When Threats Substitute for Therapy

Changing oneself through legitimate psychotherapies can be hard work – work of the kind that adults can decide to do, but work that most children and even adolescents are not mature enough to manage. Child psychotherapies usually offer gentle though concentrated guidance in the direction of changes that adults think will be good for the child. The child does not necessarily think the changes are needed and may not really understand change processes, so treatments must be pleasant to experience, and any hard work must be encouraged and thoroughly supported by the therapist.

Of course, people can be made to change their behavior in ways other than their own hard work or gentle guidance. They can be threatened with punishment or unpleasant experiences unless they straighten out. If a person is capable of changing voluntarily, threats can be an effective change agent, and they work that way in most of our everyday lives. I’m looking for a parking place--  there’s a good one--  but there’s a sign that threatens me with having my car towed away if I park there. The threat makes me change my planned parking behavior.  Or, I don’t want to take time to go to the doctor and get a flu shot—I’d rather go for coffee and gossip. But I had flu once, and the threat I perceive of catching it again is enough to change my behavior. Even preschool children can respond to clearly-stated threats of unpleasant experiences in the near future: “If you hit your sister, you will get a time-out”.

Do threats make up any part of normal therapies? No, they don’t, and therapists generally are uneasy about situations where there is an implicit threat to a client--  for example, a court order to seek treatment. But there are unorthodox treatments for children where threats are used, and those threats may bring about behavior change if the child is able to make such a change voluntarily.

The classic case of threats as part of an unconventional treatment is “holding therapy”. Children receiving this treatment were (and perhaps still are) threatened that if they do not “work hard”, their parents will abandon them and simply leave them at the treatment facility. The children do not know that such an action would be child abuse and would create serious legal repercussions for the parents; even voluntary legal termination of parental rights is quite difficult and subject to continuing financial responsibility for the child. Children in holding therapy may also be assured that if they do not change in some way, they will end up by killing someone and will spend their lives in prison. Adults may know that these are not realistic threats, but children do not know that and are terrified of the outcome, especially if they do not know how to change or even what needs to be changed.

I recently received a long email from a young woman I’ll call Polly. She is 17 years old, has finished high school, and recently went to court to become legally emancipated. But her emancipation petition was not Polly’s first experience with the courts. Her parents, who are divorced, have become locked into an accusation of “parental alienation”—the idea that Polly and her sister, who preferred to live with their father and avoid their mother’s household and her boyfriend, must have this preference because their father had “brainwashed” them into believing bad things about the mother. (Proof of this claim was that the girls insisted that it was their own decision!)

Polly’s mother contacted a California therapist whose psychology license had been revoked but who said he could practice a “psychoeducational” method called Family Bridges. As is the case for many proprietary treatments, it is not easy to find a description of Family Bridges. However, Polly has described what happened to her and to her younger sister when a judge ordered the girls to travel from their home state to California and to participate in Family Bridges.  

According to Polly’s report, when the girls tried to refuse, they were taken away from the courthouse by employees of a “youth transport service”. (These “services” and the little regulation they undergo were discussed by Ira Robbins at www.americancriminallawreview.com/files/7714/0539/9315/Robbins.pdf.) The transporters responded to Polly’s crying and lying down on the ground by telling her that her father would go to jail if she didn’t go, and hinting that she herself would be confined in a residential treatment center. The two girls were taken to a town in California, where they were met by their mother, the mother’s boyfriend, and several psychologists, who met them in a hotel room and apparently do not have an office. The plan was to provide the girls with treatment that would convince them that their father had made them think that their mother was abusive.

The treatment, or “psychoeducation”, consisted of watching and discussing a number of video presentations. These included material about visual illusions, about how people may express opinions that are not really their own because of social pressures, and about the well-known study by Milgram in which participants who believed they were giving other people serious electric shocks often continued to do so when ordered by an authoritative experimenter. The implications of these presentations were apparently that the girls should understand that opinions they thought were their own had actually been created in their minds by their father—a plan with its own logic, perhaps, but not one based on any evidence that deeply emotional beliefs can easily be changed, nor indeed on any evidence that they had been influenced in their opinions by the father.

At almost 18, Polly was almost four years past the age when adolescents are normally given the chance for informed consent to medical or other therapeutic procedures. Instead, threats were used to force her cooperation, and her concerns and opinions were ignored. The threats came into the picture when Polly continued to be resistant and to speak rejectingly to her mother in spite of this “treatment”. According to Polly, one of the psychologists told her, “If you continue that behavior, you will be sent somewhere else. You seem like you need more help than we can give you”—superficially an offer of help for a vulnerable person, but in essence a threat of further disruption to her life. Arrest was threatened if she did not mind her mother, and for several days both girls were told that if they did not cooperate they would go to a treatment facility for juvenile offenders or to wilderness therapy--  these both being situations where teenagers are held incommunicado, have no opportunity to report abuse, and live in austere, even dangerous conditions. Back at the mother’s house, too, incarceration in a residential treatment center was the threat used to obtain obedience.

If Polly had not succeeded in her emancipation petition, or if she had been much younger, no doubt her behavior would have continued to be manipulated by threats--  and perhaps some of the threats would even have been acted upon. What if her behavior had changed in response to those threats? Would that have indicated that the “treatment” was effective—or simply that people respond at least temporarily to sufficiently serious threats?

One other question: when people are trained to do interventions that in practice include threats, are they trained in effective threatening?

If It's Not RAD, What Is It? Disturbing and Aggressive Child Behavior

For some years now, this blog has featured correspondents and me going around in circles about Reactive Attachment Disorder. I comment that symptoms of RAD do not include aggressive or dangerous behavior; correspondents then reply, “Are you saying my child does not behave aggressively? Of course he does! That’s how I know he has RAD.” I then say I am not arguing about the child’s behavior, just saying that this behavior has nothing to do with attachment and can’t be treated with efforts to strengthen attachment, even effective ones--  and around and around we go in our merry disagreement.

Occasionally I’ve pointed out that the behaviors these parents mention actually belong to disorders other than RAD, for example Oppositional Defiant Disorder, and that they may be associated with ADHD too. I haven’t really gone into much detail on this, but today I would like to say more about it, drawing information from an article titled “Narcissism and callous-unemotional traits prospectively predict child conduct problems” (Jezior, McKenzie, & Lee [2016], Journal of Clinical Child and Adolescent Psychology, 45(5), 579-590). Jezior and her colleagues focused on conduct problems (CP), which include oppositional defiant disorder (ODD) and conduct disorder (CD). These problems involve behavior like hostility, defiance, aggression, and property destruction. They are associated with callous-unemotional (CU) personality traits such as low empathy, lack of guilt, and shallow emotions, which also tend to go along with severe and persistent externalizing problems—behavior that expresses anger and resentment. CU traits are highly heritable, a fact that helps to explain how difficult they are to correct—if these problems did not result from experience, a change in experience will not so readily alter them.

Jezior and her colleagues also looked at narcissism in childhood as a factor in conduct problems. This disorder is characterized by bragging, thinking oneself better or more important than other people, and making fun of others, behaviors that are associated with ADHD, ODD, and conduct disorders.

Jezior’s group looked at boys (mostly) between  6 and 10 years of age to see whether their behavior at a first measurement was a good predictor of  conduct problems some years later. In fact, two years after the first measure ,increases in ODD and CD symptoms were related to earlier narcissism and CU traits.

 *** But let me make one note for readers of this blog: these researchers were not looking at preschool children. Younger children are well-known to their parents and teachers for their ready anger and aggression, their selfishness, their inappropriate bragging, their self-importance, and their tendency to ignore or fail to recognize other people’s needs. By age 4 or 5, some children may be more noticeable for their delays in mastering all these undesirable, antisocial characteristics, but the great majority will also still be struggling with their impulsive natures. It is not until school age that we begin to see real individual differences in narcissistic or callous-unemotional traits, so parents should not generalize from Jezior’s study results to thinking about preschool children. It remains to be seen whether preschoolers’ characteristics can predict their later antisocial behavior.

Jezior and her colleagues suggested that early assessment of CU and narcissistic characteristics could be beneficial, in that with early diagnosis, early treatment could begin before adolescence. They noted that detailed assessments might help determine the best form of treatment for conduct disorders. But do existing treatments actually help mitigate conduct disorders and help to decrease further development of problems? Ollendick et al carried out a randomized controlled trial of two treatments, Parent Management Training (PMT) and Collaborative & Proactive Solutions (CPS). Readers should note that each of these interventions works with parents and children together to diminish oppositional behavior--  these are not just attempts to “fix” the child and to give the parent a break. Children aged 7 to 14 were randomly assigned to either PMT or CPS or to a waiting list control group. Both PMT and CPS had better outcomes than the waiting list group, with about 50% judged to be either  much or very much improved, and maintaining their gains six months later. But not only is it notable that about 50% did not improve—in addition, Ollendick et al referred to such weaknesses of the study as the small groups and the number of families who dropped out of treatment. They noted also that younger children responded better to treatment than older ones.

A review by Bakker et al (“Practitioner review: Psychological treatments for children and adolescents with conduct disorder problems—A systematic review and meta-analysis.” Journal of Child Psychology & Psychiatry, 2016; epub Aug. 8) looked at 17 research articles dealing with 19 interventions and reported small effects on reduction of conduct disorder, but pointed out that many of the reports did not provide enough information to assess.

This is all a bit discouraging, of course. It seems that conduct problems can be identified early (although not in the preschool period, when antisocial behavior is to some extent the norm), and that some interventions working with children and parents together can have positive effects. However, the nature of the problems, with their genetic component, means that a “cure” is not likely to emerge. What can be helpful is to realize that these behavioral difficulties are not associated with attachment experiences, are not part of Reactive Attachment Disorder (though they may exist side-by-side with RAD), and are most unlikely to respond to efforts to change or strengthen attachment.  

Worried About Whether Your Baby Looks at You? Take a Developmental Perspective

Dr. Seuss was so right when he said “a person’s a person, no matter how small.” But he forgot to say that a person who is small is not exactly the same person he will be when he gets bigger. Remembering that fact can help parents of young babies who get worried sick when their babies don’t behave in ways that are much more characteristic of older people. To know what’s going on with any big or small person, we need to know where that person is developmentally.

Every week or two, I get a query from a frantic young parent who is terribly concerned that her baby, somewhere in age between birth and three months, does not make enough eye contact or even seem to be interested in looking at the parent. Mothers particularly seem inclined to jump to a conclusion that a young baby will not look at the mother because he does not like her face.

The anthropologist Ashley Montague recognized that babies in the first few months do not pay a lot of attention to what is going on around them. He referred to the first months after birth as a period of “exterogestation”--  when babies continue to develop along the lines they followed in the uterus, but now do their developing outside the mother’s body. Montague pointed out that in fact humans, with our large and complex brains, need a year to develop after conception, but have to be born too early because our big heads could not otherwise fit through the mother’s pelvic bones, thickened as those bones are by our walking upright. Other authors, like Margaret Mahler, have referred to this period as one of “normal autism” because young infants seem to be so self-focused and inattentive while they continue through their first months of development.

During this early period, infants’ behavior is very much affected by what is called their state. This term refers to the effects of a group of variables in the nervous system that determine what behavior a baby is likely to carry out. We adults have “states”, too, but we usually think of them just as being asleep or being awake—though we may also understand differences between REM (rapid eye movement) and non-REM sleep. For babies, there are six states that make a difference to behavior. These are 1. active or REM sleep, 2. quiet or non-REM sleep,3.  drowsy awakeness, 4. quiet but alert awakeness,5.  fussing and high activity, and 6. crying. Of these six states the fourth, quiet alert awakeness, is the one in which attentiveness and learning are most likely to occur.

 For very young babies, states shift rapidly and are poorly organized. There is a lot of sleep, and periods of quiet alertness, when looking at faces and interacting with people might occur, are brief. It can be hard to get a baby’s attention even during one of these brief quiet alert periods, even if some parenting “tricks” like opening eyes and mouth wide while moving toward the baby’s face are deployed. After about three or four months, babies spend more time in the quiet alert state and are more attentive to adults. Their vision also improves over this period of time and they are more able to see in low-contrast situations like dim light or light coming from behind a person’s face.

State issues mean that young babies do not spend much time looking around them, at people or -in looking at other things, but this fact needs to be interpreted in light of the reality that they do not spend much time looking at anything. This changes with further development--  they look more, and it’s more evident that they like faces, as time goes on.

Most of us feel that we’re aware of a special experience when someone makes eye contact with us—a sort of “zap” that’s different from how it feels when they just look in our general direction. But that “zap” is not necessarily a good way to measure whether a young baby has actually looked at somebody. It used to be difficult to measure and record whether a baby did look at a face, so for a long time we did not have really good information about the developmental progress of this behavior. Nowadays, though, there are much better baby-friendly devices that can measure where a baby is looking.

Writing in the publication Child Development Perspectives, the Finnish psychologist Jukka Leppanen  recently reviewed what is known about developmental changes in babies’ looking at faces(“Using eye tracking to understand infants’ attentional bias for faces”, Child Development Perspectives, 2016, Vol. 10 (3), pp. 161-165). The review reported that when babies were given several things to look at, 4-month-olds looked at a face only on 15% of the exposures, but by six months the proportion was 50%. (Adults looked at the face preferentially 90% of the time, not 100%.) Three-to-six-month-olds did not look particularly at faces when face pictures were given in shades of grey. At 6 months, when looking at faces rather than other things 50%, babies did not act as if everything besides faces was the same--  they also showed a lesser preference for looking at upside-down faces, at pictures of body parts, and at animals.

Leppanen also reviewed information about how long babies looked at faces once they had noticed them. Before five months, babies easily move from looking at a face to some other interesting and distracting object. For 5-month-olds, continuing to look at a face when something distracting comes into the picture is done, and happens in the same way whether the face has a neutral or an emotional expression. By 7 months, babies look longer at a fearful face even though some other interesting distracting sight is available. Compared to what a newborn can do, these older babies show great progress in finding faces visually and continuing to look at them without getting distracted.

Parents who are worried about what they think is a delay in looking at faces have often been influenced by Internet material warning them of signs of autism. As we have seen here, it is quite typical for young babies not to look much at faces or “make eye contact”. It’s not until six months or more that this kind of looking becomes more like what adults do and expect, so it’s best not to be too concerned about whether young babies seem to look at faces or eyes.

As for detecting autism in those early months--  well, there is work being done to try to measure whether there are characteristics of very early looking that can tell us whether a baby is likely to be diagnosed as autistic a couple of years in the future, but the work is not finished yet, and this may not prove to be possible.  While we wait, let’s just remind ourselves that babies of all kinds benefit from having cheerful, affectionate caregivers who understand that a small person is not exactly the same as a bigger one.