Child Psychology Blogs

Concerned About Unconventional Mental Health Interventions?

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

Wednesday, March 14, 2018

Unusual Attachment Behaviors and Their Implications

The concept of attachment—a toddler’s wish to stay near a familiar caregiver, especially when frightened, tired, sick, or injured, or when in an unfamiliar place—has given rise to thousands of research studies and much speculation sine it was formulated by John Bowlby in the 1950s. Some of Bowlby’s work focused on the attachment experiences of children who later turned out to be delinquents, so from an early point ideas about attachment have been connected with explanations of undesirable behavior and predictions of emotional problems.

The most established measure of attachment, the Strange Situation Paradigm, uses an artificially slightly scary situation to look at how toddlers respond to their mothers’ leaving them briefly in a strange place, and the way they respond to reunion with her when she returns. The great majority of young children behave in the Strange Situation in ways that let researchers categorize them in one of three categories. The largest number are classified as securely attached, and smaller proportions as either insecure-avoidant or insecure-ambivalent in their attachment relationship to the specific familiar adult who is with them in the test situation. All of these categories are within a normal range of social and emotional development , and although “secure attachment” sounds better than the other categories, it is not necessarily strongly associated with any great developmental advantage. These attachment classifications may change over time and may well be different from other attachment classifications a child would receive if tested with a different familiar person--- that is, the attachment classification is neither permanent or “in the child”, but is changeable and “in the relationship”. 

Because similar language is used, people may jump to the conclusion that insecure attachments lead to so-called “insecure” adult behavior like lack of self-confidence or jealousy or poor social skills, but this is not the case. Insecure attachments are not considered the ideal for toddlers, but neither do they require treatment to prevent current or later difficulties. In addition, it is very clear that the Strange Situation Paradigm was developed for research work comparing groups of children and not for clinical purposes—insecure attachment classifications in individuals are not diagnoses.

Years after Bowlby’s work, the psychologist Mary Main and her colleagues described a form of toddler behavior in the Strange Situation that was different from the three primary classifications of attachment. They referred to this behavior as “disorganized attachment”. Young children who were classed as having disorganized attachment behaved in quite unusual ways when reunited with their mothers after a very brief separation. Some froze in place after starting to approach the mothers; some backed toward the mothers; some simply collapsed to the floor. For their parts, the mothers, many of whom had endured earlier traumatic experiences, often appeared frightened as they looked at the children.  It seemed that the children needed and wanted contact with their mothers, but they had no effective way to get this because of their own state of fearfulness, perhaps associated with the mothers’ apparent fear. Not only was the relationship between child and mother disorganized and inadequate to give the child needed support and comfort, but children in this kind of relationship would not be able to use their mothers as “secure bases” to give them confidence for exploring and learning—one of the most important benefits of toddlers’ attachment.

Disorganized attachment has been thought of for years as an important indication of the need for treatment of mother and child. But recent work suggests that it is not completely clear how disorganized attachment develops, so it is in turn not completely clear what to do about it. In one recent article (Duschensky, R. [2018]. Disorganization, fear, and attachment: Working towards clarification. Infant Mental Health Journal, 39, 17-29) , the author suggests three different pathways by which toddlers may have arrived at disorganized attachment behavior: serious rejection by the mother, traumatic experiences leading to emotional dysregulation, and temperamental characteristics present at birth. These different possibilities would suggest different treatment approaches, so simply screening young children for disorganized attachment does not necessarily give useful guidance about what help to offer. And, once again, the Strange Situation Paradigm was never intended to make clinical decisions about individuals, but was created as a way to compare groups for research purposes.

Research on disorganized attachment has looked at whether this form of toddler behavior toward a mother is associated with abusive treatment. It’s easy to see why this question would be asked, because two of the pathways to disorganized attachment mentioned above – rejection by the mother and traumatic experiences—could be connected with abuse. Indeed, there are weak statistical relationships between child abuse and disorganized attachment. But these correlations unfortunately have led some practitioners to the idea that disorganized attachment behavior can be used to screen families for child abuse. This conclusion is wrong for various reasons. One is the oft-repeated but equally oft-forgotten fact that correlation of two events does not show that one causes the other. It’s possible that abusive treatment of a child could cause that child to show disorganized attachment behavior, but it’s also possible that children who for other reasons show unusual attachment behavior could trigger both fear and abusive treatment in their caregivers. Even more likely, additional factors like poverty and family trauma could cause both disorganized attachment behavior and abusive treatment, or could cause one or the other separately. In any case, disorganized attachment behavior cannot be used as a proxy measure or screen for child abuse; however much time and resources this approach might save, it would not find all cases of child abuse, and it would find many false positives as children who had never been treated abusively could still show disorganized attachment behavior.

A recent article on disorganized attachment, written by a large number of well-known attachment experts, has clearly stated the limits of usefulness of the disorganized attachment classification ( Granqvist, P., et al. [2017]. Disorganized attachment in infancy: A review of the phenomenon and its implications for clinicians and policy-makers. Attachment & Human Development, 19, 534-558 ). The paper commented on four assumptions about disorganized attachment that they characterized as false and misleading. These were first, that attachment measures can be used to evaluate individual children in judicial or child protective contexts; second, that the presence of disorganized attachment behavior reliably shows that a child has been maltreated; third, that disorganized attachment behavior reliably predicts emotional or behavioral problems in the future; and fourth, that disorganized behavior indicates a lasting characteristic of the child rather than one that can be influenced by changed circumstances. The last assumption, particularly, is contradicted by the fact that it is not unusual to see some mild level of disorganized attachment behavior occur in toddlers in the Strange Situation, especially if they come from challenging environments.

If children show organized insecure responses in the Strange Situation, and if their families need treatment or services, a goal may be to increase attachment security, but this does not mean that insecurity is or predicts serious problems. If toddlers show severely disorganized attachment behavior, they and their families may well need help for one or more reasons, and various kinds of help (as well as maturation) may encourage better organization of relationship-related behavior. However, it should never be assumed either that clinical work with individuals can usefully be based solely  on the observation of disorganized attachment, or that disorganized attachment shows that a child has been maltreated and signals the need for authorities to intervene in the family. Removal of the child should not be contemplated simply because of disorganized attachment behavior.

Tuesday, March 13, 2018

Distracted Parenting, Cell Phones, and Technoference

Everyone who has been a parent—or a teacher, nanny, babysitter, or other caregiver—knows what it is to multitask. Taking something out of a hot oven while using your knee to block a crawling baby from approaching this interesting event, remembering that you need to call for a doctor’s appointment while getting a shoe on a small foot, replying to “right, Mom, right?” while writing a grocery list, watching what one child is doing while comforting another with a skinned knee. Let’s face it, a great deal of parenting (or teaching or other caregiving) is distracted parenting, and children are able to deal with that fact as long as there is some minimum level of undistracted, sensitive, responsive, attentiveness. This has been the case since our Paleolithic ancestors had to keep the kids from falling in the campfire while judging the distance from them of the tiger whose cough they can barely hear.

But: enter the cellphone and assorted screens, all of which may be more attention-getting for adults than all but the most loudly shrieking child. Has distracted parenting now reached epic proportions? Is this a problem? What could we, or should we, do about it?

It’s easy to see that distracted parenting can be a safety problem for preschoolers and even for younger or more risk-taking school-age children. Look at that distracting phone for a minute and while you do so, a child who is not yet street-wise runs after a ball and is hit by a car, or one who thinks she can help herself to lunch touches a hot burner on the stove. For children of all ages who need supervision in the bath, slips and falls are more likely (although there should be fewer bathtub drownings because parents with cellphones don’t need to leave the room to take a call).

For infants who are not yet mobile themselves, there may not be so many physical safety concerns connected with parent distraction by screens, but “technoference” (the interference of electronic devices with interactions between parent and infant or toddler) presents some very real potential risks for early development. Babies’ emotional and cognitive development (including language) follows a transactional pattern, involving a series of interactions between parent and child in which each partner is influenced by the other and the way each influences the other changes over time. The baby is an active partner and seeks parent responses as well as responding to parent communications like talking, pointing and facial expressions.

 Babies of 4 months or so respond with distress to a parent face that looks at them but also looks blank and fails to respond to smiles or other communications. The baby looks away, may begin to whimper, and acts more and more distressed. In addition, when the parent looks responsive again, it takes a little while for the baby to warm up and start to interact normally.   This “still-face” situation is one that can happen with any parent and baby from time to time as a parent is temporarily distracted by the demands of life. It is more likely to happen if a parent is depressed or disturbed by something that demands attention more effectively than the baby can manage, and when this is the case the interaction between the two gets less effective or enjoyable over time. When a parent responds to a screen often, even in the midst of an interaction with a baby who is trying to get a response, we can expect “still-face” effects to be multiplied. (And how puzzling it must be for a baby who is working on developing language to see that someone talks when no one else is there, appears to look in the baby’s direction, and yet talks and looks completely differently than at other times! This would seem to signal that those noises people make with their mouths have no real meaning after all.)

A recent article in the journal Child Development (McDaniel, B., & Radesky, J. [2018]. Technoference: Parent distraction with technology and associations with childhood behavior problems. Vol. 89, pp. 100-109) reported a study that looked at parent distraction by screens and the associated behavior problems displayed by children. (Because of the study design, this work was not able to show whether “technoference” caused behavior problems or whether one or more other factors [like parent anxiety] caused both parent distraction and child behavior problems.) The authors reported other publications that have presented evidence that parents who use technology when with their children have fewer parent-child interactions, that they are less responsive to children’s bids for communication (and I should point out that sensitive and responsive parenting is well-known to be connected with good child development), and that parents even respond with hostility to child communications when they are attending to devices.  Looking at 183 families with young children, these authors concluded that parents who reported a high level of “technoference”  also reported more of both externalizing (angry acting-out, for example) and internalizing (depression or social withdrawal, for instance) problems in their children. Why this should be is not completely clear, and the authors speculated that  children of distracted parents may need to “act up” in order to get their parents’ attention—or alternatively that parents who are bored or depressed may turn to their screens to escape those uncomfortable feelings.

Most human beings find babies very attractive most of the time and respond with pleasure to young children’s efforts to interact. (We have probably evolved to have this kind of pleasurable responsiveness to the very young of our species.) These facts are what encourage most parents to do a good job caring for their children during the first few demanding and highly emotional years of the children’s lives.  Unfortunately, cellphones and other screen devices seem to be potentially even more attractive and attention-getting than our babies are. Although it isn’t clear what the eventual outcomes of “technoference” will be—and they are probably different for different families—the safest assumption seems to be that young children and parents' screens do not mix well for a wide range of reasons.

Thursday, March 1, 2018

Trust Based Relational Intervention (TM) (TBRI): Another Case of Claims Without Evidence

The alternative psychotherapy for adopted and/or traumatized children, Trust Based Relational Intervention or TBRI, promulgated by the late Karyn Purvis, is receiving much attention from adoptive and other parents’ groups. The major adoption agency Holt International shows much enthusiasm for TBRI methods on its Internet sites. A presentation by Purvis, “Introduction to TBRI”, is available at https://www.youtube.com/watch?v=TvjVpRffgHQ.

Purvis was a warm and charming presenter, and she conveyed genuine affection and concern for children who have come, as she says, from “hard places”.  But it’s clear that much of what she says in this youtube piece is without empirical support and to a considerable extent without plausibility.
What is TBRI in practice? Here is a description I gave in a recent article in Child and Adolescent Social Work Journal, including a long quotation from Purvis and her colleagues: 

"A treatment called Trust-Based Relational Intervention (TRBI®; Purvis, McKenzie, Razuri, Cross, & Buckwalter, 2014) ) bears some resemblance to AT/HT principles and practices. In a case study of this treatment as it was used with an aggressive and self-harming teenaged girl, Purvis et al. described a three-phase intervention in which Phase I was meant to mimic the early social relationship between child and caregiver which results in secure attachment.  Rachel was assigned one specific staff member to be with her at all waking hours during the day, with approximately 36 inches or less to separate them. When Rachel’s mother was present, she assumed the 36-inch role, with a staff member remaining in close proximity. Proximity between the child and caregiver is important. The rationale for maintaining this close proximity is twofold. First, proximity is important from an attachment perspective. In line with attachment literature that suggests that the proximity between a caregiver and infant in a secure attachment relationship is important for maternal responsiveness …, bringing Rachel’s caregiver closer allowed the caregiver to be aware of Rachel’s needs and meet them quickly so that Rachel could learn to trust the adult and build connection. Second, proximity is necessary for a temporally loaded response and is important to support learning” (Purvis et al., 2014, p. 362). In addition, “in mirroring the development of the infant-caregiver attachment relationship, Rachel was not given choices that pertained to her daily routine (e.g., what to eat or wear), but rather those choices were made for her. During the program, choices were presented in a compassionate and kind tone, often utilizing a playful voice to neutralize any negative affect on her part. Again, this transference of choices from Rachel to staff was intended to simulate early life experiences where a child is cared for, rather than needing to care for herself. There was the potential for compromises if Rachel’s reaction to a caregiver’s choice was too disagreeable” (Purvis et al., 2014, p. 363). A second phase of treatment involved role-playing."

In her youtube presentation (one of several, incidentally) Purvis specifically stated that TBRI is evidence-based. She referred to the treatment as having “proven efficacy with children of all ages:. She stated that TBRI “can bring any child back on line” and spoke of “many documented cases” where TBRI had been useful.

The term evidence-based treatment (EBT) has a fairly clear definition among professional psychologists and clinical social workers. Before a treatment can be said to be evidence-based, its efficacy must have been supported by two independently-done randomized clinical trials. Under some circumstances, well-implemented nonrandomized trials may also  help to establish an evidence basis for a treatment. None of these exist for TBRI,  Purvis published several before-and-after studies concluding that TBRI improved aspects of children’s moods and behavior, but those study designs are not acceptable, particularly for research on children whose development may change rapidly and be mistaken for the effect of a treatment. It is incorrect for these reasons to say that TBRI is an EBT. (It is also incorrect to claim, as some alternative psychotherapists do, that EBTs are simply treatments about which articles have been published in peer-reviewed journals.)

Purvis also claimed in the youtube piece that treatment of children who had experienced abuse and neglect should take the form of recapitulation of events in their earlier lives. I was astonished at the use of this  particular term, which I have often used in critiques of attachment therapy, primal scream therapy, “breathwork”, and so on, but I have never before seen this assumption stated so plainly. Yes, Purvis believed and said clearly that in order to treat emotional problems, it is necessary to replicate the experiences of care that a child should have had but did not receive. This theme is apparent in the quotation from the Purvis publication I gave earlier. In the youtube piece, Purvis referred to this assumption as a “scientific parable” – that if a capacity is lost, its causes must be recapitulated by going “back to the beginning”. In addition to the proximity and absence of choices used in the treatment of “Rachel”, Purvis proposed needs for hydration every two hours, food every two hours, and motor activity every two hours, a schedule based on care of a newborn infant, and implausibly applied to every age group right up into the teens. This would appear to be sympathetic magic at work, not psychotherapy.

Further implausibility behind TBRI was shown in Purvis’ belief that mental illness is caused solely by experiences from conception onward rather than by genetic and other biological factors as they interact with experiences (although she mentions substance exposure as a possible factor). She agrees with the Association for Pre- and Perinatal Psychology and Health (APPPAH) that   maternal psychological stress (e.g., from family difficulties) can cause childhood emotional disturbances. In order to counteract these difficulties, which she saw as based on sensory processing disorders, she recommended following  a range of treatment methods as recommended at one time by the occupational therapist A. Jean Ayres. These include a “sensory diet” involving the Wilbarger protocol of light and deep pressure stimulation, the use of weighted blankets, and toys buried in dry rice so that children receive skin stimulation as they try to find the toy.

Purvis referred to herself in her presentation as “a woman of science”. It would be a great deal more accurate to use the term “pseudoscience”.  A recent article by David Grimes and Dorothy Bishop (“Distinguishing polemic from commentary in science…”, Child Development, 2018, 89, 141-147) offered a list of questions that are useful ways to examine claims about TBRI as Purvis made them.

1.     1.  Is there a plausible mechanism for the effect claimed? No, there is no evident way in which recapitulation of early events could cause a repetition of development from scratch, especially not the claimed reshaping of the brain.

2.      2. Does evidence come from peer-reviewed sources? There are publications in peer-reviewed journals , but they do not meet standards for claims of an acceptable evidence basis.

3.      3. Are all relevant studies considered? The published studies are not at a level that makes them relevant to the claims made.

4.      4. Are results of specific studies misrepresented? Because of the design problems of the existing studies, it is a misrepresentation to conclude that they provide acceptable evidence about the effects of TBRI.

5.     5.  Are there claims of impacts on multiple diseases and disorders? This is difficult to answer because of omissions of diagnoses and proportions of specific problems in published material, but certainly there are claims of efficacy for children in such a broad age range that multiple problems must be under consideration, the problems of preschoolers and teenagers being different.

6.     6.  Are causal claims based on experiment, correlation, or analogy? The published studies are nonrandomized, before-and-after comparisons. Analogy to animal studies is a major argument  brought in favor of TBRI.

7.      7. Is technical, scientific information used to obfuscate rather than clarify? Yes, obfuscatory references to brain and hormonal functions are a major part of the youtube presentation. For example, Purvis followed the popular belief by recommending half a turkey sandwich for  a sleepless child (but see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2077351/ for a discussion of this idea.)  She stated that it takes “400 repetitions of an act to get one synapse”, or 12 such acts done with joy and laughter to create one synapse. (There are plenty more examples if anyone would like to follow up on this point.)

Claims made about TBRI are not evidence-based or plausible, and organizations like Holt International would do well to examine them carefully before making a commitment. Adoption has been described as the most effective treatment for children who have had bad beginnings to their lives, and experiencing sensitive, responsive care will facilitate good development for any child. Where TBRI has been helpful to families, those general factors are likely to be responsible for any benefits. Whether or not TBRI carries a risk of harm may depend on the age and other characteristics of a child. How ”Rachel” felt about the 36-inch rule, and what effect this practice had on her, is an important question yet unanswered.