental differences in child homicide victims reflect a range of factors like physical vulnerability, contact with family and with outsiders, and active involvement in dangerous activities, all of which change with age. Children and crime offers information about psychological theories of development and about social and community factors like those discussed by Urie Bronfenbrenner, as Dr. Tang uses these concepts to discuss how maltreatment, delinquency, and children’s eyewitness testimonies can be understood.

This is a really valuable book. It is not a general discussion of children and the law , or even an extensive discussion of the laws of various countries concerning  a single topic (like the enormously-detailed tome of Hoyano and Kennan, Child Abuse: Law and Policy Across Boundaries, that covers most English-speaking countries). Much more usefully for most readers Children and crime brings together overviews of relevant topics in ways that introduce important ideas to beginning students or general readers and that prepare readers to go more deeply into the complex research literature.

PS: I do have a tiny criticism. If I had written this book (which I would be proud to have done) I would not have been so nice about repressed memory! This is a contentious topic, but I think the results are in, and do not support the idea of repression or the related “recovered memory”.



Sunday, September 9, 2018

Separation of Migrant Children: Commenting on Proposed HHS Rule Change

Some readers may be aware that the Department of Health and Human Services proposes to make a change in the Flores amendment that (in theory) limits separation of  undocumented migrant children from their parents to 20 days.  The new rule is described as:
The Department of Health and Human Services (HHS) Proposed Rule: Apprehension, Processing, Care, and Custody of Alien Minors and Unaccompanied Alien Children

You can comment on what rules should apply in these cases by going to 


Here is the comment I posted:

I am a developmental psychologist and the author of a book on infant development, one on emotional attachment in childhood, and textbooks on child development. I am concerned about the assumption that a HHS rule about separation of children from parents can be equally appropriate for children of all ages, birth to 18 years.  Clinical and observational studies of child development show that the impact of separation on children is most severe during the toddler period, roughly 10 months to 3 years of age. Preschool children are also negatively affected, but because of their better language development,  can tolerate separation somewhat better than toddlers can. Both toddlers and preschoolers show the impact of abrupt and long-term separations by crying, withdrawal, failure to play or explore, and problems with eating and sleeping. Notably, if separation  goes on for more than a few days, these effects will not disappear when the child is reunited with a parent, but will continue to be apparent for weeks or months, as the child has sleep problems or nightmares, is easily startled and frightened, and both clings to and behaves aggressively toward the parent. These reactions are difficult for any parent to cope with, but are especially so for a parent who is also frightened and distressed about an uncertain future.

School-age children are also distressed by separation, especially when they are confused by a new language, but their reactions and long-term responses are much less seriously negative than is the case for toddlers and preschoolers. In my opinion, decisions about rules on treatment of separated migrant children should focus on care of toddlers and preschoolers if triage needs to be done because of limited resources. Ideally, toddlers and preschoolers would remain with parents in whatever detention is used. A less ideal solution, but a better one than seems in place at this time, is that separation be limited to 20 days at the most, and that care for the separated young children follow guidelines for high-quality child care as provided by organizations like the National Association for Education of Young Children (NAEYC). These guidelines would set maximum numbers of children to be cared for by one caregiver , with a ratio of 1:3 for the youngest children in this group and 1:5 for older preschoolers; would provide that children have assigned caregivers rather  simply placing a number of caregivers to work with all of the children in a large group: would provide that these young children be cared for in small groups rather than large rooms full of children; and would emphasize individualized care for the children, with physical contact and talking prioritized.

Much concern has been expressed in recent years about the physical and mental health consequences of adverse childhood experiences (ACEs), and how these consequences continue into adult life. Most migrant children have already experienced a number of ACEs in their home countries-- these being the reason for the family's migration-- and have often experienced more on their journeys. For toddlers and preschoolers, separation from familiar caregivers is a seriously adverse childhood experience in and of itself. When this separation is abrupt and long-term, when the separation has occurred in frightening, even violent, circumstances, and when young children do not receive the care that could help them escape the worst effects of these events, we must consider the accumulation of traumas  that are being inflicted and their real consequences. Although we cannot undo the effects of earlier ACEs on migrant children, we can refrain from subjecting them  to further distress and further needs for social services that neither they nor their parents may have access to.

I do not mean by these statements to minimize the distress of 6- and 7-year-olds or of older children when confined to prison conditions following terrifying events before and on their journeys. However, my concern is that it is developmentally inappropriate and potentially harmful to assume that the youngest children can tolerate abrupt separation and the apparent loss of all they know in the same way that older children and adolescents can manage. It is time for the HHS rule to recognize the different needs of younger and older children and to assign resources accordingly.



*********** Readers, if you would like to comment on this issue, you should understand that you do not have to identify yourself or explain your credentials as I did. There is also a checklist that you can read before commenting that will give you an idea of how to approach this. I hope people will speak up while the chance exists. 

Monday, September 3, 2018

Autism Treatments, Science, Risks, & Benefits


The Association for Science in Autism Treatment (https://asatonline.org) is an interesting organization that includes some big names ( like Tristram Smith) and seems to have the admirable goal of providing information about autism treatments that can help parents make their own choices of treatment. The website has a considerable list of specific treatments and the empirical evidence that supports them, if there is any. It’s a good place to find definitions and descriptions of both well-known and obscure treatments that target autism spectrum disorders.

Looking at the evidence for various autism treatments as discussed at asatonline.org, we’re reminded of the great difficulty of outcome research in general and work on autism in particular. Because therapies have shared general factors (like individual attention) that can cause improved outcomes, it’s important always to compare the outcome of a type of treatment to the outcome seen when there is no treatment, or a treatment whose effectiveness is already known. It’s not enough to report that a group of people did better after a treatment than they did before—they might have done just the same (or even still better!) if they had no treatment at all. When a study focuses on children, this is a point of special importance, because children change quickly as a result of their natural development, even if they are on an unusual developmental trajectory like autism.

When a comparison group is used in studying treatment outcomes, it’s essential that every person being treated has an equal chance of getting into the treatment group or into the comparison group. They need to be randomly assigned to groups, not allowed to choose for themselves which group they prefer. If that’s not done, it may appear that a treatment is more effective than the comparison simply because the people who chose it are in better shape to begin with or are more sensitive to treatment.

You can see how difficult these things may be to do, especially with respect to autism. Permission for autistic children to be in outcome research has to be sought from their parents, who may be horrified at the thought that their children will be “guinea pigs” , may be frightened of what researchers might do, may be extremely protective of their vulnerable children, and may simply have so many demands in their lives that they cannot cope with the inconvenience of being responsible  for participation in research. They may resent the idea of having their children assigned at random to treatment conditions or to a comparison group, even if they are promised that each child will eventually get treatment. The children themselves may be reluctant, anxious, oppositional, or in other ways require a great deal of individual handling.

It’s far from surprising that no autism treatment has nearly enough empirical work supporting it, and it’s to the credit of ASAT that they do their best to make this plain. However, there are some points they fail to make as clear, and I am not sure whether this failure occurs because the website authors don’t want to offend anyone who proposes an autism treatment.

The first problem I see on this website is that quite a few proposed treatments are listed under the heading “doesn’t work or is untested”. Now, although I am quite aware that it is not possible to show that something does not exist (unless you can find some mutually exclusive thing that can be shown to exist), but I would argue that there is a big difference between treatments that have been thoroughly tested  and shown to be ineffective, like Facilitated Communication, and those that have never been tested in any systematic way, like Son Rise.  When a treatment has been systematically tested, there are some things we can know about it, for example that there are people who have been trained to apply the method in a predictable way. In addition, we have evidence that the treatment does not make a condition worse; not all therapies are really “therapeutic”, and some actually exacerbate problems. Systematic investigation of a therapy can also tell us whether other forms of harm were done, including whether autistic children (or others) found the treatment distressing or frightening. Choosing a treatment scientifically requires attention to both demonstrated benefits and demonstrated risks of the treatment.

The asatoline.org website is not very different from some similar sites with respect to this problem of grouping together untested and tested but ineffective treatments. The California Evidence Based Clearinghouse for Child Welfare (www.cebc4cw.org) similarly confuses issues  as it rates treatments both in terms of their evidence basis and of their importance for child welfare concerns; users may not notice the difference between these ratings. In addition, cebc4cw.org bases its rating on information provided by advocates of treatments. The California site also rates many of the listed treatments NR (not rated) because no evidence is provided—leading to a situation somewhat like that of asatonline.org, where the listing of a treatment does not necessarily indicate that its outcome has been tested systematically or that it has been shown to be effective.

A second problem of the asatonline.org site is that the material presented mentions almost nothing about potential harms associated with treatments. This topic has received increasing attention over the last twenty years or so, and that attention has been strongly focused on unwanted effects on vulnerable individuals like autistic children. The journal Clinical Psychology is preparing to do a special issue on potentially harmful psychotherapies. Potential harms from mental health interventions can range from physical injury and death to “opportunity costs”, the loss of opportunities to make use of effective treatments or of limited resources like time and money that might be better spent on other needs of an autistic child or of other family members.

The ASAT website lists “patterning” as an ineffective or untested treatment. Patterning is a physical movement therapy that involves having five adults move a child’s head and limbs through positions characteristic of infant reflex movements, on the assumption that the nervous system can be “rebuilt” by this reenactment of early life. Patterning for autism and nervous system injuries has been rejected twice by committees of the American Medical Association It  has not only never been shown to be ineffective, it also has the potential for physical injury as untrained people move the child’s head and limbs into different positions. Above all, patterning has opportunity costs, as it is to be done several times a day, exactly on schedule, by a number of adults greater than is found in most Western households. Patterning is privileged over adult work and the needs of other children in a household, so that family functioning is negatively affected, as are relationships with family members, friends, and neighbors who are repeatedly asked to help with the therapy.

Similarly, asatonline.org lists Faciitated Communication (FC) as an unsupported or untested therapy for autism. FC is a method by which an adult works with a child to use a keyboard with the intention of understanding thoughts the child cannot express in speech. FC has received systematic investigation and it has been demonstrated that what is “said” on the keyboard stems from the beliefs and thoughts of the facilitating adult, not the child. The website makes this clear, but does not note the harm done to a number of families when a facilitating adult used the keyboard to accuse a family member of sexual abuse of the child, causing a criminal investigation with all its associated stress and mutual distrust in the family.

The ASAT website lists under unsupported and untested treatments two associated therapies, one under the name “bonding (attachment ) therapies “ and the other under the name “holding therapy”. The first covers both holding therapy and “gentle teaching”, although holding therapy appears again under its own name. Egregiously, neither of the references to holding therapy gives a complete description of how it is done and the potential for physical and psychological harm inherent in this coercive restraint treatment, although the first description does use the word “forcibly” and warns parents against covering the child with blankets as part of this method. The first description also notes that autism is not a bonding or attachment issue, so a therapy that is posited to increase attachment is in any case irrelevant. Both descriptions end with the idea that well-designed and implemented research on holding therapy is needed. None of the risks, child injuries, or deaths associated with holding therapy are mentioned. The pain and fear experienced by children undergoing this treatment are well established and are frequently discussed by adults who went through holding therapy on a closed Facebook group called “Attachment Therapy Is Wrong”.

I find it quite disturbing that a website stressing a scientific approach should omit well-known information about the potential for harm shown by some treatments. The risks associated with holding therapy have been understood for over two decades. A scientific approach must examine both risks and benefits of a treatment, even one for competent adults--  when the patients are autistic children who cannot make their own choices, the information give to parents must be particularly concerned with the potential for harm. 

I'm going to add to this post a statement made by an English man with autism, Les C., now an adult, about his childhood experiences with holding therapy: 


My life experience as a undiagnosed autistic/ aspergers child.

My parents have always said that my problems started when I started school. At age 4 I went to playschool with my mam, so I was never left with other children, until my first day at primary when I was 5.
I was very upset, and I could not understand why my mam had gone home and left me, so during most of the day I sat crying and saying I wanted to go home and I didnt like being with other children who just got on with it. After break time when the whistle was blown, all the other children lined up ready to go back inside, while I ran the other way onto the field and rolled on the grass. I vaguely remember doing this and maybe because I thought it was funny to get the teacher to run after me.
The head teacher had said to my mam that my behaviours were not acceptable and that I could end up in borstal if something was not done. In a later year, I found out that I was the only one in the class that was adopted when someone in the class mentioned it, but I didnt know what it meant, and the other children seemed to treat it like a joke that I didnt have natural parents. My mam explained to me what it meant and at first I felt left out, but I didnt have a problem with it, but my parents started to think that I did.
Over the years I never mixed or made friends like others did, and had many problems at home and at school. My parents found my behaviour very alien and badly behaved. I was born in the 70s when in them days some parents punished with shouting and slapping. I was also taken to see numerous  child psychologists and councillors, where my parents would do the talking, while for me I could not communicate. My mam had read some information on autism which was very little at the time, and mentioned the possibility to a psychologist of me being autistic, but they said no and that I was just a very naughty attention seeking child. My autism has affected me differently to how it has other people. I see and feel things differently to others. I could not help the way I behaved, and my parents could not cope and were getting to their wits end. For me I had a high sensitivity of being physically touched in childhood. I was fine with my parents holding my hand to go out or being asked for a light hug, but anything more than that was uncomfortable and distressing if pushed over my limit.
If my mam came and touched me or to put her arms around me, I would resist and push her away. To a parent, that may seem perfectly natural and comforting, but to me it was not, but as a child I couldn't think of a way to explain it. The times when I was slapped for something wrong, and what is just a little tap to a parent, was like a big bash over the head for me, so I naturally went berserk, and retaliated and all hell breaks loose. I wondered when are they going to get the message that its painful for me to be touched.
Every so often I had to go to hospital appointments to see a orthopaedic doctor about my legs because they were not growing right along with my weight issue. Again I hated these appointments because of the touching, so I was probably being awkward. The doctor included in the medical notes that I was out of control and disturbed in some way. When the time came that they felt I needed to have surgery, which I didnt want and still wish I had not, because I wasnt unhappy with the way things were. My parents were concerned about my mobility in case I ended up disabled, so I didnt get listened to, and was taken to hospital, which I thought was a good way to get off school because I was bullied with no friends, and I was early years at the big school now. I was pressurised into having it done. The nurses were horrible to me, they treated me like I was some sort of a freak, and didnt care about my pain until I asked for painkillers. I hated them touching me to remove my stitches and dressings. My leg was stiff, they told me to bend it, or they would get the physiotherapist onto me. The physio came and she was great with the other children on the ward, but she was nasty and brutal with me while the others watched me scream, cry and shout in pain.
I assumed the nurses told my parents everything that happened, but they had not, and they would not have allowed this if they did. It sounded like the psychologist I was under at the time told my parents and the hospital staff not to listen to me. Time off school for another traumatic experience of pain and physical touch, I was no better off.
Sometime later after that, I decided I wanted to spend some time on my own away from home and school. I had bath, got into my favourite clothes and left with my savings book without saying anything. I was found by the police and brought home, and they all wanted to know why I did it.
I did this on 2 occasions, and the 2nd time, 2 nice policemen brought me back and said if I went missing again I would be taken into a home.
My parents thought that I did this because I was adopted, so again I was taken to see a doctor who introduced me to a lady that I could see and talk to and go out and do things with, and that she was adopted too. I did not want this because I didnt really have a problem with it.
Then later my mam read something in a magazine about holding therapy, or someone that had told her about a lady that did it. She did not know what it was or what it was all about, but she told me that we were going to see a lady that could help. A lady who learnt from Welch, unknown then.  As usual, I would just be sitting listening to my parents tell her about everything including our rows, being pushed away and that I was adopted. Surely with experience with others, she should know that I have a resistance to being touched. So what sounded very nice and loving to my parents was agony to me. The distress I have had with unwanted physical touch was bad enough. My parents were desperate for a solution, so they listened to whatever she said to do a hold no matter what I was to say or do to get away from this prolonged uncomfortable painful touch.  A week later, after it had happened 3 more times at home, including the lady coming to our home where another session took place, and seeing her doing this on a TV documentary with others, I was lucky that my dad put a stop to this because he couldnt see how it would solve anything, and he did not like the atmosphere, and for me this had greatly pushed my limits of touch over the top to torture.  My grandparents at the time were told about this, and they agreed that my dad did the right thing. After this last resort, my parents just had to accept the way I was.
END.
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Friday, August 24, 2018

Refusing to Visit a Divorced Parent: Reasons Other Than "Parental Alienation"

There is no question that some children and adolescents in divorced families refuse to visit one of their parents. It’s also very possible that some of these reluctant kids have been influenced by the attitudes or even the insistence of their preferred parent. What’s not so likely is that all cases of resistance or refusal on the part of children, unless they are connected with abusive treatment, are matters of “parental alienation” deliberately brought about by the preferred parent’s campaign of denigration against the other parent.

Very few human attitudes or behaviors are determined by single factors in the way proposed by parental alienation (PA) proponents. That’s why psychologists tend to be suspicious when they come across single-factor theories or theories limited to a very small number of factors but used to explain complex situations. Unfortunately, single-factor theories—so easy to explain, and apparently, to understand—are all too easy to introduce into legal decision-making, while more complex and realistic views may be excluded.

The PA view has been that there are only two categories of children who resist or refuse contact with one parent. One group has been physically abused by that parent, and the abuse has been documented, so their reluctance is seen as rational. The other group, with no documented history of physical abuse, have only  “irrational” explanations for their aversion to one parent, and therefore must have been intentionally alienated by the parent they prefer. A range of bad consequences for the children are predicted if they remain with the preferred parent, and a complete change of custody is demanded.

Given that it’s possible that the PA claims are true in some cases, can we list some other possible reasons for children’s avoidance of a parent in the absence of a history of physical abuse? Of course we can, and I am far from the first to mention this. Children and adolescents may prefer to exercise their developing autonomy; to stay in the house they call home rather than having to go back and forth; to be in easy reach of their friends; to spend their time with friends’ companionship rather than having to devote time to a parent; to avoid criticism or demands from a parent or emotional abuse; to manage to ignore a parent’s disturbing sexual or romantic relationship with one or more new partners; to avoid a step-parent, step-siblings, or parents’ boyfriends or girlfriends; to arrange school, sports, or social activities as they prefer; to escape from questioning about the preferred parent.

 Any or all of these issues may have very different impacts on children at different ages, so the child who at age 8 was indifferent to a parent’s romantic life may at age 14 find any evidence of such excruciatingly embarrassing. A child who at age 12 was delighted to spend a weekend camping may at age 16 want only to socialize with peers. In addition, individual differences in temperament may make one child easily distressed by unsought changes, while a brother or sister of different temperament can accept changes with equanimity.

When we examine psychological and behavioral issues that are not well-understood, one useful strategy can be to find some analogous events that are easier to study. Given that there are so many factors that can help to explain a child’s avoidance of a parent, it seems to be a good idea to find some parallel situation that may give insights into this kind of avoidance. Are there other things children avoid with intense emotion and resistance? Yes, and one of them is not uncommon: school refusal. About 35% of children sometimes  refuse to go to school without a “rational” explanation--  some do this infrequently, while others may manage to avoid school most days for long periods of time. Children who refuse school not infrequently fight against going to school each morning, plead stomachaches, even vomit, scream and have tantrums. The great majority of their parents do not like this, want the child to go to school, fear the consequences for their own work responsibilities, and are disturbed about the social and educational outcomes for the child.  (Parents who actually want the child to stay at home have the option of homeschooling, after all.) The parents don’t know what to do to get the child to go to school, and it is noticeable that they are rarely if ever accused of alienating the child from school.

In a 2009 article in Child Development Perspectives (Pina, Zerr, Gonzales, & Ortiz; “Psychosocial interventions for school refusal behavior in children and adolescents”, Vol. 3, pp. 11-20), the authors discuss children’s motivations for refusing school. I will list these, and in each case state in brackets a possible parallel with refusal to visit a parent:

1.      1.To avoid school-based stimulation like bullying that provokes negative emotion such as anxiety and depression [A child avoiding a parent may also be distressed about parental behavior that is anxiety- or depression-triggering, such as criticism of the child or the other parent, demands for more time or attention, poor parenting skills, insufficient attention paid to the child when he or she is present, or issues that have to do with the parent’s home, friends, or partners and their children]

2.      2. To escape aversive social or evaluative situations like difficulty in making friends or public exposure for lack of school achievement [A child avoiding a parent may find it difficult or awkward to have social interaction with that parent, especially a parent who lacks social or parenting skills, or may feel exposed to criticism for failures to perform scholastically or athletically to the parent’s expectations]   

3.      3. To get attention from significant others such as parents and concerned teachers [A child avoiding a parent may find his or her behavior rewarded by the attention of one or both parents who have been distracted, perhaps for several years, by their own marital situation]

4.      4. To pursue reinforcing events outside school, like playing or shopping [The child avoiding a parent may enjoy his or her own devices, toys, and books and “own room”, as well as familiar foods and routines, a parent who is easier to be with, and the availability of siblings and friends]

In addition to this list of motivations with their possible parallels in avoidance of a parent, Pina et al noted characteristics of children who refuse school, such as poor social skills, social isolation, high levels of family conflict, and a poor sense of self-efficacy in stressful situations.

For a better understanding of why some children refuse to visit a parent, we might do well to examine these aspects of school refusal and see whether the behaviors are analogous in more than a superficial way. PA proponents have not gotten very far in terms of basic science by insisting on a single factor operating in cas