Tuesday, December 17, 2019
In the last several months I’ve had several emails from an outfit called Forbrain™. These emails give purely anecdotal evidence for the use of some devices that are supposed to treat a variety of childhood problems such as motor and balance difficulties, autism, sensory processing disorders, and ADD/ADHD. As these problems probably have different causes and certainly have different trajectories, it seems unlikely that one form of treatment can help all of them, but who knows? I would not care to swear that it can’t, without further evidence.
However, neither would I swear that it can help without further evidence. One email I received stated that there were “scientific studies” supporting this view, but when I clicked on the link I got a warning so I didn’t go any further. The email described the case of a child named Josephine who was said to have had her speech and general conduct much improved by use of Forbrain™ technology and even stopped having frequent tantrums. This is very nice,(although obviously it can’t be checked, nor could we know whether Josephine would have started doing better even without this treatment. Nothing here seems to be providing the kind of information that consumers should demand before they commit to a treatment for children.
Forbrain™ apparently involves the wearing of a headset that provides conduction of sounds through bones into the inner ear, rather than stimulation of the inner ear in the usual way by the passage of sound waves through air in the auditory canal, followed by movement of the eardrum, etc. The Forbrain™ device also filters some sounds and is said to allow practice on the “audio-vocal loop". A second device advertised by the Forbrain™ advocates is called Soundsory ®; this one uses “specially designed music processed with neuro-acoustic modifications as well as a series of movement-based exercises” and is intended to “establish good foundations, from the fundamentals of sensory integration to more complex cognitive functions”.
Listening to special music? Being exposed to certain kinds of sound patterns? It’s all rather familiar—and the name Tomatis springs to mind. Yes, an Internet search shows Tomatis therapy , Forbrain ™ and Soundsory® on the same page. It would appear that there is no systematic evidence to support any of these practices.
What should consumers ask for before they commit to the trouble and expense of methods like these? Anecdotes are not good enough. It may be that Josephine’s condition did improve—but would this necessarily be true for any other child? Was Josephine’s improvement caused by Forbrain™? Might it have happened anyway? Or could it even have been that she would have improved more without Forbrain™? These questions can’t be answered by even the most touching story, but touching stories are likely to make us forget to ask the right questions.
For adequate demonstration that either Forbrain™ or Soundsory® technology are useful for any of the problems mentioned earlier, we need the following: A large group of children who share a problem that can be evaluated and quantified. These children are to be divided into two groups (treatment and comparison) with equivalent age ranges, gender proportions, and severity of problems. Assignment to groups is done by staff who do not have information that identifies individuals. Treatment is done by staff who do not know which group each child belongs to. One [treatment] group is given the treatment recommended by Forbrain™ advocates. The other [comparison] group receives a “sham” program—they wear headsets for the same amounts of time as the treatment group but hear different things. At the end of the treatment period, all children are re-evaluated by staff members who do not know which group a child was in. Finally, changes seen in the treatment children are compared to changes seen in the comparison children. If the changes seen in the treatment children are positive, and are statistically greater than those in the comparison group, then advocates of Forbrain™ and Soundsory® can say that they have evidence that their treatments are effective.
Until this happens, caveat emptor!
Wednesday, December 11, 2019
I hear from concerned people in the Netherlands that a new issue about “parental alienation” (PA) has arisen. Not only are some divorced parents accused of “alienating” children who do not want to have contact with the other parent, even though many factors other than alienating behavior are likely to be responsible for the children’s attitudes, and not only is notional PA argued to be a reason for prohibiting contact between children and their preferred parents. Now, in addition, it has been proposed that policemen can be trained to identify PA cases!
Let’s examine this proposal under a strong light.
The first question we need to ask is a simple but critical one: can anyone identify PA? Is there any established, evidence-based protocol that can be used to differentiate PA cases from other cases in which children’s refusal can be based on a range of causes, from domestic violence and abuse to dislike of a step-parent or step-sibling to situations where contact with one parent interferes with sports or friendships?
No, there is no such method. Identification of PA cases is a subjective process based on the opinions of PA proponents. In no case does such identification involve observation or even corollary evidence for alienating behavior by preferred parents. In a few cases known to me, the PA identification did not even consider whether a child had refused contact. In one I can think of, a girl actually asked to have contact with her father and he refused on the ground that she would accuse him of molesting her if he saw her; he stated that he planned to send her to boarding school if he got custody. In another case, a 17-year-old who had for years been alternating weeks at her mother’s and father’s houses said she needed more stability and wanted to have a “home” at her mother’s house while continuing to visit her father, and this was alleged to be a PA case.
Interestingly, Richard Warshak, a long-term proponent of PA and supporter of the Family Bridges treatment, has written of his concerns about false positive identifications of PA and about the need to discriminate between PA and other causes of contact refusal. He appears to recognize that children have been identified as PA cases when in fact they were not. (Although Warshak did not express concern about this point, the consequences of PA identification can include custody change and prohibition of contact with the preferred parent as well as court orders for that parent to pay extravagant fees for PA treatment. As PA proponents also argue that PA is child abuse, such parents are in danger of being affected personally and professionally when mistakenly identified as abusers.) However, Warshak did not mention false negative cases in which PA was not identified even though it was present. I assume that this means that he feels all PA cases—and then some—are being identified, and that only one kind of mistake is being made: the mistake that has the most obvious and serious bad consequences for the child and the preferred parent.
So it seems that nobody can clearly identify PA in a way that would allow others to confirm the identification. On the contrary, people are concluding that PA is present when even its proponents admit that this may not be correct. Among the undesirable consequences of this situation are possibilities that a child’s custody may be given to a genuinely abusive parent—and research has already indicated that this has happened.
Let’s get back to these policemen in the Netherlands. Can they be trained to assess PA? Well, it’s possible that they could, IF anyone else was able to make this assessment. As there is no one who can identify PA validly and reliably, with some known proportion of false positives and false negatives, it would appear that we have nobody to train the policemen. You can’t teach what you don’t know.
One more point: when child custody evaluations are done, they are supposed to include information from corollary sources. What do neighbors, teachers, grandparents, family friends think about the parents and children? Has domestic violence formed part of the background for the child’s refusal? Gathering this kind of information takes time and expertise. No doubt policemen could be trained to do this, but it hardly seems like their job. Of course, PA proponents are not doing this kind of investigation either, even though it should be part of their job.
Perhaps the conclusion here should be that policemen are just as capable as PA proponents of identifying PA: in other words, not particularly capable at all, and possibly not particularly interested in doing the job as they should.
I have been neglecting this blog so badly, because a lot of my time in the last six months has been taken up by writing and talking about “parental alienation” (PA) and I don’t suppose anyone wants to read about that every day. But a few days ago someone asked me a question about a non-PA issue and I think it’s one that may be of interest to a number of people.
My correspondent is a lawyer who works with an anti-child-abuse non-profit organization. She wrote to me to ask if I could recommend a psychologist who could diagnose a type of factitious disorder or “Munchausen’s by proxy”. These terms are used to describe cases in which an adult, usually a parent and often the mother, asks for medical treatment for her child but secretly does things that would cause the child to seem to need treatment. For example, the adult might substitute something else for the child’s urine for a urinalysis, or more seriously-- and this has been videorecorded—partially suffocate the child and then call for help because the child has stopped breathing. These cases are obviously to be taken very seriously. What if the child actually is sick but no treatment is provided because it’s mistakenly thought that the parent is causing the symptoms? What if the parent is causing the symptoms, this is not recognized, and the child dies because of the parent’s actions? It’s no wonder that there is much concern when such a situation is suspected.
Here is the story my lawyer-correspondent gave me. (Readers with infant mental health background will quickly see why I am bringing this up.) A woman of 40, who had a 5-year-old child, began to make frequent emergency room visits when her second child was about 2 months old. When I say frequent: she took the baby in on 27 of 30 possible days. No medical problems were detected. A neighbor reported that she had come into the house to find the baby turning blue and had restored the airway; as far as I know, she did not see the mother causing this episode.
Medical personnel were worried about this situation and suspected factitious disorder. They moved to have the baby placed in foster care and the mother has for at least a month had only supervised visitation. A forensic psychologist, who may or may not have any infant mental health training is to evaluate the mother. My lawyer-correspondent was concerned about the extent of the evaluation, and that was why she asked me to recommend an evaluator.
My response was that everyone was ignoring the most obvious explanation of the mother’s behavior: a perinatal mood disorder (PMD). PMD, sometimes called post-partum depression, is a state of anxiety and depression that sometimes occurs during pregnancy and/or after childbirth. Mothers with PMD may feel incapable of caring for the children and sometimes focus on the idea that there is something terribly wrong with a baby. By far the largest number of comments and queries I have had on this blog have come from mothers who were tortured by their beliefs that their babies were somehow damaged; many of the mothers were convinced that a baby of a few weeks of age might be autistic. When I answered these queries I usually recommended that the mothers see their ob-gyns for PMD evaluation and receive the treatment they needed, because the problem was in their own conditions, not in the babies. Many of them subsequently wrote and said that they had done this and had been helped a great deal.
PMDs have been known for quite a long time to be identifiable and treatable. They are no one’s fault and although the mothers often blame themselves, the rest of us should not blame or punish them. About 15 years ago, several states had innovative programs to educate people about PMD. New Jersey, for example, had a program called “Speak Up When You’re Down” that was sponsored very effectively by the wife of the then-governor. (I was at that time part of the train-the-trainer program for that program.) Regrettably, political forces cancelled funding for these programs and it appears that we are back where we started on this issue.
Ob-gyn offices should be making regular use of a screening instrument for PMD, the Edinburgh Depression Scale. This is quick and easy to use and identifies women who may benefit from treatment for PMD. In addition, I would argue that its use with every new mother benefits everyone, not just those with mood problems, as it reminds everyone of the potential for PMD in themselves and others. This is especially important as PMD symptoms may not occur until later in the first year after childbirth, and women who were screened early may realize later that new symptoms they experience are related to what they were asked on the screening instrument. In the case brought up by my lawyer-correspondent, the mother had apparently not been assessed for PMD, and candidly I remain unsure whether this is happening at this point, although I suggested some possible resources in addition to her ob-gyn.
I want to take a moment to talk about the experience of the mother in this case. I’m basing my comments on the assumption that PMD is at work here—I do not have enough details to know this, of course. The mother’s anxiety about her baby, expressed by multiple ER visits, has not been understood as an expression of her disordered mood, but instead has been interpreted as highly abnormal maternal behavior that is a danger to the baby. The obvious solution from that viewpoint is to put the baby in foster care. But what if the mother’s behavior is symptomatic of PMD and is thus both identifiable and treatable, but neither identified nor treated? In that case, the mother’s experience is of validation of her abnormal mood. Yes, we say to her, you are right to be anxious and depressed and feel that something is wrong, and we are taking your baby away because something is so wrong with you that you cannot be helped.
The mother now sees the baby only under supervision, and it is no longer “her baby”. The constant tiny maturational changes of the early months go by between visits without the mother having any chance to learn from them, and the baby at each visit is a somewhat different person than the mother saw the last time. Her behavior toward the baby is bound to be out of synch for exactly that reason, so she will be observed on each visit to be awkward and uncertain with the baby and not to behave like a “normal mother”. This kind of experience adds to her sense of anxiety and sadness, which apparently is not being treated by appropriate medication and talk therapy. Who will step in to help this family? When will anyone do anything to support the mother in her fight with PMD and to facilitate her relationship with her baby? Or is the solution seen to be indefinite foster care, even termination of parental rights?
N.B. I should point out that there is a severe form of perinatal mood disorder, sometimes called post-partum psychosis, and some readers will recall the tragic case of Andrea Yates, who killed all her children after repeated post-partum problems that were ignored by the children’s father. But these horrible cases are very unusual, and most cases of PMD, when identified, can be treated quite effectively.