When Peer Review Fails: With Special Relevance to RAD

The idea of peer-reviewed articles in professional journals is, or at least was, a helpful way of keeping nonsense and excessive speculation out of respected print publications. Authors submit articles to journals, and editors send them on to professionals who are knowledgeable in relevant fields. Those people, peers of the article authors in that they have similar training, review the submitted material and convey their conclusions to the editors. These conclusions may be to reject the article entirely or to accept it just as it stands, but most often peer reviewers suggest acceptance with some major or minor revisions. Good reviewers can assess the background of a submitted article, can understand whether information cited from other work is correct, can evaluate research methods that were used, and can advise on improving organization and writing.

This is a lot of work and may or may not be done as well as we’d like. Not all peer reviews catch problems—and when big problems remain, journal editors may sometimes have to retract an article that contains major errors or that is just a repetition of something the author has published elsewhere.

In addition to the occasionally failures of reviews, nowadays we have the problem of the ever-expanding number of journals. Some of these are “predatory” journals whose real purpose is to collect fees from authors (conventional professional journals do not charge except sometimes for publication of  illustrations). Some are “open access” journals that charge fees and provide quick publication for articles that might not be accepted otherwise, or whose publication might be delayed longer than is comfortable for an author who is afraid of perishing without a publication. These journals refer to themselves as “peer reviewed”, and no doubt someone does “peer” at the submissions, but little effective reviewing happens.

When predatory or open access journals make mistakes about accepting articles, those mistakes are rarely corrected. Journals that take seriously the job of reviewing are likely to retract wrong articles or publish corrections—or, they very quickly publish additional articles critiquing the problem material. For example, the journal Child Development, which is about as serious and respectable as a publication can get, recently published a piece claiming that exposure to wireless technologies has been shown to affect child development (Sage, C., & Burgio,E. [2018]. Electromagnetic fields, pulsed radiofrequency radiation, and epigenetics: How wireless technologies may affect childhood development. Child Development, 89, 129-136). Interestingly, when this article was published on line, it did not include a conflict of interest statement, which was added for the print version, as one of the authors is the owner of an environmental consulting firm and a consultant on relevant policy and decisions.

When the Sage and Burgio article appeared on line, it was seen by others than the original reviewers, and these people were able to recognize that the authors had “cherry-picked” and misrepresented material. Two authors submitted a commentary that the journal published in the same print edition as the Sage and Burgio article—the commentary stating that “these claims are devoid of merit, and… should not have been given a scientific veneer of legitimacy” (Grimes, D., & Bishop, D. [2018]. Distinguishing polemic from commentary in science: Some guidelines illustrated with the case of Sage and Burgio [2017].) Grimes and Bishop stated that it was their view “that this piece has potential to cause serious harm, and should never have been published.” They followed this statement with a suggested series of questions to be used by readers and reviewers in ascertaining whether an article deserves publication or should be regarded as credible. Among these questions, all of which deserve real attention, were four of particular interest: 1. Is there a plausible mechanism for a claimed effect? 2. Does evidence come from [genuinely] peer-reviewed sources? 3. Are all relevant studies considered? 4. Are results of specific studies misrepresented?  Applying their list of questions, Grimes and Bishop were able to show that the Sage and Burgio paper was completely unacceptable. However, because the paper was not actually retracted, Sage and Burgio may (unfortunately) continue to argue that their work was validated by its acceptance by a prestigious peer-reviewed journal.

In the title of this post I said we would get to Reactive Attachment Disorder, and I am about to do that, with a description of an article that probably should not have been accepted by a journal and of another article that critiqued the first one. The problematic article was an effort to argue that difficult and oppositional behavior, conduct disorder, and callous-unemotional traits are closely associated with RAD (Mayes, S., Calhoun, S., Waschenbusch, D., Breaux, R., & Baweja, R. [20i7]. Reactive attachment/disinhibited social engagement disorders: Callous-unemotional traits and comorbid disorders. Research in Developmental Disabilities, 63, 28-37).

A little history is needed to understand the background of the Mayes et al article. Definitions of RAD have changed over the years, beginning in 1980 with the idea that the disorder involved infant failure to thrive and gradually changing to comprise unusual behaviors of young children toward adult caregivers. Until recently, RAD was considered to exist in two forms, an inhibited form in which young children did not seek care or comfort from adults, and a disinhibited form in which young children were as likely to approach strange adults as to approach familiar people for care and social interaction. The 2013 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) separated the inhibited version, which kept the term RAD, from the disinhibited version, which now became Disinhibited Social Engagement Disorder (DSED).

Meanwhile, however, there had been as far back as the 1990s an effort to create an alternative view of a disorder attributed to early separations, abuse, and neglect. This putative disorder was often referred to as Reactive Attachment Disorder, but instead of involving unusual social behavior toward caregivers, it was said to include disturbing aggressive behaviors like cruelty, theft, lying, and “fascination with blood and gore”. Some alternative practitioners claimed that they had discovered a new form of the disorder, not Reactive Attachment Disorder at all, but something they called simply Attachment Disorder. This notional diagnosis was promulgated by practitioners of Holding Therrapy/Attachment Therapy, by a number of adoption groups, and by support groups for adoptive parents. The idea of violent Attachment Disorder behavior was taught by made-for-TV movies like “Child of Rage” and by various related websites. For a number of years, newspaper articles about child abuse have often proposed that abused children showed disturbing behaviors said to be characteristic of RAD or AD and in some sense had forced adults to mistreat them. These beliefs continue to be promulgated, as can be seen at https://blogs.psychcentral.com/childhood-behavioral/2018/05/why-parents-of-r-a-d-children-always-look-like-aholes/, a blog where commenters claim that adoptive parents of children  “diagnosed with RAD” and behaving aggressively must treat those children as coldly and mechanically as possible. In reply to criticism of this position, comments are focused on the idea that anyone who does not think RAD includes callous-unemotional or aggressive behavior has simply never lived with such a child—a rather inconsequential response, as no one has said that their children do not display the claimed behaviors, just that these are not evidence of RAD.

Conventional, evidence-based work on childhood mental illness has rejected the idea that externalizing behavior, conduct disorders, or callous-unemotional characteristics such as lack of empathy are related to attachment experiences or should be treated by methods that stress attachment. The article by Mayes et al argues against that conventional view and presents a small amount of data that are used to conclude that children diagnosed with RAD are also likely to be violent, cruel, callous, and unemotional. The study examined 20 children, ages 4-17, who had been diagnosed with RAD or DSED or both, and compared them with much larger groups of children diagnosed as autistic or as having ADHD. The authors suggested that the DSM discussion of RAD should include references to conduct disorders and callous-unemotional traits as associated with RAD.

A trenchant response by a competent critic of misused attachment concepts followed the Mayes et al paper (Allen, B. [2018]. Misperceptions of reactive attachment disorders persist: Poor methods and unsupported conclusions. Research in Developmental Disabilities, 77, 24-29). In keeping with our concern with failed peer review, Allen offered guidelines for reviewing articles that stress attachment issues. He used the Mayes paper as an example of a publication about which reviewers had not asked the right questions.

Here are the questions Allen suggested as review guidelines:

1.      How well is attachment research reviewed? This is an area where, Allen suggests, Mayes et al seem to have “cherry-picked”, stressing early writings of John Bowlby and omitting some of the contradictory conclusions of his later work.

I would like to add that Mayes et al used a 2003 paper by Hall and Geher to support the claim of aggressive externalizing behavior in children with RAD; the Hall and Geher paper in turn was dependent on what may be the ur-article on such behavior in children diagnosed with RAD, an obscure publication, probably not peer-reviewed in any real sense, that put forth the idea that RAD children can vomit or defecate at will and do so simply to antagonize their caregivers (Reber, K. [1996]. Children at risk for attachment disorder: Assessment, diagnosis, and treatment. Progress: Family Systems Research and Therapy, 5, 83-98 ; this publication of a freestanding California institute used to be available on the Internet but I have not been able to find it recently). (Reber’s claims may have been behind the Internet arguments that Candace Newmaker died intentionally in order to cause trouble for the therapists who asphyxiated her.) The influence of Reber on Hall and Geher and subsequently on Mayes et al demonstrates that reviewers need to be aware not only of the background publications being cited in an article, but also of the nature of the material cited in those publications.

2.      Are attachment constructs clearly defined? Unfortunately, attachment concepts seem to have achieved the position of obscenity, in that most people can’t define them but believe they know them when they see them. Nonetheless, as Allen suggests, it is crucial to know whether authors are concerned with attachment behavior, attachment representations, or attachment theory. The choice of constructs is directly related to understanding of how a diagnosis was made—a point left obscure in the Mayes et al paper.

3.      Are assessment measures and methods clearly specified? All too often, discussions of RAD have involved “validation” of assessment methods against the intuition or “practice wisdom” of one or two clinicians. Elizabeth Randolph’s Randolph Attachment Disorder Questionnaire (RADQ) is described by its author as substantiated in part by her ability to diagnose an attachment disorder when a child cannot crawl backward on command.

Unspecified and vague assessment measures in the Mayes et al paper are especially important because of the age range of children examined—from 4 to 17 years of age, with a mean age about 10. Although toddlers can be expected to reveal the quality of their attachment to caregivers by their behavior with strangers or when separated from familiar people, this can hardly be expected with school-age children or teenagers, whose cognitive and emotional development and daily experiences allow them to handle separation or contact with strangers as normal events that affect their behavior very little. Assessments of 4-year-olds, 10-year-olds, and 17-year-olds can hardly take the same forms, yet Mayes et al do not state differences in evaluation of children of different ages, and ignore the many discussions in the literature about the maximum age at which RAD could be a meaningful diagnosis.

4.      Do the authors use tautological reasoning? When clinicians believe that RAD involves aggressive or callous-unemotional traits, they may use such traits as a reason to diagnose RAD, even though RAD by definition does not include these traits. Allen queries whether this illogical approach is responsible for the conclusions drawn by Mayes et al.

Historically, proponents of the idea that externalizing problems were part of attachment disorders have also argued  that children with problematic attachment histories (separation, abuse, neglect) will of necessity have RAD and [therefore] externalizing problems, such a history being in the past a factor in the RAD diagnosis; this claim was even applied when children showed no behavioral disturbance, with convinced clinicians telling parents that the child’s normal behavior was simply an indication of the degree of disturbance, intended to lull the parent’s concerns until the child found a way to attack effectively. 

5.      Do the authors make remarkable conclusions, which may not be supported by their data? Allen suggests that mistaken conclusions are drawn by Mayes et al, for example that it is incorrect to claim that RAD is associated with internalizing problems and DSED with externalizing problems (e.g., cruelty, lack of empathy), even though this is what other  unemotional traits, the Mayes et al conclusions fail to recognize the limitations of their study  as stated above and discussed in the Allen paper.

It is clear that if reviewers had used the questions supplied by Allen in their reviews of the Mayes et al paper, the paper would never have appeared except in a considerably revised form.

Revisions would also have been required for publication if the guidelines proposed by Grimes and Bishop (2018), some of which were discussed earlier in this post, had been applied. The plausible mechanism demanded by Grimes and Bishop is certainly missing in the Mayes et al article—by what mechanism would a failure of attachment lead to cruel and callous-unemotional behavior posited by Mayes, or the disobedience, ingratitude, and lack of remorse claimed by Randolph and others? Attachment theory and the idea of attachment representations, with their stress on cognitive and social development, do not provide any explanation of the proposed mechanism.

A question about causal claims put by Grimes and Bishop would also require Mayes et al to revise their article and supply a much elaborated discussion of limitations. This nonrandomized study design does not allow for the stated conclusion that externalizing behaviors are caused by problematic attachment histories.

There is little question that guidance is needed by peer reviewers dealing with submitted papers involving the complexities of attachment concepts and the conflation of established views of attachment with alternative attachment theories. Given the approaches proposed by Allen and by Grimes and Bishop, we can hope, along with Allen, that “through this process of enhanced scrutiny of papers examining RAD/DSED that misperceptions and subsequent substandard clinical services can be significantly improved.”

How Do We Know Whether an Intervention Is Effective? (E.g., PA Treatments)

There’s a lot of discussion right now about whether psychological interventions are or are not evidence-based (or empirically-supported) treatments. Even when there is strong evidence that a treatment is efficacious—causes good outcomes under ideal circumstances—there are further demands for evidence that it is effective and causes good outcomes in the less-than-ideal settings of the real world.

The strongest evidence in either case depends on research that has used randomized controlled trials. RCTs (not to be confused with residential treatment centers!) are studies in which people who have received the treatment being tested are compared to a control group of people who have not received it (and may have had no treatment, or had a well-established different treatment, or have been placed on a wait-list for the treatment being tested). Because this kind of research is randomized, prospective patients do not get to choose which group they want to be in, but are assigned to one or the other in some objective way like the flip of a coin or the use of a list of random numbers. The point here is to eliminate the bias that might be present if people got to choose the treatment they want—just believing that something will be good for them, or expecting that a treatment will be effective, can be enough to change people’s moods and behavior. (If we’re talking about treatments for children and adolescents, parents may be affected by their expectations about a treatment so that they behave differently toward their children if they think they are getting that treatment, or see their children’s behavior differently if they think the children are getting a good treatment, or, of course, both of these things.)

Having a control or comparison group as part of the research design adds to what is called the internal validity of the study. Internal validity is also influenced by factors like having a blinded evaluation, or assessment of children by people who do not know them or know what treatment they have been receiving or will receive. When parents, who know both of these things to some extent (even if not told their children’s treatment, they may figure it out from things the child tells them), are involved in evaluation of the children’s response to treatment, other biases can creep in; parents are the ones to say whether they liked a treatment, but can not say objectively whether it helped their children. A number of alternative therapies, like Love & Logic training for parents, make the mistake of asking parents whether their children have improved and then acting as if it is known what changes have really occurred in the children.

Many studies that claim to give evidence supporting unconventional, alternative therapies are more than one step below RCTs. They look very simply at measures (often parent opinions) taken before and after treatment. Does this seem like a good idea? Well, only if you think that children and adolescents do not change unless they are made to change by an intervention!

I recently had pointed out to me the statement by a guardian ad litem that changes she heard about in a girl between ages 11 and 13 could only have been caused by a PA treatment method the girl had experienced. It would appear that the GAL thought that nothing happened in those two years other than the treatment and separation from the preferred parent. But in fact much had happened.

A small amount of the change reported was no doubt due to adjustment over a couple of post-divorce years, during which one parent had remarried. A much larger factor, causing changes of all kinds, physical and mental, was the occurrence of  puberty for this girl—just under 13years being the average age of menarche (first menstruation) in the Western world today. Puberty in both sexes is associated with dramatic social and cognitive changes and the redirection of “attachment” and positive social attitudes toward peers and away from parents. Height and weight increase, breasts develop, hair and skin change, all producing a mixture of delighted and anxious feelings about the self, and further reducing (though not eliminating) the adolescent’s concern about relationships with parents.

 Maturation, the series of developmental changes that is largely governed by genetic programs, is rapid and intense during this period when “nothing happened” except the PA intervention. Without good research design that takes maturation into account, studies of PA or other interventions for children and adolescents are wrong if they claim they show the influence of their intervention. Because children and adolescents are always changing—most rapidly around puberty, beginning about age 9 in girls—every study of a psychological treatment for them needs to have a control group, similar to the treated group but nor receiving the treatment, whose characteristics will show us the natural maturational changes that occur during an age period. The effect of the PA or other intervention is shown (roughly speaking) by subtracting:

Changes following intervention (maturation + intervention) - Changes with maturation alone  =

Changes attributable to intervention

There would be many other technical details to be considered in designing a good study of PA or other interventions, but the two mentioned here, blind evaluation and a control for maturational change, are absolutely critical.

Interesting Times in the Parental Alienation World

The idea of “parental alienation” has been around for some decades—starting with Wilhelm Reich, the orgone man—but in recent years it has been adopted by lawyers and some judges as a way to get child custody transferred from one divorced or separated parent to the other. “Parental alienation” is a concept applied to situations where a child refuses or resists contact with one parent and where the child can give no reasons for this position or gives reasons that are deemed unacceptable by adult authorities. (Physical abuse is considered an adequate reason for avoidance of a parent, but practically the only one.) In these cases, proponents of the “parental alienation” (PA) idea argue that the child’s resistance or refusal is occurring only because the preferred parent has manipulated the child’s thoughts and emotions so that he or she dislikes or fears the non-preferred parent. In this scenario, the preferred parent is referred to as the “alienator” and the non-preferred parent as the “targeted parent”. The child’s mental condition is referred to by PA proponents as “parental alienation syndrome” or “disorder” (PAS or PAD), and this condition is said to involve “splitting” and black-and-white thinking in the present and to predict the development of a personality disorder like narcissism. Actions that bring about mental illness in an individual are considered abusive to that individual, so part of the PA argument is that the preferred parent is abusive and the child must for his or her own sake be removed from that abusive person’s custody. As I noted a few weeks ago on this blog, some PA proponents also argue that for a court to pay attention to a child’s preferences would have malignant effects on the child’s psychological development.

The solution offered by PA proponents for this notional syndrome or disorder is that a child who resists or refuses contact with one parent must be removed from his or her present living situation and placed in the custody of the non-preferred parent. In addition, the child needs to be treated in one or another of several similar residential programs that may last from 4 to 90 days, during which contact with the preferred parent is prohibited or used as a reward for affectionate behavior toward the non-preferred parent. (These programs are to be paid for by the preferred parent and court orders include this proviso.) The programs are referred to as “psychoeducational” and consist of videos and discussions, mixed, apparently, with threats to send the child to a wilderness camp or residential treatment center where they will not be able to communicate with anyone outside.  

Obviously, there really are children of divorce (or even of intact families) who avoid one parent and who cannot explain to the satisfaction of adults why they do this. It’s not unimaginable that the PA scenario of influence actually takes place in some of these cases. But the declaration that there is a related psychological syndrome or disorder, and particularly that such a syndrome is the forerunner of serious personality disorders, is a claim that requires empirical support. Such support has not been presented, and that is why the American Psychiatric Association did not include such a diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

The claim that PA-related residential programs, psychoeducational or otherwise, can repair disturbed parent-child relationships/incipient personality disorders—and do this so effectively that courts should order such treatment to be used against the will of older children and adolescents who would normally be allowed to decide to consent to treatment—also requires empirical support. No amount of speculation in terms of well- or ill-chosen theory can tell us whether a treatment will be effective, and in fact attempts to claim that analogies provide evidence is characteristic of pseudoscience.

None of these points has impressed proponents of PA, and they have been experiencing a good deal of success in influencing high-conflict custody cases and enrolling children in their residential treatment programs.  Some attorneys have been eager to run with the PA argument, and some judges have accepted it with little question. But an event and an observation this week seem to suggest that the PA concept as presented by some of its proponents may be on the way out.

The event is one with a history that needs explanation. In June, 2017, the PA proponents Craig Childress and Dorcy Pruter (a psychologist and a “life coach” respectively) gave a presentation on their views at a conference of the Association of Family and Conciliation Courts (AFCC). Psychologists who attended this presentation received professional continuing education credits (needed for maintaining licensure), as AFCC is an approved provider of continuing education for the American Psychological Association. Although the conference brochure carried a disclaimer to the effect that  including a presentation did not mean approval of its content, to my knowledge at least one attendee came back to his practice full of enthusiasm, declared to a client that the APA CE credit meant that APA approved of the treatment described in the presentation, and attempted to persuade the client to send her child to California for the Childress program.

Complaints about the Childress-Pruter presentation led the APA continuing education committee  to announce this week an agreement with AFCC that Childress and Pruter may never again make this kind of presentation at AFCC. AFCC also agreed to provide an alternative webinar by Michael Saini on evidence-based views of child resistance and refusal and have posted this at www.afccnet.org. Given that according to Childress’ blog he is planning a sort of “March on Washington” where he and his followers will deliver a petition to APA and will videotape its reception, this AFCC-APA agreement may appear as a considerable blow. No doubt the rejection of Childress’ PA claims by APA will only strengthen the cult-like belief of his followers, but the APA decision will prove a powerful argument in many cases where parents are under attack as “alienators”.

The observation I referred to earlier has to do with the CV of a PA proponent (not Childress this time, although his has a sticky problem in the omission of some years of activity). In connection with a current PA suit, I saw the CV of Demetrios Lorandos. Lorandos has been a powerful advocate for the PA position, bringing to the argument both a law degree and a doctorate in psychology. But wait… that doctorate seems to be rather open to question. It came from the Union Institute in 1978. The Union Institute is pretty problematic in itself, having been the alma matter of a number of alternative psychotherapists like Gregory Keck of holding therapy fame. Students there have written dissertations on the topics they chose, and then decided what discipline (e.g. psychology or criminology) they wanted their degrees in. (An Internet search will show you why I say this about what is not quite a diploma mill but more a “wannabe university”.) But on top of those problems, Lorandos’ degree in 1978 predated by seven years the accreditation of Union in 1985. In other words, he does not have a doctorate from an accredited university and therefore should not call himself “Doctor”. (See, for comparison, https://www.insidehighered.com/news/2011/10/12/top_two_leaders_at_community_college_earned_doctoral_degrees_from_diploma_mills.) He may, of course, call himself a psychologist, as he is licensed in that field because of a master’s degree from the New School for Social Research.  How is it that no one has noticed before that Lorandos’ CV shows that he does not have a doctorate from an accredited institution? Well, not everybody spends their time looking at fraud and deception in psychology the way I do.

Am I arguing that Lorandos’ lack of a genuine doctoral degree means that he can have nothing useful to say? No, of course not. There are plenty of expert witnesses who have excellent backgrounds outside academia. But when someone presents himself repeatedly as having a doctorate, and fools people who are not familiar with the Union Institute story, I must question his integrity as well as his training in assessment of research.

Between the Childress and the Lorandos events, I think we may be able to look forward to a day when attorneys and judges will be able to recognize the weaknesses of the PA concept and of the treatments proposed by PA advocates.  

Love & Logic (R) and Other Non-evidence-based Programs: How to Argue Against Them

A colleague passed on to me a letter from a person with a MSN degree who is involved with community mental health issues for children. The writer expressed her profound concerns with the program Love & Logic ®, developed and promulgated by Foster Cline, an early advocate of Attachment Therapy/Holding Therapy, and a pediatrician of problematic licensure who declared some years ago that “all bonding is trauma bonding”. No doubt aided by its brilliantly alliterative name, Love & Logic ® has become a great commercial success, earning much public money as school systems buy into this method of group training for parents and teachers, even though it is clear that the program is not an evidence-based treatment.

The author of the letter I mentioned has had years of contact with Love & Logic ®, beginning with a personal experience involving a child she  advocated for, and continuing with discussions with people committed to the method, and awareness of increasing advertising. She checked the level of research evidence for Love & Logic ® with the California Evidence-based Clearinghouse for Child Welfare (www.cebc4cw.org ). CEBC, which is well-known for its descriptions and ratings of treatments for children, lists Love & Logic ® but notes that the program cannot be rated because there is no adequate research evidence for its effectiveness. CEBC lists a 2005 article that reported that parents liked the Love & Logic ® program but did not touch on its effectiveness as a behavioral treatment for children. CEBC notes that there are no standards that trainers for Love & Logic have to meet other than attendance at training workshops (and it is my understanding that there is no follow-up from the organization to insure that trainers are teaching the program correctly).

  

Love & Logic ® is not listed by the National Registry of Evidence-Based Programs and Practices (run, at least until recently, by SAMHSA) or by www.effectivechildtherapy.org, a service of the Society for Clinical Child and Adolescent Psychology. I should also point out that in the opinion of some psychologists, the trademark for Love & Logic ® should prevent its ever being listed as an evidence-based treatment, because commercial considerations mean that evidence may be kept secret rather than being presented transparently as is required by scientific investigations.

I wrote in more detail about Love & Logic ® several years ago (https://childmyths.blogspot.com/2014/06/having-a-look-at-love-and-logic.html ) so I won’t go into more detail about the program. Instead, let me turn to the issue of dissuading school systems from engaging in the selling of this and similar “trainings”.

The argument against Love & Logic ® hinges on the concept of evidence-based treatment. Unfortunately, American public education is coming very late to the idea that evidence-based programs are preferable, and indeed the greater number of educators and school administrators have little training or interest in understanding how safe and effective treatment programs can be identified. A recent wave among psychologists of opposition to the privileging of evidence-based treatments will no doubt be welcomed by many educators.

How, then, to argue against treatments that are unsupported by acceptable research evidence? Surely the key to this argument is to approach the organizations that fund school systems’ activities. State and local governments may also be indifferent to research results in general, but they do not like to spend money, and they do like to get what they pay for. Being revealed as wasters of public funds is a good way not to get re-elected. School officials themselves do not allocate funding--  they simply ask for funds to be spent, so they are not likely to suffer public disapproval for choosing a non-evidence-based program. Neither are they elected and subjected to public scrutiny and possible loss of their positions.

A major point of the movement toward evidence-based treatment is that scarce resources are conserved when programs are chosen on the basis of high levels of evidence of their safety and effectiveness. Are state and local officials prepared to justify expenditures that are based on unsupported commercial claims rather than on evidence of effectiveness? It’s hard to imagine that they could get away for long with giving a school lunch contract to a company whose service did not live up to the standards required in the contract. A heating company that kept schools at 45 degrees F. all winter would not be hired again. It’s a lot harder to decide whether parent and teacher training programs have been effective, so there will probably be few complaints from the recipients—but community members who publicly bring up the lack of existing evidence for a program may well have a political impact on the actions of elected officials.

In addition to suggesting that state and local officials receive public criticism for funding non-evidence-based programs like Love & Logic ®, I’d like to point out that teachers’ unions are a powerful force and indeed are organizing for greater effectiveness just now. Union organizers may be receptive to the argument that ineffective training programs are being funded while money is not made available for a variety of educational necessities, even textbooks in some cities.  Union members may be pleased with parent or teacher training that can make their work more successful, but why should they stand by to see needed funds expended without results? Speaking up on this kind of issue can be a way for teachers’ organizations to work against the increasing deprofessionalization of their jobs and to make clear that collective bargaining can work toward goals other than salary and benefits increases, important as those are.

A point to be brought up when arguing against programs like Love & Logic ® is that the choice is not between these programs and nothing. There are effective programs to help parents and teachers work with children who are at risk for a range of developmental problems, and especially with children who are aggressive, oppositional, and noncompliant. One such program, with many years of evidentiary support behind it, is Parent Child Interaction Therapy (PCIT), which focuses on children of preschool and early school age and works to correct behavior problems before they interfere with school achievement. PCIT uses play but is not a “play therapy” and does not depend on children’s insight or private thoughts. Instead, its stress is on improving relationships between children and adults and training adults to help children comply with adult rules without having to use harsh or constant discipline.

Evidence-based programs like PCIT provide a lot of “bang for the buck”. Money spent for them is not wasted, and authorities who approve this kind of spending can be proud of their fiscal responsibility. Non-evidence-based programs like Love & Logic ® waste money that is much needed for other educational purposes. Now that programs like Love & Logic® have co-opted the public school system for their own commercial advantage, it’s important for concerned people to persuade state and local governments and  teachers’ organizations to re-think past decisions and stop this present and future waste of public funds.

Adverse Childhood Experiences: A Helpful or a Harmful Idea?

There’s a great deal of discussion nowadays about adverse childhood experiences (ACEs), as defined by a study in the late ‘90s which interviewed thousands of adults and reported associations between their adult physical and mental health and their early experiences of events like abusive treatment or family conflict (see www.cdc.gov/violenceprevention/acestudy/index.html for much more explanation). Many people have experienced one or two ACEs during their childhood years, but the study reported a positive correlation between having large numbers of ACEs in one’s history and having illness or premature death in adulthood. The ACE study positioned adverse childhood experiences as important factors for public health, and prevention of those experiences as a way to improve adult health in the future.

The adverse childhood experiences studied were not on the whole events that would directly affect health—that is, most of them did not involve physical injury to the child or even failure to provide medical care when needed. The ACE events could be, but most often were not, actual traumas, catastrophic situations in which death or serious injury were feared. The association with later health problems was surprising for those reasons, and it has been argued that the ACEs studied may be proxy measures for other unmeasured events that are the actual cause of later health problems. For example, one of the original questions had to do with whether a person had in childhood or adolescence been sexually approached by someone 5 or more years older. Such an experience might or might not be disturbing—in fact, it might be flattering and pleasurable for a 14-year-old girl to be in a sexual relationship with an admired young man of 20—but the existence of such a sexual experience might indicate parental neglect and lack of supervision, which in turn could be the actual cause of various psychological and physical health effects.

The ACE questionnaire was intended as a “quick and dirty” measure of childhood experiences as recalled and reported by adults. Retrospective studies of this kind are sometimes the best that can be managed, but they are subject to all kinds of obvious problems; people may not remember what happened, or may remember something that did not happen, or may conceal an event out of embarrassment, or may invent some shocking story to impress the interviewer. Without some way to validate the reports, it seems much more accurate to say that the people’s reports of childhood experiences are correlated with their adult health, rather than to say that the experiences themselves are correlated with health.

It’s certainly possible at this point to criticize the ACE study because it did not achieve goals that were never part of the study plan. The study did not try to identify which ACEs had the biggest effect, or whether one of the experiences had the same effect as another. It did not look at interactions between the individual’s developmental age at the time of the experience and the experience itself—for example, a sexual experience with a person at least 5 years older would presumably have a different effect when the pair involved a 7-year-old and a 2-year-old, than when the pair were the 14-year-old and the 20-year-old mentioned earlier. It will be important someday to know about these issues, of course, but we can’t demand this information of research that considered only the number of adverse events experienced in childhood and adolescence, and how that number went statistically with physical and mental health disorders in adulthood.

Information about ACEs has been helpful in that it has directed much attention to preventable adverse events experienced by children. This has been persuasive because authorities and funding agencies can be convinced to invest in resources for families when they see a benefit to public health and its associated costs , but are less likely to do so simply because children are miserable and failing in school or bound for the school-to-prison pipeline.  This is a bit like the attention paid to mental illness  when it is called a “brain disorder” (which of course it is, in a sense, but hardly the same as a seizure disorder), but not when it is regarded as an unhappy state that the patient could rise above if he or she had some gumption.

But while helpful, ACEs scores can be scary too, when they are misused. It’s important to keep in mind that although an individual child’s high ACEs score is a good reminder to us that help is needed for the family, that score is not a predictor for that child’s life. ACEs scores help us predict events for populations—large numbers of people—but not for individuals. Individuals may display greater or less resilience or vulnerability to adverse events, may experience the events at different ages, and may or may not have sources of support and buffering that protect them from poor physical and mental health consequences. For adults, by the way, a high ACEs score can be frightening when we think about it, but it’s important to realize that many other factors influence health, and some of those are under our control.

A recent discussion on a psychology list revealed that a potentially harmful forensic use of the ACE score seems to be coming into play in legal arguments and decisions. Sentencing often takes into account the probability that a person will repeat a crime in the future, and some are arguing that criminals with high ACE scores are likely to be mentally ill and therefore to have a high probability of re-offending, so they should have lengthy sentences. This is a particularly bad example of trying to use the score to predict an individual’s behavior when the original work had to do with what happened to a population.

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Did the Pendulation Chicken Come Before the Emotional Shuttling Egg?

Who lives may learn, we are told, and I am constantly learning new things about alternative psychotherapies. I used to think they were rather separate entities, one splitting off as a “heresy” from another, but the more I consider them, the more I see how much they have in common. I mentioned this a few days ago with respect to one of Bruce Perry’s themes, that a rhythm that resembles a maternal heartbeat can “reset” lower brain functions to normal after they have been distorted by trauma. Like many pseudoscientific ideas, this one has a foot in real science, because human rhythms of breathing or movement can be “entrained’ to other rhythms that they come to match. We use entrainment to soothe babies by rocking, singing, and patting, because we can override the baby’s (upset) tempo and bring it down to our calmer one. But Perry overgeneralizes from the fact of entrainment and decides that rhythms must shape the brain in a powerful, even permanent way—just as practitioners of thought field therapy (TFT) believe that physical tapping at certain rhythms on certain areas of the body can alter psychological functioning. These claims are without any acceptable evidence basis and that’s why we call them pseudoscientific.

Yesterday I had various reasons to be looking into Internal Family Systems therapy (IFS; see https://selfleadership.org/evidence-based-practice.html), a pseudoscientific treatment that claims to treat not just family relationships, but the dissociated “parts” inside a person’s mind. Apparently IFS makes use of “somatic experiencing” and a technique called “pendulation”, in which there is “movement between regulation and dysregulation. The client is helped to move to a state where he or she is dysregulated (i.e. is aroused or frozen, demonstrated by physical symptoms such as pain or numbness) and then iteratively helped to return to a state of regulation”  ((https://en.wikipedia.org/wiki/Somatic_experiencing – incidentally, I would not normally use Wikipedia as a source, but it’s a terrific way to find out what alternative therapists have written about their own beliefs.) I was puzzled by a comment on a blog related to IFS, though—the writer said she “pendulated on” her shoulder or her elbow. I have no idea how this would be done and had assumed that “pendulation” was something an alternative therapist did to a client, but perhaps you can do it to yourself. However, it seems to be yet another use of rhythmic stimulation with the goal of psychological change.

Anyway, what came to my mind on reading this material was a memory of “emotional shuttling” as a part of holding therapy as practiced on children by members of the Evergreen, Colorado, group , such as Neil Feinberg and C.J. Cooill, formerly Connell Watkins, as well as various Utah holding therapists. This involved alternating distressing experiences for the child, like being shouted at and made to shout disturbing statements like “I want to kill my mother”, with calming, apparently sympathetic or even affectionate behavior by the therapist. Again, repetitions of this rhythmic sequence were seen as essential.

The shared goals of  rhythmic “pendulation” and “emotional shuttling” would appear to be the establishment of the power and authority of the therapist over the client. This is not characteristic of modern evidence-based treatments, in which therapist and client--  or therapist and parent—usually work together toward goals that a client hopes to reach. These may be better understanding of impulses and motives, or better knowledge about a relationship, or improved capacity to deal with frustration and impulse control, or better social skills. In all these cases, reaching the goal is a team effort, not something the therapist does to the client. In alternative psychotherapies, the therapist “fixes” the client (or not, as the case may be); in evidence-based psychotherapies, the client is an active participant.

Did pendulation come out of emotional shuttling, or the other way around?  I can’t tell, at this point, and I am thinking that both “rhythm methods”, and their authoritarian roles for therapists, emerged from the 19^th century shift from mesmerism (involving touch) to hypnotism, in which the practitioner’s gaze, the rhythmic passes of the hands, and the swaying and ticking watch were all ways in which the hypnotist sought to manage and control the client. Combine those factors with the stress on hypnotism of Milton Erickson, and the physical manipulations of Wilhelm Reich, and there we have common sources for a range of alternative psychotherapies of the present day—not new or innovative approaches, but the same old same old, refurbished with new names and claims.

Incidentally, I should point out something about IFS. At https://selfleadership.org/evidence-based-practice.html, proponents of IFS state that their techniques are evidence-based. Their reasoning is that IFS is listed on the National Registry of Evidence-based Practices and Programs (NREPP), a registry supported by SAMHSA, and if it’s on the registry of evidence-based practices, surely it must be evidence-based. But… awkwardly enough, not everything on NREPP is evidence-based in the sense of being supported by two well-designed, well-implemented randomized controlled trial studies. There are various levels of evidence on NREPP, as there are on other similar sites. In fact, examination of the NREPP material on IFS (https://nrepp.samhsa.gov/ProgramProfile.aspx?id=1) shows that IFS is only rated as “promising” (the third level of evidence), on the basis of one study published in Journal of Rheumatology, not in a psychiatry or psychology journal. Either the authors of the IFS site don’t understand what levels of evidence mean, or they are counting on the strong possibility that their readers won’t know—so, caveat lector!

Does Ontogeny Recapitulate Ontogeny? (Nope, It Doesn't)

Most people who have taken a biology course that touched on reproduction have come across the claim by Ernst Haeckel that “ontogeny recapitulates phylogeny”—that is, that the development of an individual repeats or at least is similar to stages in the development of the species that individual belongs to. Haeckel’s statement was based on the observation that in the course of development of the human embryo, the embryonic individual will temporarily resemble the embryos of other species whose members are less complicated and developed than human beings are. For example, at one stage, the human embryo has gill slits like those of embryonic fish; at another stage, the human embryo has a tail that will be lost as development proceeds. For Haeckel, the stages of embryonic development recapitulate or repeat the stages through which the ancestors of human beings evolved, although actually it’s probably more accurate to say that the stages through which the human embryo develops are periods in which the developing individual resembles embryos of other species.

The idea of recapitulation, so exciting to 19^th-century biologists, has also proved exciting to alternative psychotherapists. They applied the idea to ontogeny, individual development, itself, and not simply to the resemblance of a developing human embryo to embryos of other species. As is common in pseudoscientific thinking, these people jumped from Haeckel’s principle to the idea that they can make recapitulation of early development happen by imitating some of the events that might have been present during an original early developmental stage. Magically, the imitation of the past makes the consequences of earlier events vanish, and they are replaced by the consequences of the imitation. Rituals of imitation—like handfeeding a child in imitation of early feeding experiences—are said to return the child’s development to “square one”, to take a detour around any previous problems or bad experiences, and to deliver the child to a good developmental status, as if previous problems had never been.  

This treatment claim, based on a partial analogy with embryonic development, would require nonexistent empirical support before it could be acceptable. It’s also weakened by alternative psychotherapists’ tendency to forget that child development is driven by two major forces, experience and maturation (genetically determined growth and change), and that although experience is the only factor under the therapists’ control, the power of maturation is essential to developmental change. Alternative therapists like to reference the brain’s plasticity, but when they forget maturation, they omit experience-expectant plasticity—time-limited sensitivity to experience like that seen in the development of vision, or language, or emotional attachment.

For example, Bruce Perry, in a 2006 publication ( “Applying principles of neurodevelopment to clinical work with maltreated and traumatized children”, Chapter 3 in N. Boyd Webb (Ed.), Traumatized youth in child welfare, New York: Guilford), claims that the fetal brainstem’s neurology is shaped by the heart rate of the mother and the rhythmic beat that impinges on the fetus.  ( This claim ignores the maturational factor in the development of any part of the brain.) From this claim, Perry goes on to propose that the brainstem, the part of the brain responsible for functions like temperature control, can be changed by exposing the individual to rhythmic stimuli, drumming, music, dance, and so on; he suggests that EMDR treatment uses this rhythmic reshaping function, and although I have not seen that he expects “tapping” treatments to follow the same pattern, that would make sense within his framework. Many alternative therapists have followed Perry’s pseudoscientific claims and used them to argue that somatic treatments are essential for all forms of mental disorders. Perry’s ideas are the basis of, or supports for, various alternative psychotherapies that use re-enactment of early childhood events with the intention of recapitulating ontogeny.

Did Perry, or any of his colleagues, invent the idea that ontogeny can recapitulate ontogeny (but make it come out right)? No, in fact most of Perry’s ideas go back to somewhere around Haeckel’s time. 

John Hughlings Jackson, a 19^th century neurologist, developed the idea that the nervous system is hierarchically organized, using his work on patients with brain injuries or diseases. He saw that when the cortex was damaged, the patient’s behavior reflected the functioning of lower areas of the nervous system—functioning that had been present in that individual before the cortex was fully developed. Jackson gave this phenomenon the name “regression”, and the term and an analogous concept, psychological regression, were promulgated by Sigmund Freud. Freud’s colleague (and later rival) Sandor Ferenczi, suggested that psychological regression and recapitulation could be accomplished  by “babying” a patient. This proposal has been repeated right into modern times by some transactional analysts, “primal scream” therapists, dance and music therapists, holding therapists, rebirthers, and so on and on. Claims about brain plasticity have been used to support the idea that it should be possible to repeat and correct development.

For all the advocacy, however, we still see no systematic evidence that ontogeny can recapitulate ontogeny. It would be rather surprising if re-enactments could cause recapitulation, because the more developed person is a different individual today than he or she was years ago. Both maturation and experience have done their developmental work, and any new experience—even am imitation of an old one—must interact with that work in order to have an impact. You can’t step into the same river twice, and you can’t learn something for the first time more than once, because the river changes while moving, and you, the individual, are not the same person after that first experience.

Another Query About Eye Contact

I received the following question on a page that is already completed filled with comments and cannot post any more. I hope the writer will see this-- and that everybody interested in this issue will read my request NOT to post to the filled page! There are plenty of other pages commenting on eye contact that you can use!



Hi Dr. My baby is 8 months old (corrected age 7) was admitted in NICU for 18 days... I am worried he is not making eye contact though he looks at the lights and tracks bright objects but then his attention diverts to smthn else... He is sitting with support and sits unsupported for 4-5 min... Not yet crawling... I am worried.. We got his eyes chek-up and the doc said may be he wl need glasses.. is that a reason fr him nt mkin contact?? He does not recognise whether i m in the room or not... though he recognises my sound n touch.. plz doc help m worried



Yes, certainly not seeing well is an excellent reason for failing to make eye contact. The baby has to see your eyes before he can "contact" them. It's not unusual for babies born prematurely to have visual impairments. He may be able to see the easy, attention-getting things like lights and bright objects but not have good enough uncorrected vision to see your face well. It sounds as if your doctor is monitoring the situation and may even get glasses prescribed soon. If glasses are prescribed, please do your best to make sure they are worn as required in order for him to use vision for cognitive and motor tasks-- he may hesitate to crawl or walk if he can't see where he is going.

Meanwhile, do talk to and play with him as much as you can so he can be learning about the social world even though he can't see well. Good luck to your family!

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.

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.

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.