Dyadic Developmental Psychotherapy Claims on Amazon

On an Amazon comment page, a mother recently wrote of her concern for her 9-year-old daughter, who had much difficulty coping with frustration and responded with lengthy tantrums to everyday problems. The mother sought suggestions for treatments focused on attachment, and stated that she was now aware that her own behavior was partially responsible for her daughter’s situation (although she did not comment on how she knew this or what she felt about her conclusion).

In response to the mother’s comment, the following appeared:

“Arthur Becker-weidman says:

DDP would be most helpful for you as it is an evidence-based and empirically validated treatment. See the California Evidence Based Clearinghouse for Child Welfare for their independent review of this and many other approaches.
http://www.cebc4cw.org/program/dyadic-developmental-psychotherapy/                “             

For those who have not encountered Becker-Weidman before, I should point out that he is a clinical social worker who was at one time associated with Dyadic Developmental Psychotherapy (DDP) as promulgated by Daniel Hughes. Becker-Weidman and Hughes published several papers in which they claimed, incorrectly, that there was an acceptable evidence basis for DDP. The British DDP website, which Hughes now runs together with Kim Golding, no longer refers to Becker-Weidman’s work, but acknowledges that there is currently no published evidentiary foundation for DDP.

So, let’s have a look at the claims Becker-Weidman is making on Amazon.

1. He points to the California Evidence Based Clearinghouse for Child Welfare (www.cebc4cw.org), an organization that posts information about child mental health treatments that are used or marketed in California. I looked into CEBC in some detail for a presentation at a conference last September and found the following:

 The information posted is obtained by asking developers of treatments to supply materials that can be used in rating each treatment. 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”.

To be rated 3, promising research evidence, as DDP was, requires only one nonrandomized study that compares outcomes for treated individuals to outcomes for some other group. This is a good deal lower bar than even the 2 rating, which requires one randomized controlled trial; treatments are properly described as evidence-based only when two independent randomized controlled trials have shown significant benefit from a treatment.

Incidentally, CEBC was responsive to my 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. When I have time, I need to comment to CEBC about the difficulties with research on DDP that I will come to in a moment.

2. The material Becker-Weidman (or someone) may have provided to CEBC has serious problems beyond its relatively weak design. As other authors and I have pointed out in professional publications, the treatment used in one study and a follow-up published by Becker-Weidman does not appear to have been DDP as it is presently described by Hughes. The original study, done in the late ‘90s, appears to have a number of features that are closely associated with holding therapy (HT), an intrusive and dangerous unconventional treatment. Becker-Weidman cites in his papers recommendations to parents to learn and use methods associated with HT, especially those suggested by the foster parent/dog trainer Nancy Thomas. Given the likelihood that DDP today does not use those methods, and that Becker-Weidman’s version did use those methods, it appears that Becker-Weidman did not do outcome research on DDP, but instead did it on DDP plus some other treatments, making it impossible to generalize from Becker-Weidman’s conclusions to current DDP as practiced by Hughes and Golding. A rival hypothesis about this situation is that Becker-Weidman and Hughes do still use the HT methods but do not disclose the fact; if true, that would earn DDP the CEBC rating of 5, concerning practice.

As I said earlier, the Hughes and Golding website no longer references Becker-Weidman’s publications. They would certainly do so if they thought the work provided evidentiary support for DDP. Becker-Weidman, however, seems to retain his conviction that “what I tell you three times is true”.

What Are the Probable Earliest Signs of Autism?

Of the comments and queries I receive on this blog, the greatest number are from parents concerned that their babies are showing signs of autism. Of questions about autism, almost all of them focus on a lack of eye contact—the babies do not gaze at their parents’ faces as much as the parents expect them to.

Most parents, and certainly many Internet authors who discuss autism, assume that whatever are the signs and symptoms of autism in older children and adults, those will also be the signs and symptoms of autism in young infants. They know that social awkwardness and a lack of eye contact and other communicative gestures are common among older children with autism spectrum disorder (ASD), so they assume that infants who are fated for an ASD diagnosis will also lack eye contact. But in making this assumption they miss two important points.

The first point is that infants in the first two or three months are not easily attracted to pay attention to people. They will do it now and then, but often they respond only to quite dramatic adult facial expressions with wide open-mouthed smiles. Years ago, this developmental period was referred to as a stage of normal autism—the word “autism” deriving from the Greek word for “self”, and the babies being focused on themselves rather than the environment. Now that people are terrified about ASD, one doesn’t come across this expression, normal autism, any more, but that doesn’t mean that the stage no longer exists. What would be a symptom of ASD in an older child is a sign of perfectly normal development in a young infant. There is no point in expecting a baby of a few months to make extensive eye contact, any more than there would be any point in expecting her to build a tower of two blocks or to spoon-feed herself.

My second point is that earlier and later behavior patterns may be remarkably different in cases where there are developmental problems. A good example is the pattern shown in Williams syndrome, a genetic syndrome resulting from loss of certain parts of a chromosome. Williams syndrome is not terribly debilitating, but it does cause developmental changes that are rather different from typical development. Young babies with Williams syndrome are terribly colicky and cry frantically no matter what is done to soothe them. They are not interested in other people at that point. But when the colicky stage passes, they become extremely interested in people, stare at them intently, and appear to be “starved” for eye contact. We might expect them at this point to be very interested in communication and to speak early, but no; in fact, their speech is delayed by about a year. Once they do start to speak, they became chatty conversationalists. As adults, they are still talkative, with wonderful language abilities, and highly sociable—but socially awkward at the same time because they seem to lack the social anxiety that guides most of us. The screaming colic and delayed speech of the younger Williams syndrome individual are by no means symptoms of either the strengths or the weakness of the Williams adult—and it’s very possible that a similar situation holds for ASD people, whose later symptoms may not mirror the earlier ones (if there are any).

A possible conclusion from these two points is that the current preoccupation of parents with eye contact may be irrelevant to the diagnosis of autism. The fact that older ASD children may not use eye contact for communication very much does not mean that we can identify infants who will later be diagnosed with ASD by looking for them to make eye contact.

A recent paper on autism  provides some interesting insights into possible early symptoms of autism. (Thomas, M., Davis, R., Karmiloff-Smith, A., Knowland, V., & Charman, T. (2016). The over-pruning hypothesis of autism. Developmental Science, 19, 284-305.) This is a very complicated paper, and I am only going to refer to one of its points here.

The Thomas paper is one that discusses an idea about how ASD develops. The basic idea is that autism results when a particular problem occurs during early development. It is well known that during the first year, there is great overdevelopment of synapses or connections between neurons in the brain, followed by disappearance of many that are little used—a process sometimes called “pruning”. Although some authors have suggested that autism results from too little “pruning” of synapses, Thomas and his co-authors hypothesize that too much “pruning” could be the problem. They have tested this hypothesis by developing a neurocomputational model to allow them to predict what kinds of problems should result from excessive “pruning”.

Like all good scientists, Thomas and his colleagues are testing their model against some longitudinal studies of development of autistic children, and to some extent are finding that the longitudinal studies show the symptoms they predict on the basis of the timing of pruning events during early development. These do NOT include symptoms of social interaction problems. They do include difficulties with sensory development like over- or under-sensitivity to sound or touch stimulation, and difficulties with motor development. Motor development problems as a precursor to autism have been discussed since the 1980s, when studies of home videos were sought by researchers as a way to see the early development of children later diagnosed with ASD. Even before that, clinicians had noted that unusual movement patterns like crawling asymmetrically or always reaching with one hand during early childhood were related to a variety of later developmental problems. These sensory and motor problems in the first year or two may indicate that children will later show the social interaction problems often associated with autism—even though the children when younger do not show unusual social interactions.

The sensory and motor forerunners of autism are not yet clearly understood, so they cannot be used for accurate  identification of “pre-autistic” babies. In addition, many young children who are thought to be autistic at age 2 show normal development later. Much as we might like to have early identification and early intervention, we don’t have it yet. But if identification and intervention are ever going to work, they will have to be focused on development that is really not typical—and it is quite typical for babies in the first weeks and even months to look at things other than faces a good deal of the time.  

Qigong Parent Training (Believe It or Don't)

Today I received an email from a professional group I have respected in the past. They invited me to attend a session about qigong training for parents. I am somewhat startled about this, especially because this group, like others of its kind, is supposed to be alert to the evidentiary foundations of methods they recommend. They need not restrict themselves entirely to evidence-based treatments, because there may be perfectly good treatments that have not yet been thoroughly researched, but they should not be suggesting methods that are neither research-based nor plausible. They apparently don’t know this.

Qigong is a method that the National Center for Complementary and Alternative Medicine classes as a “putative energy therapy”. This classification indicates that qigong is said by its proponents to involve a field of energy (qi) that fills the body and surrounds it, but this energy is not electricity, light, or heat, and is not measurable by any physical means. Qi is thought not only to surround and fill the body, but to flow dynamically along meridians or pathways that connect body parts. If qi movement is blocked, there is resulting pain or distress. Of course, the distress experienced by the individual is the only thing that indicates to proponents that there is blockage of qi, or indeed that there is qi at all, since it cannot be measured.

Like many other “energy” methods, qigong is claimed to be an ancient tradition handed down for centuries. Although the practice does use traditional Chinese philosophical systems and meridian charts, the anthropologist David Palmer, in his 2007 book, dated current qigong practices to 1949. The method was created by a Chinese political functionary as a body training technique combining breathing techniques, meditation, and gymnastics—with the traditional belief systems omitted. In the 1950s, qigong became popular in China as political objections to foreign influences developed and there was new encouragement of Chinese traditions.

In the 1970s, however, a new group of qigong masters began to claim that they could “externalize” their qi , focus it on patients, and cure them, even at a great distance. Followers began to experience trances, “holy rolling”, and speaking in tongues, much as charismatic Christians sometimes do. Participants no longer needed to achieve skills  in qigong themselves, but could depend on a master to heal them. The Chinese government began to find these activities embarrassing and tried to suppress them, leading to emigration of qigong masters to the West.

There have been some attempts to demonstrate systematic evidence for the effectiveness of qigong (for example, a 2010 study by Oh et al). Unfortunately, like studies of other unconventional treatments I have mentioned on this blog, the research on qigong failed to isolate the variable being tested. For example, in the Oh study of the effect of qigong on fatigue and mood of cancer patients, patients were randomized either to a group that met twice a week for 90-minute qigong sessions, or to a “usual care” group that did not meet. This means that any differences between the groups may be due to social contact, to expectations, to the relationship with the leader, to effects on their qi, or to all these factors or many others.

The existence of qi, an undetectable entity, is not plausible, and attempts to manipulate qi have not received the appropriate testing that might or might not establish an evidentiary foundation for the practice. So—does that mean that training parents in qigong is a bad idea? It’s true that doing qigong will probably not hurt anyone directly, so in that sense the practice is a harmless one, however implausible. However, there are a number of problems associated with encouraging parents to believe unlikely methods or explanations. One is that parents who are convinced that they know the secret way to health for their child may reject conventional medical help when it is badly needed (yes, I’m talking about Christian Scientists too).  Another problem is that parents caught up in unconventional treatments may be unduly influenced by practitioners whom they admire, and may be unable to realize that they have been drawn into a cult that can have ill effects both on their children and on themselves. To state just one further point: of course, no one expects either conventional or unconventional practitioners to give their services for free, and parents involved with unconventional and ineffective treatments may find at the last that they have no resources to use for effective treatments.      

Netflix and Misunderstandings About Suicide

The recent release of 13 Reasons Why on Netflix is worrisome to mental health professionals and to parents who need to talk to their older children about the realities of suicide. Please go to this link for a very helpful approach to this problem:

https://700childrens.nationwidechildrens.org/13-reasons-parents-concerned-netflix-series/

If you are concerned about the issue, you may also want to see https://www.suicideinfo.ca/resources/

Keep in mind that talking about suicide does not cause suicide, and if your children are watching the Netfliz series talking to them may be one of the best things you can do.