- A parent, another adult in the household, or a therapist often or very often swore at the child, insulted the child, put the child down, or humiliated the child, OR acted in a way that made the child afraid that he or she might be physically hurt.
- A parent, another adult in the household, or a therapist often or very often pushed, grabbed, slapped, or threw something at the child, OR at some time hit the child so hard that he or she had marks or was injured.
- The child often or very often felt that no one in the family loved him or her, and that no one, including the therapist, thought him or her important or special.
- The child often or very often felt that he or she didn’t have enough to eat, had to wear dirty clothes, and had no adult protector.
Monday, December 19, 2016
When Proposed Childhood Mental Health Treatments Are Potentially Harmful
I recently published an article in the Child and Adolescent Social Work Journal, under the title “Evidence of Potentially Harmful Psychological Treatments for Children and Adolescents”. Interested people can read this paper at the following link: http://rdcu.be/nRB3.
However, assuming that most readers won’t be quite that interested, I’m going to summarize the article here and add a few comments.
The point of this paper is that there is clear evidence that certain psychological treatments that have been used for children have been harmful, and that in fact it would have been possible to predict these harms beforehand by careful examination of the principles and practices of the treatments themselves. Evidence for harm done by certain treatments goes back to the 1960s, so no one should be surprised to find that this is a possibility. Nevertheless, specific discussion of potentially harmful psychological treatments goes back only to 2007, and even then there was little emphasis on potentially harmful treatments for children. An important publication in 2007 assumed that harms can be identified through systematic research evidence, whereas in fact anecdotes and journalists’ reports may be the first line of information to warn of us of harm to children.
My paper proposes that potentially harmful treatments for children may be identifiable – before harm is done—by several characteristics that make them unusual in comparison to most childhood mental health treatments.
One of these is that they create an emotional burden for the child, making him or her feel distressed by the treatment. Although it has been claimed that people in psychological treatment must feel uncomfortable so they can be motivated to change, this idea is not evidence-based, and the great majority of child treatments focus on comforting the child as he or she tries to master issues like anxiety resulting from trauma. Treatments that are distressing for a child run the risk of re-traumatizing rather than helping.
A second characteristic that is proposed for potentially harmful treatments for children is derived from the Adverse Childhood Experiences (ACE) study, currently underway and revealing that problems of both mental and physical health in adulthood are associated with increased numbers of adverse experiences of painful and disturbing experiences in childhood. There are ten ACE questions used for research purposes; of these, the four following questions are most relevant to potentially harmful psychological treatments for children.
I propose that when a childhood mental health treatment features these ACE events, this fact helps to identify the treatment as potentially harmful
The third characteristic I suggest for identification of potentially harmful treatments for children is drawn from the fourth National Incidence Study of Abuse and Neglect (NIS-4). NIS-4 identifies for research purposes a list of adult actions that are to be considered abusive to children. The following table shows adult behaviors that are relevant to the identification of potentially harmful psychological treatments for children.
Behaviors coded as physical neglect Behaviors coded as physical abuse
Refusal to allow needed care for diagnosed Hit with hand
condition or impairment Hit with object
Unwarranted delay or failure to seek Push, grab, drag, pull
Refusal of custody/abandonment
Illegal transfers of custody
Inadequate personal hygiene
Behaviors coded as educational neglect Behaviors coded as emotional abuse
Permitted chronic truancy Close confinement: tying, binding
Failure to register or enroll Close confinement: other
Other refusal to allow or provide needed attention Verbal assaults and emotional abuse
to diagnosed educational need Threats of other maltreatment
Behaviors coded as emotional neglect
Inadequate nurturance/affection Exposure to maladaptive behaviors and environments
Other inattention to developmental/emotional needs
I propose that treatments that include these behaviors are identifiable as potentially harmful to children.
Having established these criteria for potentially harmful psychological treatments for children, I examined five psychological treatments for children to see whether they met the criteria: aversive conditioning using electric shock, holding therapy/attachment therapy adjuvant treatments associated with holding therapy/attachment therapy (Nancy Thomas parenting), “holding time” (Festhaltetherapie), and conversion therapy for change of sexual orientation. In practice, although not necessarily in theory, each of these treatments met all or most of the criteria for potentially harmful treatments for children. Two of the treatments, aversive conditioning using electric shock and holding therapy/attachment therapy, have over many years moderated their practices, but their potential for harm remains. Interested readers can look at the paper for many more details about these five treatments and for the sources I used in writing the paper..
I certainly do not mean to suggest that these five treatments are the only child mental health interventions that have the potential for harm. I would have liked to include an analysis of various treatments for children displaying “parental alienation” by rejecting and avoiding one of their parents, but there is little systematic evidence either about the effectiveness of these treatments or about their potential for harm. There is no question that they cause an emotional burden to the children. In addition to this, there is anecdotal evidence that these treatments may be associated with frightening experiences with youth transportation services, and with threats to send an uncooperative child to residential care or to wilderness programs where the child cannot communicate with anyone outside the treatment program and may be at the mercy of staff members.