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Child Psychology Blogs

Concerned About Unconventional Mental Health Interventions?

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

Tuesday, March 17, 2020

"Promising" Parental Alienation Treatments and Confusing Terminology

I recently mentioned discussions about “parental alienation” (PA) on the World Health Organization website, where there is ongoing discussion of the 11th edition of the International Classification of Diseases (ICD-11). PA advocates would like to include PA as an index term—a term that can be found in the index, but in this case that leads the reader to a much more general classification. People concerned about the potential harm of PA “diagnoses” and treatments have opposed this.

If you are interested in this discussion you can go to the WHO website and set up an account that lets you read and comment on proposals.

I have just commented on one statement there, and I want to elaborate  here on what I said. On the WHO website, a PA advocate cited a paper I published in Journal of Child Custody, in which I said that the outcome research on PA treatments was at no better than a “promising” level. The advocate used this statement to assert that I had said PA treatments were promising and therefore ICD-11 should include PA.

Unfortunately, this PA advocate apparently does not understand that a “promising” treatment is not in fact particularly promising, in the everyday sense of that term. The “promising” category is one that has real meaning for people who do and use outcome research in psychology, but its name is deceptive for others. This is a nuisance but I am not sure what we can do about it now—except to educate people.

Research on the effectiveness of psychotherapies can be evaluated as being at one of five levels of evidence. These levels are essentially measures of the quality of the research and the extent to which confidence can be placed in its results. The two highest levels of evidence, randomized controlled trials and clinical controlled trials, are not identical but share some important features. The crucial feature is that each method builds in standards of comparison, so that the results of  a treatment are compared to the results shown in other circumstances, which may be no treatment at all, established treatments, sham treatments (placebo conditions), etc. Because treatments may—indeed are supposed to—have long-term effects, and for other reasons as well, these two high-quality methods compare people receiving the treatment to other, similar people who receive the control/comparison condition. Using such comparisons is especially important in work with children and adolescents, who are developing rapidly and whose natural changes may easily be mistaken for the effects of a treatment.

When research at those two high levels of evidence shows positive effects of a treatment, and when those effects are confirmed by independent researchers, the treatment can properly be called evidence-based. “Promising” research is work that has been designed and carried out at a lower level of evidence, for example a simple before and after comparison of a group of people, prior to and following their treatment.  The “promising” nature of a treatment that shows positive results under those circumstances is that it is worth doing more complex research on the treatment, although there are no guarantees that the treatment will be shown to be effective with more challenging designs.

PA treatments are “promising” because positive effects have been reported when parents’ views of children’s attitudes after a treatment have been compared to their views before a treatment. As there is no standardized way to evaluate a child’s PA as present or absent, much less to quantify it, there have been no comparisons of the children’s attitudes themselves before and after treatment. And there certainly are no published studies reporting randomized controlled trials or clinical controlled trials of PA treatments, using controls which are essential for work on treatments for quickly-changing children and adolescents. These facts are among the many reasons why ICD-11 will not contain PA as a disorder.

When you see that a treatment is “promising”, be sure to consider exactly what is being promised!

Wednesday, March 11, 2020

ICD-11 Rejects "Parental Alienation"

Readers who are aware of the fight against accusations of “parental alienation” (PA) probably know that some years ago PA advocates were bitterly disappointed when the notional Parental Alienation Syndrome (PAS) was not included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-5). Although PA proponents already experience much success in family courts, where they argue that avoidance of one parent by children of divorced couples is likely to be due to “alienating” behavior by the preferred parent, and that the remedy is to force the children to live with the rejected parent and undergo proprietary treatments, the PA advocates would enjoy many advantages if PAS were listed in DSM. Such listing would provide the diagnostic code that is the magic word for access to health insurance coverage.

Exclusion from DSM-5 was not enough to convince PA advocates that they are far outside the mainstream of psychology with their claims about PA. They went on to attempt some level of inclusion in the forthcoming ICD-11, the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems, WHO’s list of diagnoses for both physical and mental disorders. Although PAS was known not to be included as an ICD-11 diagnosis, PA proponents were agitating to include PA as an “index term”—that is, it would be listed in the ICD-11 index but take the reader to another diagnostic term. As often as WHO said that inclusion of an index term was not an indication of acceptance of the diagnosis, nevertheless it was clear that PA advocates were claiming victory for their views even if PA appeared only as an index term.

An international group of concerned professionals has been fighting the PA index term inclusion, and has been successful. The link below will tell you the story—which has a good outcome not only because of the number of people who engaged in this fight but because of a few people who used personal contacts effectively and devoted much time to the endeavor:

PA websites that come up first on search engines still claim that ICD-11 is indexing PA. It is not! If you are engaged in a divorce and PA claims are being made, be sure your attorney knows this fact. Letting PA advocates get away with various claims is a sure way for innocent parents to find themselves separated from their children by court order, paying huge sums for “treatment”, and being embroiled in court-ordered "treatment” for themselves at the risk of being found in contempt and punished with fines or even a jail sentence.  

Friday, March 6, 2020

The Fight Over Parental Alienation (PA)

A number of publications in professional journals in the last few years have argued strongly against the idea of parental alienation (PA)--  the belief that when a child of divorced parents avoids contact with one parent, the reason is likely to be that the preferred parent has “brainwashed” the child into this negative attitude. Journal articles have pointed out that PA advocates have given no acceptable scientific evidence to support their views, and in addition the treatments advised by PA proponents may be not only ineffective but harmful.

 Because of this lack of supportive evidence, PA advocates were unable to get their claimed “syndrome” listed in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association when a new edition was published in 2013. The goal of inclusion in DSM-5 was an important one for PA proponents because this would be the key to payment for PA treatments by health insurance companies, who require a DSM code diagnosis.

It seems as if PA advocates and practitioners of PA treatments should recognize that they have been called out, but they are continuing to fight, and the money and power associated with bringing the PA concept into the courtroom are no doubt good enough reasons to do this. There are two fronts on which PA-related conflicts are intense right now.

One area of conflict is the International Classification of Diseases (ICD) produced by the Workd Health Organization. ICD includes both mental and physical disease and provides codes as DSM does, though DSM does this for mental illness only. The eleventh edition of ICD is in preparation. ICD-11 will not include PA as a diagnosis—there is no argument about that. There is, however, conflict over the proposed conclusion of PA as an index term. That means that a person could look up PA in the ICD-11 index, find it, and be directed to a page discussing child-parent relationship problems. This is legitimately seen by opponents of PA beliefs as the camel’s nose under the tent, with indexing of the term suggesting that there is a meaningful concept there, possibly to be followed by a later acceptance of PA as an ICD diagnosis. Comments have proliferated on the WHO website, with most of them arguing that PA should be included. An interesting comment recently was a masterpiece of irrelevant conclusion, arguing in favor of the inclusion of Craig Childress’s views and comparing statements about the lack of evidence for PA to climate science denial (apparently the fact that some denials are incorrect is taken as proof that this, and maybe all, denials must also be incorrect). Interested readers can find this material on the WHO website and can set up an account to read it.

A second area of conflict for PA opponents and proponents has to do with the demonstrated association between allegations of PA against one parent and domestic violence or child abuse by the other parent. It appears that women who charge their husbands with DV or abuse are more likely to have it alleged that they, the women, are interfering with the fathers’ relationships with their children and thus causing PA. This has come to the point where women may be afraid to state that they or their children have been abused because this statement may be taken as evidence that they are “brainwashing” the children and that they are irrationally hostile toward their husbands. In family courts, these arguments may well result in court orders prohibiting a mother to have contact with a child, making complete custody change to the father, and sending the child to a parental alienation treatment at the mother’s expense. Once these events have occurred, the possibility that the mother will regain contact (much less custody) diminish in a number of ways that would be familiar to Franz Kafka.

One belief behind this series of events is that family courts are biased against men and therefore, in all fairness, and to right this wrong, men’s claims and wishes should be given extra consideration. This idea appears to be a myth, and thus any effort to put a judicial thumb on the father’s side of the scale is going to create bias against mothers. The Guardian discusses this issue here:     Biased outcomes are undesirable in all cases, but they are actually dangerous if they lead to custody of children being given to abusers.

The argument thus goes on, but it seems to me that only the anti-PA side is paying any attention to the facts about outcomes.

Thursday, March 5, 2020

Banning a Potentially Harmful Treatment for Children

According to an article in the Washington Post (, the U.S. Food and Drug Administration has after at least six years of consideration decided to ban a device that delivers electric shocks to children and adolescents. The shock is given  with the intention of stopping dangerous or undesirable behavior and helping children learn not to do the unwanted things. Although the use of electric shocks as aversive treatments was not uncommon several decades ago, such methods have been used less and less as they have been shown to have potential dangers like skin burns and in addition to create so much distress that little learning may take place.
In fact, there is only one place in the United States that has continued to use aversive shocks regularly for behavior management. That is the Judge Rotenberg Center in Massachusetts, which will be uniquely affected by the FDA ban and plans to appeal the ruling in court. Judge Rotenberg staff claim that aversive shock use is lifesaving for some children.

There are a few circumstances where aversives, if effective, can prevent even worse outcomes than they risk. For example, some genetic syndromes drive their victims to mutilate themselves, even gouging out their own eyes and pulling out teeth. A skin burn seems a small price to pay for keeping one’s eyes in place.

Unfortunately, the effective use of aversives is not a simple matter. Ideally, a shock or other aversive should begin as the patient starts a concerning behavior. The longer the time that passes between the behavior and the aversive, the less effective the aversive will be—but adverse side effects like burns or general fearfulness will still be present. Staff must be carefully trained and supervised to make sure that aversives are used correctly if used at all.

Staff problems are exactly how FDA attention was drawn to Judge Rotenberg. Not only did staff members fail to use aversive shock correctly some years ago, but they were reported to have used it in a totally arbitrary and even sadistic way. One staff member telephoned in the night to a colleague on duty, pretended to be an administrator, and told the colleague to wake up a boy and to give him a large number of shocks. The on-duty staff member did as he was told, against every principle on which use of aversives is normally founded. There was no unwanted behavior to try to stop or prevent, as the boy was sleeping, and the number of shocks was far beyond the usual practice. That the off-duty staff member thought this trick was clever or funny and ignored the impact on the patient is almost unbelievable, but that’s what seems to have happened. I have to question whether any level of training could correct this attitude, or the readiness of the on-duty staff to comply, but surely careful supervision could have prevented this incident from occurring.

It is far from clear what is currently happening at Judge Rotenberg with respect to the use of aversive shocks. It appears that the center wants to continue use as in the past. The FDA gives the center 180 days to retool and transition from the use of the shock device to other methods. A possible change might be to the use of unpleasant sounds as aversives, a method that is safe and has been reported to be as effective as shocks. Even if this were accomplished, however, abolishing shock use may be only one step toward safe and effective use of aversives, which if applied capriciously can create anxiety that interferes with good functioning. (What if you were awakened from a sound sleep by repeated loud, unpleasant sounds that you could not escape or avoid?) Training and supervision are keys to appropriate use of aversives, and I hope this point will be thoroughly discussed as the Judge Rotenberg Center challenges the FDA decision.  

Monday, February 24, 2020

PA, CC, and ABAB

I recently had an inquiry from a mother who is about to face a child custody trial in which a fan of Craig Childress is advising her opponent about “parental alienation”. This mother and others find it hard to figure out what Childress is talking about in his book “An Attachment-based Model of Parental Alienation”, published by a company that shares his office address. They are often especially concerned about Childress’s way of identifying “parental alienation” (PA) in children of divorce who want to avoid contact with one of their parents. 

People have frequently asked me about Childress's diagnostic methods. What I am about to discuss is in his book "An Attachment-based Model of Parental Alienation", pp. 308-310. 

Childress suggests that diagnosis should be done using an ABAB single-case protocol. This is a real thing. It is intended to help decide whether a particular treatment is helpful to a particular person. Here's what happens with the ABAB method:

Condition A is a set of circumstances that the client is experiencing. During these circumstances, observations are made of a concerning behavior. For example, a child is living with his mother and has no contact with father; behaviors showing hostility and rejection toward the father are recorded.

In Condition B, the client is placed in a different set of circumstances and the concerning behavior is again observed. For example, a treatment is started, and the child's rejection of the father is recorded.

Condition A is repeated and the concerning behavior is recorded. For example, the child is returned to the mother's custody and attitudes toward the father are again recorded.

Finally, Condition B is repeated.

If the concerning behavior (rejection of father) is less in condition B than in A, this is an indication that the treatment may be effective. Childress also concludes on p. 310 that if the treatment is effective, this is powerful evidence that the mother's pathogenic parenting is responsible for the child's behavior.

BUT! Here's where his claims fall apart.

1.      When the ABAB protocol is used, Conditions A and B must be different only in one characteristic. If they are different in more than one way, it is impossible to know which factor might cause the difference. So, typically, ABAB might be used to test a treatment (Condition B) for bedwetting. The child stays at home and follows his ordinary habits, but sometimes receives the treatment and sometimes does not. Differences in bedwetting between A and B suggest that B is an effective treatment (although it could also be that the child just matured)....In Childress's method, however, there are many differences between A and B. B includes separation from the preferred parent, much contact with the nonpreferred parent, possibly different behavior from the nonpreferred[parent than occurred in the past, and four days of “High Road” treatment, which may include transportation by youth transport service workers. The child is frightened and has no idea what is happening. As most of these kids are not very young children, we can expect them to catch on to what they are supposed to do and to do it in order to avoid further unpleasant events. Whether behavior is different in A and B because of separation, because of treatment, because of fear, or whatever-- that cannot be told from this approach.
2.      The ABAB approach could only be considered diagnostic if there were just one cause for the behavior, and just one treatment that was already well demonstrated to treat the problem effectively. This is not true of rejection of a parent, so whatever happens on ABAB, it does not show what caused the problem. With respect to the ABAB evidence showing what caused the rejection, Childress seems to envision only one way in which the behavior can be caused. Like other PA advocates, he has a single-factor theory that omits to consider any of a myriad causes of behavior and especially does not look into the rejected parent's own actions, whether abusive or simply awkward and lacking in parenting and communication skills. The ABAB protocol is a real set-up, as most children are likely to alter behavior as instructed when powerless in a strange situation; when they do so, Childress then points to this-- skipping a number of logical steps-- as empirical evidence of the diagnosis. (What he would conclude if the child did not change, I cannot guess, but it would probably be that the preferred parent has caused serious mental illness in the child!)

The ABAB protocol sounds most impressive to those who have never heard of it, but the way Childress uses it (if indeed he does—he does not seem to provide any examples of actually doing this) cannot demonstrate that a treatment works with a particular child. (It is not intended to, and cannot, show that a treatment is generally effective). The ABAB protocol, no matter how well implemented, cannot show the cause of a problem unless there is only one cause AND unless it has been demonstrated that the treatment is generally effective.

A long time ago, Dr. Spock wrote that if your child has a fever, you can sponge her with cool water and it helps as much as an alcohol rub, but “it doesn’t smell so important”. Childress’s ABAB protocol smells important to people who don’t understand it, but in fact the odor you detect is not alcohol.