Wednesday, April 18, 2018
There’s a lot of discussion right now about whether psychological interventions are or are not evidence-based (or empirically-supported) treatments. Even when there is strong evidence that a treatment is efficacious—causes good outcomes under ideal circumstances—there are further demands for evidence that it is effective and causes good outcomes in the less-than-ideal settings of the real world.
The strongest evidence in either case depends on research that has used randomized controlled trials. RCTs (not to be confused with residential treatment centers!) are studies in which people who have received the treatment being tested are compared to a control group of people who have not received it (and may have had no treatment, or had a well-established different treatment, or have been placed on a wait-list for the treatment being tested). Because this kind of research is randomized, prospective patients do not get to choose which group they want to be in, but are assigned to one or the other in some objective way like the flip of a coin or the use of a list of random numbers. The point here is to eliminate the bias that might be present if people got to choose the treatment they want—just believing that something will be good for them, or expecting that a treatment will be effective, can be enough to change people’s moods and behavior. (If we’re talking about treatments for children and adolescents, parents may be affected by their expectations about a treatment so that they behave differently toward their children if they think they are getting that treatment, or see their children’s behavior differently if they think the children are getting a good treatment, or, of course, both of these things.)
Having a control or comparison group as part of the research design adds to what is called the internal validity of the study. Internal validity is also influenced by factors like having a blinded evaluation, or assessment of children by people who do not know them or know what treatment they have been receiving or will receive. When parents, who know both of these things to some extent (even if not told their children’s treatment, they may figure it out from things the child tells them), are involved in evaluation of the children’s response to treatment, other biases can creep in; parents are the ones to say whether they liked a treatment, but can not say objectively whether it helped their children. A number of alternative therapies, like Love & Logic training for parents, make the mistake of asking parents whether their children have improved and then acting as if it is known what changes have really occurred in the children.
Many studies that claim to give evidence supporting unconventional, alternative therapies are more than one step below RCTs. They look very simply at measures (often parent opinions) taken before and after treatment. Does this seem like a good idea? Well, only if you think that children and adolescents do not change unless they are made to change by an intervention!
I recently had pointed out to me the statement by a guardian ad litem that changes she heard about in a girl between ages 11 and 13 could only have been caused by a PA treatment method the girl had experienced. It would appear that the GAL thought that nothing happened in those two years other than the treatment and separation from the preferred parent. But in fact much had happened.
A small amount of the change reported was no doubt due to adjustment over a couple of post-divorce years, during which one parent had remarried. A much larger factor, causing changes of all kinds, physical and mental, was the occurrence of puberty for this girl—just under 13years being the average age of menarche (first menstruation) in the Western world today. Puberty in both sexes is associated with dramatic social and cognitive changes and the redirection of “attachment” and positive social attitudes toward peers and away from parents. Height and weight increase, breasts develop, hair and skin change, all producing a mixture of delighted and anxious feelings about the self, and further reducing (though not eliminating) the adolescent’s concern about relationships with parents.
Maturation, the series of developmental changes that is largely governed by genetic programs, is rapid and intense during this period when “nothing happened” except the PA intervention. Without good research design that takes maturation into account, studies of PA or other interventions for children and adolescents are wrong if they claim they show the influence of their intervention. Because children and adolescents are always changing—most rapidly around puberty, beginning about age 9 in girls—every study of a psychological treatment for them needs to have a control group, similar to the treated group but nor receiving the treatment, whose characteristics will show us the natural maturational changes that occur during an age period. The effect of the PA or other intervention is shown (roughly speaking) by subtracting:
Changes following intervention (maturation + intervention) - Changes with maturation alone =
Changes attributable to intervention
There would be many other technical details to be considered in designing a good study of PA or other interventions, but the two mentioned here, blind evaluation and a control for maturational change, are absolutely critical.
Thursday, April 12, 2018
The idea of “parental alienation” has been around for some decades—starting with Wilhelm Reich, the orgone man—but in recent years it has been adopted by lawyers and some judges as a way to get child custody transferred from one divorced or separated parent to the other. “Parental alienation” is a concept applied to situations where a child refuses or resists contact with one parent and where the child can give no reasons for this position or gives reasons that are deemed unacceptable by adult authorities. (Physical abuse is considered an adequate reason for avoidance of a parent, but practically the only one.) In these cases, proponents of the “parental alienation” (PA) idea argue that the child’s resistance or refusal is occurring only because the preferred parent has manipulated the child’s thoughts and emotions so that he or she dislikes or fears the non-preferred parent. In this scenario, the preferred parent is referred to as the “alienator” and the non-preferred parent as the “targeted parent”. The child’s mental condition is referred to by PA proponents as “parental alienation syndrome” or “disorder” (PAS or PAD), and this condition is said to involve “splitting” and black-and-white thinking in the present and to predict the development of a personality disorder like narcissism. Actions that bring about mental illness in an individual are considered abusive to that individual, so part of the PA argument is that the preferred parent is abusive and the child must for his or her own sake be removed from that abusive person’s custody. As I noted a few weeks ago on this blog, some PA proponents also argue that for a court to pay attention to a child’s preferences would have malignant effects on the child’s psychological development.
The solution offered by PA proponents for this notional syndrome or disorder is that a child who resists or refuses contact with one parent must be removed from his or her present living situation and placed in the custody of the non-preferred parent. In addition, the child needs to be treated in one or another of several similar residential programs that may last from 4 to 90 days, during which contact with the preferred parent is prohibited or used as a reward for affectionate behavior toward the non-preferred parent. (These programs are to be paid for by the preferred parent and court orders include this proviso.) The programs are referred to as “psychoeducational” and consist of videos and discussions, mixed, apparently, with threats to send the child to a wilderness camp or residential treatment center where they will not be able to communicate with anyone outside.
Obviously, there really are children of divorce (or even of intact families) who avoid one parent and who cannot explain to the satisfaction of adults why they do this. It’s not unimaginable that the PA scenario of influence actually takes place in some of these cases. But the declaration that there is a related psychological syndrome or disorder, and particularly that such a syndrome is the forerunner of serious personality disorders, is a claim that requires empirical support. Such support has not been presented, and that is why the American Psychiatric Association did not include such a diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
The claim that PA-related residential programs, psychoeducational or otherwise, can repair disturbed parent-child relationships/incipient personality disorders—and do this so effectively that courts should order such treatment to be used against the will of older children and adolescents who would normally be allowed to decide to consent to treatment—also requires empirical support. No amount of speculation in terms of well- or ill-chosen theory can tell us whether a treatment will be effective, and in fact attempts to claim that analogies provide evidence is characteristic of pseudoscience.
None of these points has impressed proponents of PA, and they have been experiencing a good deal of success in influencing high-conflict custody cases and enrolling children in their residential treatment programs. Some attorneys have been eager to run with the PA argument, and some judges have accepted it with little question. But an event and an observation this week seem to suggest that the PA concept as presented by some of its proponents may be on the way out.
The event is one with a history that needs explanation. In June, 2017, the PA proponents Craig Childress and Dorcy Pruter (a psychologist and a “life coach” respectively) gave a presentation on their views at a conference of the Association of Family and Conciliation Courts (AFCC). Psychologists who attended this presentation received professional continuing education credits (needed for maintaining licensure), as AFCC is an approved provider of continuing education for the American Psychological Association. Although the conference brochure carried a disclaimer to the effect that including a presentation did not mean approval of its content, to my knowledge at least one attendee came back to his practice full of enthusiasm, declared to a client that the APA CE credit meant that APA approved of the treatment described in the presentation, and attempted to persuade the client to send her child to California for the Childress program.
Complaints about the Childress-Pruter presentation led the APA continuing education committee to announce this week an agreement with AFCC that Childress and Pruter may never again make this kind of presentation at AFCC. AFCC also agreed to provide an alternative webinar by Michael Saini on evidence-based views of child resistance and refusal and have posted this at www.afccnet.org. Given that according to Childress’ blog he is planning a sort of “March on Washington” where he and his followers will deliver a petition to APA and will videotape its reception, this AFCC-APA agreement may appear as a considerable blow. No doubt the rejection of Childress’ PA claims by APA will only strengthen the cult-like belief of his followers, but the APA decision will prove a powerful argument in many cases where parents are under attack as “alienators”.
The observation I referred to earlier has to do with the CV of a PA proponent (not Childress this time, although his has a sticky problem in the omission of some years of activity). In connection with a current PA suit, I saw the CV of Demetrios Lorandos. Lorandos has been a powerful advocate for the PA position, bringing to the argument both a law degree and a doctorate in psychology. But wait… that doctorate seems to be rather open to question. It came from the Union Institute in 1978. The Union Institute is pretty problematic in itself, having been the alma matter of a number of alternative psychotherapists like Gregory Keck of holding therapy fame. Students there have written dissertations on the topics they chose, and then decided what discipline (e.g. psychology or criminology) they wanted their degrees in. (An Internet search will show you why I say this about what is not quite a diploma mill but more a “wannabe university”.) But on top of those problems, Lorandos’ degree in 1978 predated by seven years the accreditation of Union in 1985. In other words, he does not have a doctorate from an accredited university and therefore should not call himself “Doctor”. (See, for comparison, https://www.insidehighered.com/news/2011/10/12/top_two_leaders_at_community_college_earned_doctoral_degrees_from_diploma_mills.) He may, of course, call himself a psychologist, as he is licensed in that field because of a master’s degree from the New School for Social Research. How is it that no one has noticed before that Lorandos’ CV shows that he does not have a doctorate from an accredited institution? Well, not everybody spends their time looking at fraud and deception in psychology the way I do.
Am I arguing that Lorandos’ lack of a genuine doctoral degree means that he can have nothing useful to say? No, of course not. There are plenty of expert witnesses who have excellent backgrounds outside academia. But when someone presents himself repeatedly as having a doctorate, and fools people who are not familiar with the Union Institute story, I must question his integrity as well as his training in assessment of research.
Between the Childress and the Lorandos events, I think we may be able to look forward to a day when attorneys and judges will be able to recognize the weaknesses of the PA concept and of the treatments proposed by PA advocates.
Tuesday, April 10, 2018
A colleague passed on to me a letter from a person with a MSN degree who is involved with community mental health issues for children. The writer expressed her profound concerns with the program Love & Logic ®, developed and promulgated by Foster Cline, an early advocate of Attachment Therapy/Holding Therapy, and a pediatrician of problematic licensure who declared some years ago that “all bonding is trauma bonding”. No doubt aided by its brilliantly alliterative name, Love & Logic ® has become a great commercial success, earning much public money as school systems buy into this method of group training for parents and teachers, even though it is clear that the program is not an evidence-based treatment.
The author of the letter I mentioned has had years of contact with Love & Logic ®, beginning with a personal experience involving a child she advocated for, and continuing with discussions with people committed to the method, and awareness of increasing advertising. She checked the level of research evidence for Love & Logic ® with the California Evidence-based Clearinghouse for Child Welfare (www.cebc4cw.org ). CEBC, which is well-known for its descriptions and ratings of treatments for children, lists Love & Logic ® but notes that the program cannot be rated because there is no adequate research evidence for its effectiveness. CEBC lists a 2005 article that reported that parents liked the Love & Logic ® program but did not touch on its effectiveness as a behavioral treatment for children. CEBC notes that there are no standards that trainers for Love & Logic have to meet other than attendance at training workshops (and it is my understanding that there is no follow-up from the organization to insure that trainers are teaching the program correctly).
Love & Logic ® is not listed by the National Registry of Evidence-Based Programs and Practices (run, at least until recently, by SAMHSA) or by www.effectivechildtherapy.org, a service of the Society for Clinical Child and Adolescent Psychology. I should also point out that in the opinion of some psychologists, the trademark for Love & Logic ® should prevent its ever being listed as an evidence-based treatment, because commercial considerations mean that evidence may be kept secret rather than being presented transparently as is required by scientific investigations.
I wrote in more detail about Love & Logic ® several years ago (https://childmyths.blogspot.com/2014/06/having-a-look-at-love-and-logic.html ) so I won’t go into more detail about the program. Instead, let me turn to the issue of dissuading school systems from engaging in the selling of this and similar “trainings”.
The argument against Love & Logic ® hinges on the concept of evidence-based treatment. Unfortunately, American public education is coming very late to the idea that evidence-based programs are preferable, and indeed the greater number of educators and school administrators have little training or interest in understanding how safe and effective treatment programs can be identified. A recent wave among psychologists of opposition to the privileging of evidence-based treatments will no doubt be welcomed by many educators.
How, then, to argue against treatments that are unsupported by acceptable research evidence? Surely the key to this argument is to approach the organizations that fund school systems’ activities. State and local governments may also be indifferent to research results in general, but they do not like to spend money, and they do like to get what they pay for. Being revealed as wasters of public funds is a good way not to get re-elected. School officials themselves do not allocate funding-- they simply ask for funds to be spent, so they are not likely to suffer public disapproval for choosing a non-evidence-based program. Neither are they elected and subjected to public scrutiny and possible loss of their positions.
A major point of the movement toward evidence-based treatment is that scarce resources are conserved when programs are chosen on the basis of high levels of evidence of their safety and effectiveness. Are state and local officials prepared to justify expenditures that are based on unsupported commercial claims rather than on evidence of effectiveness? It’s hard to imagine that they could get away for long with giving a school lunch contract to a company whose service did not live up to the standards required in the contract. A heating company that kept schools at 45 degrees F. all winter would not be hired again. It’s a lot harder to decide whether parent and teacher training programs have been effective, so there will probably be few complaints from the recipients—but community members who publicly bring up the lack of existing evidence for a program may well have a political impact on the actions of elected officials.
In addition to suggesting that state and local officials receive public criticism for funding non-evidence-based programs like Love & Logic ®, I’d like to point out that teachers’ unions are a powerful force and indeed are organizing for greater effectiveness just now. Union organizers may be receptive to the argument that ineffective training programs are being funded while money is not made available for a variety of educational necessities, even textbooks in some cities. Union members may be pleased with parent or teacher training that can make their work more successful, but why should they stand by to see needed funds expended without results? Speaking up on this kind of issue can be a way for teachers’ organizations to work against the increasing deprofessionalization of their jobs and to make clear that collective bargaining can work toward goals other than salary and benefits increases, important as those are.
A point to be brought up when arguing against programs like Love & Logic ® is that the choice is not between these programs and nothing. There are effective programs to help parents and teachers work with children who are at risk for a range of developmental problems, and especially with children who are aggressive, oppositional, and noncompliant. One such program, with many years of evidentiary support behind it, is Parent Child Interaction Therapy (PCIT), which focuses on children of preschool and early school age and works to correct behavior problems before they interfere with school achievement. PCIT uses play but is not a “play therapy” and does not depend on children’s insight or private thoughts. Instead, its stress is on improving relationships between children and adults and training adults to help children comply with adult rules without having to use harsh or constant discipline.
Evidence-based programs like PCIT provide a lot of “bang for the buck”. Money spent for them is not wasted, and authorities who approve this kind of spending can be proud of their fiscal responsibility. Non-evidence-based programs like Love & Logic ® waste money that is much needed for other educational purposes. Now that programs like Love & Logic® have co-opted the public school system for their own commercial advantage, it’s important for concerned people to persuade state and local governments and teachers’ organizations to re-think past decisions and stop this present and future waste of public funds.
Thursday, April 5, 2018
There’s a great deal of discussion nowadays about adverse childhood experiences (ACEs), as defined by a study in the late ‘90s which interviewed thousands of adults and reported associations between their adult physical and mental health and their early experiences of events like abusive treatment or family conflict (see www.cdc.gov/violenceprevention/acestudy/index.html for much more explanation). Many people have experienced one or two ACEs during their childhood years, but the study reported a positive correlation between having large numbers of ACEs in one’s history and having illness or premature death in adulthood. The ACE study positioned adverse childhood experiences as important factors for public health, and prevention of those experiences as a way to improve adult health in the future.
The adverse childhood experiences studied were not on the whole events that would directly affect health—that is, most of them did not involve physical injury to the child or even failure to provide medical care when needed. The ACE events could be, but most often were not, actual traumas, catastrophic situations in which death or serious injury were feared. The association with later health problems was surprising for those reasons, and it has been argued that the ACEs studied may be proxy measures for other unmeasured events that are the actual cause of later health problems. For example, one of the original questions had to do with whether a person had in childhood or adolescence been sexually approached by someone 5 or more years older. Such an experience might or might not be disturbing—in fact, it might be flattering and pleasurable for a 14-year-old girl to be in a sexual relationship with an admired young man of 20—but the existence of such a sexual experience might indicate parental neglect and lack of supervision, which in turn could be the actual cause of various psychological and physical health effects.
The ACE questionnaire was intended as a “quick and dirty” measure of childhood experiences as recalled and reported by adults. Retrospective studies of this kind are sometimes the best that can be managed, but they are subject to all kinds of obvious problems; people may not remember what happened, or may remember something that did not happen, or may conceal an event out of embarrassment, or may invent some shocking story to impress the interviewer. Without some way to validate the reports, it seems much more accurate to say that the people’s reports of childhood experiences are correlated with their adult health, rather than to say that the experiences themselves are correlated with health.
It’s certainly possible at this point to criticize the ACE study because it did not achieve goals that were never part of the study plan. The study did not try to identify which ACEs had the biggest effect, or whether one of the experiences had the same effect as another. It did not look at interactions between the individual’s developmental age at the time of the experience and the experience itself—for example, a sexual experience with a person at least 5 years older would presumably have a different effect when the pair involved a 7-year-old and a 2-year-old, than when the pair were the 14-year-old and the 20-year-old mentioned earlier. It will be important someday to know about these issues, of course, but we can’t demand this information of research that considered only the number of adverse events experienced in childhood and adolescence, and how that number went statistically with physical and mental health disorders in adulthood.
Information about ACEs has been helpful in that it has directed much attention to preventable adverse events experienced by children. This has been persuasive because authorities and funding agencies can be convinced to invest in resources for families when they see a benefit to public health and its associated costs , but are less likely to do so simply because children are miserable and failing in school or bound for the school-to-prison pipeline. This is a bit like the attention paid to mental illness when it is called a “brain disorder” (which of course it is, in a sense, but hardly the same as a seizure disorder), but not when it is regarded as an unhappy state that the patient could rise above if he or she had some gumption.
But while helpful, ACEs scores can be scary too, when they are misused. It’s important to keep in mind that although an individual child’s high ACEs score is a good reminder to us that help is needed for the family, that score is not a predictor for that child’s life. ACEs scores help us predict events for populations—large numbers of people—but not for individuals. Individuals may display greater or less resilience or vulnerability to adverse events, may experience the events at different ages, and may or may not have sources of support and buffering that protect them from poor physical and mental health consequences. For adults, by the way, a high ACEs score can be frightening when we think about it, but it’s important to realize that many other factors influence health, and some of those are under our control.
A recent discussion on a psychology list revealed that a potentially harmful forensic use of the ACE score seems to be coming into play in legal arguments and decisions. Sentencing often takes into account the probability that a person will repeat a crime in the future, and some are arguing that criminals with high ACE scores are likely to be mentally ill and therefore to have a high probability of re-offending, so they should have lengthy sentences. This is a particularly bad example of trying to use the score to predict an individual’s behavior when the original work had to do with what happened to a population.