Concerned About Unconventional Mental Health Interventions?

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

Friday, November 17, 2017

Martha Welch Meets Bruno Bettelheim, Edgar Cayce, and the Rules of Research Design

I’ve devoted several posts and parts of some publications to the claims of Martha Welch, a New York psychiatrist, who used to claim that she could cure autism and now says she can prevent it. Welch has, inexplicably, the support of Columbia University, which has appointed her a sort of peripheral non-teaching faculty member with certain faculty privileges, and which not long ago gave her an award as a distinguished alumna.

In the 1980s, Welch visited Evergreen, Colorado, home of Holding Therapy as practiced on adopted children who were said to have attachment disorders. I have no idea exactly what happened there, but after her visit Welch decided that autism must be a form of attachment disorder, curable by facilitating emotional attachment to the child’s mother. She developed a new form of treatment that she named Holding Time. Rather than the Holding Therapy methods, which usually restrained the child in the therapist’s lap and used intrusive and painful shouting and poking to intimidate the child, Welch proposed that smaller children be held face-to-face with the seated mother and embraced so they were pressed belly to belly with her. This hold was to be maintained for an hour or more at a time, every day, as the child screamed and fought for release and eventually gave in and relaxed in the  mother’s arms. Older children were to lie on their backs while the mothers lay prone above them, partly supported on their arms. In both cases the mothers were to speak to the children, communicating all of their negative and positive feelings; the children too communicated a good deal of negative emotion.

Welch’s approach would probably have remained among the various obscure “complemetarty and alternative” approaches to autism, except that in the 1980s she made a connection with Elisabeth Tinbergen, a special education advocate and the wife of the Nobel laureate in medicine Nikolaas Tinbergen. Niko Tinbergen was a specialist in ethology, the study of innate, species-specific behavior patterns; although ethology had focused largely on insects, fish, and birds, the 1960s and ‘70s were a time when studies were attempting to find such species-specific behaviors occurring independently of culture and learning in human beings. The Tinbergens saw parallels between what Welch was doing and the occurrence of “imprinting” connections to other animals in ducks. They enthusiastically wrote a book declaring “hope” for autistic children in Holding Time methods, and included a long appendix written and illustrated by Welch. The Tinbergen book led to the publication of Welch’s 1989 Holding Time and an extensive book tour in Europe during which Welch presided over roomsfull of mothers holding tightly to screaming autistic children. (The Tinbergens also encouraged the promulgation of similar methods by Jirina Prekopova, a Czech psychologist working in Germany.) However, little was made of a point clearly stated in the Tinbergens’ book: that there was no empirical evidence to support the effectiveness of Holding Time.

I’ll leave this brief summary now because there is much more to say about Welch’s current activity. She is now running a program called Family Nurture Intervention and claims that physical contacts between premature babies and their mothers can reduce the frequency of autism, which occurs more frequently in premature than in full-term babies. You can see a demonstration and discussion of this method at https://www.youtube.com/watch?v=DIXAMaIOK64
 (my thanks to Yulia Massino for calling my attention to this video; for some reason I cannot create a link here). Welch is carrying out a research project on the effectiveness of Family Nurture Intervention as a prevention of autism and has described the research plan, a randomized controlled trial, at https://bmcpediatr.biomedcentral.com/articles/10.1186/1471-2431-12-14. Among other things, Welch proposes that autism is related to the presence of abnormal levels of peptides released from the gut, for example secretin and oxytocin (both popular suggestions for treatment of autism in CAM circles).

I want to comment on three aspects of Welch’s theory and research. First, her assumption that babies become autistic because they miss experiences of physical contact, exchange of odors, and so on with their mothers is a direct reflection of the very much outmoded “refrigerator mother” theory put forward by people like Bruno Bettelheim (an art historian who became focused on child mental health). Bettelheim claimed, without evidence, that cold, unemotional mothers caused autism by their failure to engage physically and emotionally with their children. He did not mention premature babies, but those babies can certainly be included in this hypothesis because their medical care makes it difficult for parents to touch or engage with them in pleasurable ways, and even the most loving parents of premature babies will not be able to care for them as they would normally want to do. In the video mentioned above, a scientist who works for Autism Speaks points out this problem of Welch’s approach—that she is accepting something like the “refrigerator mother” theory in spite of decades of evidence that genetic factors rather than experiences cause autism.

Second, Welch’s emphasis on literal “gut responses”, the production of peptides and their effect on the brain, is an example of an old theme in American CAM. Edgar Cayce, an early- 20th-century “prophet and seer”, emphasized the work of the “enteric brain” as a source of emotion. The Meridian Institute of Virginia Beach, VA has continued to promulgate Cayce’s ideas, which are still part of many CAM approaches. For example, Andrew Wakefield, the disgraced physician who started the claims that immunization caused autism, looked to gut contents as evidence that materials of immunization remained in the body, and, presently working in America, he continues to focus on digestive tract issues as causes of autism and ways to treat it, in contradiction to all that is known about autism.

Now, the fact that Welch’s Family Nurture Intervention smacks loudly of outmoded and CAM beliefs is not enough to condemn it. It would be very reasonable to say, “who cares if it’s based on wrong ideas? If it works, that’s what’s important.” And Welch has reported some preliminary positive results—but this leads us to the third problem about Family Nurture Intervention studies.

Welch and her colleagues state proudly that they are carrying out a randomized controlled trial, and most certainly it is randomized, with families assigned randomly to one of two treatment groups. The problem is that it is not controlled, despite the presence of a putative comparison (control) group. Here is the trouble: according to the BMCpediatrics article mentioned earlier, the two groups are receiving treatments that are different in a number of ways other than the Family Nurture Intervention itself. In the FNI treatment group, mothers have 4 1-hour intervention sessions per week, or more, plus standard care. The comparison group has no specified treatment, standard care, and 1 meeting a week with research staff in the hospital. In other words, the FNI treatment groups is experiencing 4 or more times the socially-supported time with their babies as the comparison group receives. Such social support is well-known to improve mother’s moods and therefore to help them interact more patiently and warmly with their babies.

The point of randomization is to help isolate a variable, which is the crux of all experimental work. Randomizing families to conditions means that no special characteristic of the people (like knowing about and wanting a treatment) can interfere with finding the effects of the treatment itself, which should be isolated from any other possible effects on the outcome. But randomization alone cannot isolate the effects of the treatment unless the rest of the design and implementation of the study are correct. The time spent in treatments is clearly a factor that needs to be controlled, as it is common for more of a treatment to have a greater effect on outcomes than less does. When a treatment involves social support for people in a stressful situation, the time spent and the attitudes of staff are important factors. This study should have provided 4 or more sessions per week for the comparison group, devoting them perhaps to supportive interviews and motivational discussions with the mothers. Otherwise, we can only conclude that having more sessions has a better outcome--  we can’t conclude that the Family Nurture Intervention itself is supported.

A 2015 publication by Amie Hane et al (with Welch as a co-author), https://psychology.williams.edu/files/Hane-et-al-15-JDBP.pdf, concluded that mothers’ care for babies in the NICU was improved by experience of the Family Nurture Intervention. However, this article very properly stated some limitations of the study.  “The control group received standard care (SC) (i.e., usual care) as part of our randomized controlled trial that included holding and skin-to-skin care if the mothers chose to engage in these activities. But, there were not corresponding control conditions for each of the specific activities of FNI. For instance, SC mothers did not exchange sham odor cloths with their infants (cloths that were not exposed to mothers and/or infants). The effectiveness of FNI should thus be interpreted as a function of a comprehensive and integrative intervention, since during this preliminary trial of the intervention control manipulations of FNI activities were not entirely possible.” (p. 194). In other words, mothers in the comparison group may or may not have carried out some of the activities used for the FNI treatment group, but they did not share any version of some parts of the treatment, including the length of time per week (this last not mentioned as a limitation by Hane et al.). The standard care comparison group did not receive a family support session before discharge as the FNI group did.

Martha Welch has spent many years arguing in favor of alternatives to evidence-based conclusions about causes of autism and effective treatments for the disorder. Her connection with Tinbergen was apparently sufficient years ago to earn publication of a popular book and the support of Columbia University. The Columbia IRB approved her research design, weak as it is, although even non-harmful treatments can be considered as a harmful waste of time and resources if improper design and implementation of research can lead to incorrect conclusions. What is this all about? I would like very much to know.


N.B. Nothing in this post should be taken as rejection of the extensive legitimate research on neural factors in gastric and endocrine functioning; my point is that the existence of such physiological factors is not in itself evidence that supports any statement about autism.




Monday, October 23, 2017

What Do Registries and Clearinghouses Tell Us About Child Mental Health Interventions?


I wrote the following paper for a conference about a year ago, and recently a colleague asked whether it was on line anywhere-- so here it is, for those interested. (Since writing this, I have come across cases of confusion about the meaning of the CEBC evaluations and the conflation of "relevance" scores with research scores.)





Internet Registries and Clearinghouses: Evaluation of Mental Health Interventions for Children
                                                         Jean Mercer
                                                    Stockton University
                                                           Jean.mercer@stockton.edu

                                                            Abstract
Evidence-based practice (EBP) requires a knowledge of the best current research as well as of practice wisdom and client preference. Internet registries and clearinghouses for outcome research on treatments are sources of evaluations of recent research and help identify high-quality research conclusions. This paper examines methods used by four registries and notes some problems of reporting. Ways to improve Internet registries are suggested. 


There is increasing pressure for practitioners to use evidence-based practice (EBP), an approach that combines family preferences, practice wisdom and experience, and the current “best research” to guide treatment choices.  Practitioners and clients together can work out the first two of these factors, but the third involves knowledge of outcome research that may require considerable time and access to professional journals. As a result, psychologists may turn to Internet sources of research information or to publications that summarize research work.
Internet sources range in quality from the highly variable Wikipedia, on which some articles are impeccably written and sourced but others are weak, to websites like www.wikia.psychology.com, which appear to encourage questionable statements in support of specific treatments. Treatments may also be described on proprietary websites that may provide excellent links to research support or may give no more than anecdotal evidence to support their claims. Systematic research syntheses (SRSs) also vary in quality, and journal articles assessing specific treatments do not readily allow readers to compare therapies with each other.  Although the Cochrane Collaboration ( www.cochrane.org) has evaluated some psychological treatments, their reviews are much more often concerned with physical health.
As a result of these difficulties, it is common for practitioners to go to Internet “registries” or “clearinghouses” for which volunteers evaluate outcome research and assign scores indicating the amount and quality of research supporting specific treatments. The “registry” approach is depended upon to such an extent that a 2016 publication of the National Academies of Science, Engineering, and Medicine, Parenting matters, drew its recommendations about child psychotherapies from three registries. The publication made recommendations about Triple P, PCIT, and the Incredible Years, among others.
The present paper examines a series of “registries” or “clearinghouses”, including those used in the NAS Parenting matters report, considers the evaluative methods used by each, summarizes the levels of support reported for treatments, and notes where useful information about treatments has been omitted.
                                                            Method    
Two of the “registries” used in the NAS 2016 report were examined: the National Registry of Evidence Based Programs and Practices (NREPP; www.samhsa.gov.nrepp)and the California Evidence Based Clearinghouse for Child Welfare (CEBC: www.cebc4cw.org). The new Effective Child Therapy website (www.effectivechildtherapy.org ) was also considered, as was the British registry of the National Institute for Care and Health Excellence (NICE; https://nice.org.uk ).
 .
For each registry, information on the website was used to explore a series of factors:
1.       How mental health treatments for children were chosen to be listed on the website
2.      Criteria used to evaluate information about outcome research
3.      Methods of summarizing or ranking research quality
4.      Numbers of treatments evaluated
5.      Proportions of quality ranks assigned to the evaluated treatments
In addition, experiences of the present author in correspondence with two of the “registries” were noted.

Results
NREPP
NREPP, a service of the Substance Abuse and Mental Health Services Administration (SAMHSA), evaluates treatments whose proponents apply for assessment as well as those nominated by staff members. The following requirements must be met before a treatment will be evaluated.
1.       Research or evaluation of the intervention has assessed mental health or substance use outcomes among individuals, communities, or populations OR other behavioral health-related outcomes on individuals, communities, or populations with or at risk of mental health issues or substance use problems.
  1. Evidence of these outcomes has been demonstrated in at least one study using an experimental or quasi-experimental design. Experimental designs require random assignment, a control or comparison group, and pre- and post-intervention outcome assessments. Quasi-experimental designs do not require random assignment, but do require a comparison or control group and pre- and post-intervention outcome assessments. Comparison/ control groups must be a no-treatment control group, a wait-list control group, a treatment-as-usual comparison group, or an intervention that is presumed to be ineffective or substantially less effective than the intervention (e.g., a “placebo” control or, in cases in which providing no treatment might be considered unethical, less effective treatments, even if not treatment-as-usual, such as “supportive therapy”). Studies with single-group, pretest-posttest designs or single-group, longitudinal/multiple time series do not meet this requirement, but will be considered to identify emerging programs and practices for consideration in the Learning Center.

    Comparative effectiveness trials, in which two interventions, both presumed to be equally effective, are compared, and studies in which the effects of the same intervention on various subpopulations are compared or in which various doses or components of the same intervention are compared will not be reviewed, but may be submitted as supporting documentation.
  2. The results of these studies have been published in a peer-reviewed journal or other professional publication, or documented in a comprehensive evaluation report, published within the previous 25 years. Comprehensive evaluation reports must include a review of the literature, theoretical framework, purpose, methodology, findings/results with statistical analysis and p values for significant outcomes, discussion, and conclusions (The NREPP Open Submission Process, 2016).
Changes in NREPP evaluative methods have been in the process of introduction since 2015. The website presently lists  a large number of programs that were evaluated according to the old method (“legacy” programs), and a smaller number evaluated recently. The plan is to re-evaluate all listed programs by 2019.
The original NREPP evaluation looked at outcome research reports for the following factors:




1.        Reliability of measures
2.         Validity of measures    
3.        Intervention fidelity
4.        Missing data and attrition
5.        Confounding variables
6.        Appropriateness of analysis
7.        Adverse events
8.        Plausibility of treatment, identification of therapeutic mechanism
Each treatment was given a numerical evaluation score based on these points.


Since 2015, the NREPP evaluation has examined these factors:
1.      Rigor: design, intent-to-treat assignment, statistical precision, confounding of variables etc.
2.      Effect size
3.      Program fidelity
4.   Conceptual framework
Treatments are then categorized as follows:
1.      Effective: strong evidence of a favorable effect
2.      Promising: sufficient evidence of a favorable effect
3.      Ineffective: sufficient evidence of a negligible effect OR sufficient evidence of a possibly harmful effect
4.      Inconclusive
Note that the third category classes together treatments with little effect and those with some evidence of potential harm to children.
 Of 387 NREPP-listed programs, 205 are primarily for children and adolescents. Ten of the 205 program reports mention possible adverse events as reported by the program developers. The mean rating for handling of confounded variables in programs listed on NREPP  is 2.6 out of 4.0, with a range from 4.0 to 0.0, but this was reported in this form only for the “legacy” programs.
In spite of the apparently strict criteria for admission into the registry, the NREPP list includes Thought Field Therapy, a treatment long rejected as implausible and without evidentiary support (Pignotti, 2005).


CEBC
The California Evidence-Based Clearinghouse for Child Welfare (CEBC; www.cebc4cw.org) is a searchable registry funded by the California Department of Social Services and the National Association of Public Child Welfare Administrators. CEBC evaluates programs that have strong empirical support, that are used often in California, or that are being heavily marketed in California. Evaluation is based on materials submitted by program developers.
 Programs are evaluated and rated according to the following scale (for further details, see www.cebc4cw.org/files/OverviewOfTheCEBCScientificRatingScale.pdf).
1. Well-Supported by Research Evidence
2. Supported by Research Evidence
3. Promising Research Evidence
4. Evidence Fails to Demonstrate Effect
5. Concerning Practice
NR. Not able to be Rated on the CEBC Scientific Rating Scale

 CEBC lists descriptions and findings about 286 programs, primarily for children and adolescents. Of listed programs, 26 were “non-responders” to inquiries about empirical support. Programs are rated according to stated criteria from 1 (excellent supportive evidence; 21 programs) to 5 (concerning; 0 programs, despite connections of some listed programs with adverse events), or Not Rated when supportive material is insufficient (77 programs). Seventy programs were rated “promising”.
CEBC was responsive to the present author’s query about a program, Circle of Security,  that was listed as “well-supported” although published research reports did not agree with this evaluation. CEBC took down the existing statements about Circle of Security and a representative said that further material would be requested from the program developers.

NICE
The United Kingdom National Health Service’s National Institute for Health and Care Excellence (NICE; https://nice.org.uk) provides guidance relevant to a number of UK policies and practices. For the purposes of the present paper, its important feature is an evidence search service (https://www.evidence.nhs.uk). The NICE evidence search enables users to search for information on child psychotherapies, of which 2024 are listed (although a number of these focus on pharmaceutical treatment of childhood mental illness).
NICE warns users of the uncertainties inherent in the material provided: “In relation to the NICE Evidence Search only: It is in the nature of scientific debate that not all authors will agree on all matters. Further, published papers may be in error, or superseded by later research. Users should be aware that papers accessed through the website on the same subject-matter may report different results or conclusions. It is the user's sole responsibility to assess all evidence and to reach a decision informed by it. The website is designed only to assist access to some of the material relevant to decision-making. NICE Evidence Search only facilitates access to evidence published by third parties and no representation is made as to completeness, accuracy or fitness for purpose” (“Evidence Search”, 2016). In addition, the website notes that some sources of information have been accredited by NICE, but that this accreditation or guarantee does not extend to specific information provided. Although some items on the evidence search refer to the need for randomized controlled trials, no criteria for listing information about treatments are provided.
Sources of information on the NICE evidence search include the Social Care Institute for Excellence (SCIE; www.scie-socialcareonline.org.uk), a database of social work information that is said to be updated frequently by a team of information specialists. As well as journal article summaries, sources for the evidence search include the Database of Abstracts of Reviews of Effects (DARE).
Searching NICE for the treatment Dyadic Developmental Psychotherapy (DDP; Becker-Weidman & Hughes, 2008), a therapy that has been the subject of some argument about claims to be evidence-based, yields a 2006 summary by SCIE that repeats the claim that DDP is an evidence-based treatment. Correspondence with NICE by the present author did not produce any changes in this item. However, a search on SCIE itself shows the inclusion of a series of critiques of DDP as well as the 2006 summary. This suggests that NICE is not able to keep up-to-date on information about treatments, as indeed its warning message states.
A search of adverse effects of child psychotherapies yielded no references to risks of psychotherapy but gave examples of risks of medication.

Effective Child Therapy
 Effective Child Therapy (www.effectivechildtherapy.org) is a recent registry project of the Society of Clinical Child and Adolescent Psychology (Div. 53 of the American Psychological Association). It is also supported by the Association for Behavioral and Cognitive Therapies. Effective Child Therapy lists programs as evidence-based according to rating methods used in evidence base update articles in the Journal of Clinical Child and Adolescent Psychology ( see Southam-Gerow & Prinstein, 2014.). These methods include criteria for well-established, probably effective, possibly effective, experimental, and ineffective treatments; none of these designations include consideration of adverse events. To understand the selection of programs to be evaluated and specific information used in evaluation, a reader would have to have access to the evidence base update articles that are the sources of the assessments. The site provides a listing of treatments for 19 disorders, with 82 uses of treatments evaluated (this number counts some treatments more than once, as the presentation shows the effectiveness of a treatment for a specific disorder). In 24 cases, a treatment is reported as having well-established effectiveness for a disorder; in 34 cases, a treatment is deemed probably effective; in 34 cases, a treatment is called possibly effective; in 40 cases, treatments are evaluated as experimental or with unknown support; and in 9 cases, treatments are said to be ineffective. Because the evaluative methods do not include assessments of adverse events, no treatment is described as harmful.
                                                    Discussion
Internet registries or clearinghouses are useful but not perfect in their provision of the current “best research” that should be a factor in EBP. Because there are many people who want to use these sources for a variety of purposes,  some improvements are needed. 
NREPP set an example that could well be followed by other registries when it asked for examination of the plausibility or possible mechanism assumed by developers of a treatment. This factor, now described by NREPP as a conceptual framework, is not specifically addressed by other registries.
It is notable that registries tend to omit references to adverse events or to potential harm resulting from evaluated treatments, in some cases using the same category for weakly-supported positive effects and for potential for harm. This seems to be a failure to keep up with increasing concerns about the potential harmfulness of some child mental health treatments, which have grown along with a more general awareness of the possible iatrogenic effects of both physical treatments and psychotherapies. Lilienfeld (2007) considered both adult and child interventions as they might fit into the category of potentially harmful treatments (PHTs) .Lilienfeld (2007) suggested this term, PHT,  for psychological interventions that were known to have caused or been associated with adverse events, or for treatments that might logically be expected to cause adverse events in some cases. Lilienfeld (2007) operationalized treatments as PHTs when they met three criteria: 1) demonstrated psychological or physical harm to clients or others, 2) enduring harmful effects, and 3) replicated evidence of harmful effects by independent research groups. Dimidjian and Hollon (2010) pursued these issues in a paper that discussed the concept of harm in psychotherapy and offered a distinction between treatments that are harmful and those that are simply unhelpful.  Dimidjian and Hollon noted that a treatment may worsen outcomes both for the target problem and for other domains (including the creation of new problems) , that a treatment can have both helpful and harmful effects (again, with the possible creation of new problems), that an outcome can be considered helpful or harmful in different ways when seen from different perspectives, that outcomes may be initially harmful and later beneficial or the other way around, that outcomes of a treatment may be harmful for some patients but not all, that misuse of a beneficial treatment may cause harm, and that errors about benefits and risks may cause harm by preventing the use of a beneficial treatment. Although Dimidjian and Hollon did not comment on this, it may be added that in the case of mental health interventions for children, even an “unhelpful” treatment may also cause indirect harm by wasting family resources to the detriment of other family members as well as of the treated child.  In spite of these developing concerns, however, Internet sites seem to be lessening attention to risks associated with treatments; the changing evaluative methods of NREPP are an example of this problem.
In addition to omitting attention to risks of treatments as well as to their benefits, Internet registries and clearinghouses generally fail to provide information about the cost-benefit analyses that may be important factors for choice of treatments in the present economy. Some of this information is available (Washington State Institute for Public Policy, 2016), together with assessments of the probability of benefit of a given treatment. For example, PCIT for disruptive children has been estimated to result in a benefits-minus-costs sum of $1808 and to have a probably of causing benefits of 79%; cognitive behavioral therapy models for child trauma have been estimated to have a benefit-minus-cost sum of $6550 and to have a probability of benefit of 100%; some other treatments are estimated to have costs that exceed their benefits and to have a probability of benefits as low as 4%.  For registries to include this information where possible would be helpful to users, especially those working on projects like the Parenting matters book.
Internet registries tend to depend on volunteer evaluators and/or to base evaluations on material provided by program developers. They may or may not be responsive to critiques and queries from outsiders. In some cases, such as NICE, they draw material and conclusions from other organizations which take responsibility for assessing evidence and for updating recommendations when new evidence becomes available.  Although no registry can be expected to do a perfect job or to keep up with new evidence in real time, it could be useful for registries to use volunteers primarily to search for emerging evidence and to employ trained staff to do the job of evaluating outcome research on child mental health interventions.






References
Becker-Weidman, A., & Hughes, D. (2008). Dyadic Developmental Psychotherapy: An    evidence-based treatment for children with complex trauma and disorders of attachment. Child and Family Social Work, 13(3), 329-337.
Dimidjian, S., & Hollon, S. (2010). How would we know if psychotherapy were harmful?American Psychologist, 65, 21-33.
“Evidence Search” (2016). Retrieved Sept. 3, 2016 from https://www.evidence.nhs.uk
Lilienfeld, S.O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2(1), 53-70.
National Academies of Science, Engineering, and Medicine. (2016). Parenting matters: Supporting parents of children aged 0-8. Washington, DC: The National Academies Press. Retrieved Sept. 2, 2016 from http://www.nap.edu/read/218681/   
Pignotti, M. (2005). Thought Field Therapy Voice technology versus random meridian point sequences: A single blind controlled experiment. Scientific Review of Mental Health Practice, 4, 38-47.
Southam-Gerow, M.A., & Prinstein, M.J. (2014). Evidence base updates: The evolution of the evaluation of psychological treatments for children and adolescents. Journal of Clinical Child and Adolescent Psychology, 43(1), 1-6.
“The NREPP Open Submission Process”. (2016). Retrieved Sept. 5, 2016 from www.nrepp.samhsa.gov/04b_reviews_open.aspx .
Washington State Institute for Public Policy (2016). Benefit-cost results. Retrieved Sept. 3, 2016 from www.wsipp.wa.gov/BenefitCost .


What Does Conventional Child Psychotherapy Really Look Like?

It’s all too common to read  “alternative” psychotherapists' claims that conventional psychological treatments are ineffective or even harmful, and especially that they interfere with parents’ authority and tempt children to criticize and resist their parents. None of these things are true, of course.

Watch these videos, created by clinical psychology graduate students, to see what actually happens in conventional child psychotherapies whose effectiveness is supported by good research evidence.


Cognitive-Behavioral Therapy for Adolescent Depression
by Brooke Merrow & Kendal Binion


Coping Cat to Treat Anxiety in Children and Adolescents
by Andrea Slosser & Shira Kern

Parent Management Training for Childhood Behavior Problems
by Adam Ripley & Alejandra Reyna

What is Trauma-Focused CBT for Children & Adolescents?
by Kati Lear & Sarah Steinmetz


Thursday, October 19, 2017

Questions About Eye Contact and Autism

Several people have recently tried to post comments about infant eye contact and autism on the What, Where, When page. You can't do it, it's filled up! And I can't put your queries or my answers there, either.

Please use this page for posting eye contact questions.

One recent question was about prematurely-born twins-- I just want to remind everyone that developmental age for premature babies should be counted from when they should have been born, not from when they were born. You can't expect babies born 6 weeks early to do at one month the same things done by babies born at full term.

Sunday, October 8, 2017

Talking Attachment Trauma: Sense and Nonsense

I recently received some court documents that included the statement of a psychiatrist who was arguing as an expert witness against a proposed custody change, from a mother who was accused of “parental alienation”, to the father who was alleging that the mother had caused their children to dislike and avoid him. The psychiatrist discussed the family history and the children’s attitudes and behavior in detail, emphasizing that adolescents are often temporarily “alienated” from their parents without having been encouraged to take this position by anyone. The psychiatrist concluded that “parental alienation” was not at work in the family in question, and I think he was quite correct in that conclusion.

However, this expert witness then proceeded to take a very risky step to cement his argument. Not satisfied with having shown evidence that there was no “parental alienation” going on, he marched forward onto thin ice by claiming that individuals in late childhood or early adolescence would suffer from “attachment trauma” if separated from their primary attachment figure (in this case, the mother). This was nonsense, and the expert and the children were very lucky that no one on the opposing side apparently knew that it was nonsense.

It is certainly true that most children between the ages of 6-8 months and 18-24 months will show extreme distress if abruptly separated from familiar caregivers. If the separation goes on for more than a few days, toddlers become lethargic and depressed and do not eat or sleep well. To understand what is happening here, we need to keep in mind that the attachment relationship the children originally experienced was one that penetrated their entire lives. Caregivers who are familiar attachment figures understand a child’s signals and cues and respond to them promptly and in ways a child can anticipate. Good caregivers are able to predict what will scare a given child and what words or actions are comforting to a particular child when he or she is distressed, so they can often “buffer” unpleasant experiences and help keep the child calm and engaged. A caregiver’s understanding of a given child needs to be and usually is quite individualized, because what works with one child will not necessarily work with another, even with respect to such basic caregiving functions as feeding and putting to sleep.

A young child who is separated from familiar caregivers and given to the care of a stranger loses all of the details of familiar experiences and finds that the whole world has altered, not just the presence of one person. Communication that used to work smoothly may no longer work at all until the child and the new caregiver come to know each other. All of these factors contribute to the distress of the toddler separated from a familiar caregiver, and if the environment has also changed because the child is taken to the new caregiver’s home or to a hospital, there is still more distress for the uncomprehending toddler.

These problems become gradually diminished if separation takes place after the child has mastered some communication through speech, assuming that the new caregiver and the child share a language. They are also diminished if the new caregiver can give plenty of time to the child and can make serious efforts to offer comfort and help—as one of John Bowlby’s colleagues showed, these circumstances can greatly lessen the traumatic impact of separation (although after a week or more of separation, toddlers may show their distress by “snubbing” a parent who returns for them).

When older children and adolescents are abruptly separated from a familiar caregiver, their responses are vastly different from what we see in toddlers. It is certainly true that under some circumstances they will show distress and concern, sadness and even depression. But these responses are not drastically different from what we would see in an adult who is suddenly abandoned by a spouse, whose parent dies, or whose close friend moves far away. Not all disruptions of life are traumas, and certainly not all losses of intimates are attachment traumas in the sense that we might use that term for a toddler’s experiences. An older child or adolescent prefers not to be separated from a loved parent unless he or she wants a temporary separation and can control how it happens. Toddlers do not ever seem to want a separation, but older children and adolescents do want choices about separation and use those choices as part of their developmental task of achieving autonomy. To be forced into a separation is distressing to the older child in part because this situation contradicts the child’s developing autonomy. In addition, a separation like custody change almost invariably means that the child or adolescent also loses many familiar parts of life—his or her own room, friends, neighborhood experiences, and possibly even a school situation if the child is attending a public school and moves out of the school district. These changes are distressing and will probably produce intense complaints and resistance on the child’s part, but they are not attachment traumas, or even traumas at all.


I am not intending to argue that custody changes after allegations of “parental alienation” are a good idea—I am fairly sure that in most cases they are not. I simply want to point out that we need to use terms like attachment and trauma in ways that are developmentally appropriate. The fact that an abrupt separation from a caregiver can be devastating for a toddler does not mean that the result is the same for an older child or an adolescent. If it were, we would not see sleepaway camp as a step toward maturity, nor would there ever have been boarding schools for privileged children.  Whatever they had to do with the battle of Waterloo, the playing fields of Eton were not the site of attachment traumas. 

Saturday, September 30, 2017

How Do You Know If Your Child's Therapist Commits Malpractice?

People who are dissatisfied with their physicians and psychologists sometimes mutter to themselves about malpractice, but most of us don’t really know what the term means. In this post I’m going to provide some information given at https://www.kspope.com/ethics/malpratice.pdf by the defense attorney Brandt Caudill, Jr. (By the way, Dr. Ken Pope, whose website this material appears on, is one of the most effective current constructive critics of the practice of psychology.)  Brandt Caudill intended his post to address malpractice issues for adult clients of psychologists, so although I’m going to mention the problems he envisioned as possible malpractice for everyone, I will stress and elaborate on the points that are most applicable to malpractice in the treatment of children. Caudill’s points are in italics below.

Excessive or inappropriate self-disclosure by a psychologist to a client is potentially to be considered malpractice. However, it is possible that a therapist may disclose a past history that is similar to a client’s history in order to create a sense of empathy; this would be appropriate, but for a therapist to disclose personal issues for his or her own motives is not. What about disclosure to a parent of a child in treatment? Can the therapist disclose information about his or her own children or other family members, or state how he or she solved a personal problem similar to the one the parent is contending with in the child’s behavior? These are sticky questions, and a therapist who handles them poorly may encourage parents to look for “proof by anecdote” rather than to be concerned about the evidence bases of treatments. In addition, disclosure of personal history by therapists, even as it supports empathy, may suggest to parents that they should avoid practitioners who might be helpful but do not share their personal characteristics. This has been a problem with respect to mental health treatment for adopted and foster children, some of whose parents have been told by adoption organizations and by individual therapists that they can only be helped by people who have adopted or been adopted themselves (as others “don’t get it”, no matter how well trained they are).

Business relationships with patients are a type of malpractice that is not likely to occur directly with children. However, it could occur with parents of children in treatment, especially if the therapist defines the child, rather than the family, as the client. It would not be appropriate for a therapist to hire the parent of a child in treatment as an office worker or to recommend such a parent as a foster parent or a treatment aide.

Using techniques without proper training is a potential malpractice issue whether adults or children are being treated. While this may seem obvious, the availability of weekend or on line workshops and seminars may make it easy for therapists to believe that they have mastered techniques and to use them without sufficient training and without related resources for consultation. Therapists who undertake serious training in a technique are almost sure to learn about the evidentiary foundation of the technique, and on any adverse events associated with it, whereas brief introductory trainings are much less likely to touch on these issues.  The possibility of adverse events is an especially important one for children, who of course are not in a position to decline further treatment if they experience a technique as harmful.

Using incorrect diagnosis deliberately is potentially a malpractice issue for both adults and children. Some therapists use this method, dishonestly but perhaps with the best intentions, to provide insurance coverage that may not be available for an actual problem. As Caudill points out, “The law does not recognize or permit the therapist to have one diagnosis for treatment purposes and one diagnosis for insurance or billing purposes”. Intentional use of an incorrect diagnosis may also be associated with use of inappropriate syndrome testimony. As   Caudill notes, “At this point, using syndromes which are not appropriately researched or acknowledged by the profession  is below the standard of care”. Caudill goes on to note that among the syndromes that should not be represented as accepted are Childhood Sexual Abuse Accommodation Syndrome, Parental Alienation Syndrome, and Malicious Mother Syndrome. Interestingly, as I am writing this in 2017, some therapists who used to use the term Parental Alienation Syndrome have chosen various conventionally-accepted disorders and created a “bundle” that they now present as equivalent to PAS.  Although the same comments might well be made about the use of unconventional, non-evidence-based treatments for children, I have rarely found that these trigger malpractice proceedings.


Avoiding the medical model involves decisions that are potentially malpractice issues, including failures to document informed consent, to conform to standards of care, or to keep notes and records. Psychotherapists are required to meet these obligations, which may be more complicated for children than for adults. With respect to informed consent, therapists are required to inform clients whether they are using evidence-based or unresearched, experimental methods and to communicate information about adverse events and about the effectiveness of the treatment. Some therapists who ask clients for consent do not include the information that makes consent informed. In the case of child clients, parents or guardians provide informed consent, but older children and adolescents are in many states also expected to give their consent, and adolescents may have the authority to refuse an unwanted treatment. Therapists need to handle the informed consent issue effectively, to provide complete and accurate information, and to obtain the consent of child clients in ways suitable to their developmental age.


The true love exception for sexual relationships is a common source of malpractice proceedings against therapists. One hopes that it is far more likely for therapists to convince themselves that a sexual relationship with an adult client is acceptable than to make the same decision about a child. However, there are sexual issues that may arise with child and adolescent clients even in best case scenarios. For example, a therapist may need to explore past sexual abuse in detail with a child client or to offer education about sexual and reproductive matters, and these discussions bear the possibility of misinterpretation by child or parent as seductive ploys. Young children, and older children who have had sexualized experiences, may accidentally or intentionally touch a therapist inappropriately, and these events need to be handled with clear messages. Otherwise, malpractice claims may arise, whether or not standards have been met.


These items are probably the most likely issues to be associated with malpractice by a therapist treating a child or adolescent rather than an adult. However, Caudill also lists problems that may amount to malpractice in work with clients of any age: Failure to obtain an adequate history (which needs be provided by parents, schools, and so on—including medical records—for children); uncritically accepting what a patient says (or, for children, what a parent says); out of the office contact; and failure to obtain peer consultation to help insure objectivity about a case.





Wednesday, September 27, 2017

Choosing a Developmentally Appropriate Preschool/ Child Care Program

What should a good program for preschoolers look like? This is a really difficult question for many parents of young children. There are a lot of different ways that a program for young children could look—it could be home-like, play-oriented, custodial (just “watching” the children), therapeutic, rule-driven and intensely instructional, or anywhere between these or among combinations of these categories.

A good many of today’s young parents went to preschools or were cared for in out-of-the-home settings when they were small children, but they may not remember the details, or ever have known some facts about the school or child care program. They may have much clearer memories of kindergarten, and of course remember a lot about grade school. When they search for a school or child care setting that “looks right”, they may do this by comparing what they see with their memories of their early school years, when there were quite a few children with each teacher and many rules about staying at your desk and following instructions.

But the school arrangements that may work well for older children are not necessarily developmentally appropriate for preschoolers aged 3 to 5 years, and are certainly not appropriate for younger children in a toddler program. Parents need to choose possible programs for their young children by considering the need for developmentally appropriate practices.

One approach to choosing a developmentally appropriate program is to look for certification by the National Association for the Education of Young Children, but as David Kirp has pointed out in an opinion piece for the New York Times (https://www.nytimes.com/2017/02/04/opinion/sunday/how-to-pick-a-preschool-in-less-than-an-hour.html), NAEYC certification is not necessarily the magic key to a good preschool or child care center. Neither are claims to use the methods of Montessori, HighScope, Reggio Emilia, or Waldorf. As Kirp comments, “The key is how well a particular model of teaching is being carried out.”

Kirp suggests that a visit to a preschool should focus on whether certain important things are going on. These include walls full of kids’ projects, posted at a level where kids can see them. Children should look at you and say hello but then go back to what they are doing. Ignoring you suggests that they are not developing social skills. Rushing over to be with you (a stranger) suggests that they do not get much attention—not, as some young parents might assume, that they are very friendly and thus the school or center is a good place. The noise level should be low but constant, as children talk to themselves or each other or the teacher about what they are doing. And…you should not see an emphasis on teachers giving instructions, enforcing rules, standing over children, or demanding unnecessary conformity (like coloring inside the lines).

A publication of the American Psychological Association, http://www.apa.org/education/k12/high-fve.aspx, suggests the High Five method for identifying good preschool or child care programs. (You can download a brochure about this model from the website.) In addition to describing the High Five approach, the brochure reminds parents that their job is not finished when they have chosen a program for their child, but that questions need to be asked on a regular basis, because programs change (and of course children do, too).

Here are the five questions parents are advised to ask about any program for young children:

1.   What is happening in the classroom?
Are children engaged and enjoying what they do? Would the activities interest your child or take into account any special needs she may have? Is there flexibility, so not all children have to do the same thing at the same time? Do children have any choices?

2.      How do teachers and children get along?
Do children and teachers seem to enjoy being together? Do children treat each other with respect, and do teachers act respectfully toward other teachers? Is a warm, positive approach to others encouraged?

3.      How do teachers guide and, when needed, correct children’s behavior?
Is it clear to children what the rules are? Do teachers step in early and help children solve their problems? Do teachers appreciate and acknowledge positive behavior like helping another child or showing concern for someone?

4.      How do teachers talk with children?
Do teachers ask open-ended questions to encourage children to use language? Do they talk to children while the children are playing?  Do they talk in ways that focus on what and how the children are doing things, rather than general positive comments like “good job!” ?

5.      How do teachers communicate with parents?

Are parents welcome in the classroom? Do teachers speak to parents respectfully? Do teachers have methods for communicating to parents what a child has been doing that day? Do events regularly include children's families, and are families informed or invited?



As you can see, the questions suggested by David Kirp in his Times opinion piece and by the High Five project are somewhat different from each other, but the combined question list would be very helpful for parents choosing a preschool or child care setting—certainly more useful than making a decision just based on prior certification or on advertising of a well-known early education approach.  The High Five recommendation of continuing monitoring of any program is a good one, especially if a program goes through changes of director or other staff, or if the program is part of a for-profit franchise.