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In the last several months I’ve had several emails
from an outfit called Forbrain™. These emails give purely anecdotal evidence
for the use of some devices that are supposed to treat a variety of childhood
problems such as motor and balance difficulties, autism, sensory processing disorders,
and ADD/ADHD. As these problems probably have different causes and certainly
have different trajectories, it seems unlikely that one form of treatment can
help all of them, but who knows? I would not care to swear that it can’t,
without further evidence.
However, neither would I swear that it can help without further evidence. One
email I received stated that there were “scientific studies” supporting this
view, but when I clicked on the link I got a warning so I didn’t go any
further. The email described the case of a child named Josephine who was said
to have had her speech and general conduct much improved by use of Forbrain™
technology and even stopped having frequent tantrums. This is very nice,(although
obviously it can’t be checked, nor could we know whether Josephine would have
started doing better even without this treatment. Nothing here seems to be
providing the kind of information that consumers should demand before they
commit to a treatment for children.
Forbrain™ apparently involves the wearing of a headset
that provides conduction of sounds through bones into the inner ear, rather
than stimulation of the inner ear in the usual way by the passage of sound
waves through air in the auditory canal, followed by movement of the eardrum,
etc. The Forbrain™ device also filters some sounds and is said to allow
practice on the “audio-vocal loop". A second device advertised by the
Forbrain™ advocates is called Soundsory ®;
this one uses “specially designed music processed with neuro-acoustic
modifications as well as a series of movement-based exercises” and is intended
to “establish good foundations, from the fundamentals of sensory integration to
more complex cognitive functions”.
Listening to special music? Being exposed to certain kinds
of sound patterns? It’s all rather familiar—and the name Tomatis springs to
mind. Yes, an Internet search shows Tomatis therapy , Forbrain ™ and Soundsory®
on the same page. It would appear that there is no systematic evidence to
support any of these practices.
What should consumers ask for before they commit to
the trouble and expense of methods like these? Anecdotes are not good enough.
It may be that Josephine’s condition did improve—but would this necessarily be
true for any other child? Was Josephine’s improvement caused by Forbrain™?
Might it have happened anyway? Or could it even have been that she would have
improved more without Forbrain™? These questions can’t be answered by even the
most touching story, but touching stories are likely to make us forget to ask
the right questions.
For adequate demonstration that either Forbrain™ or
Soundsory® technology are useful for any of the problems mentioned earlier, we
need the following: A large group of children who share a problem that can be evaluated
and quantified. These children are to be divided into two groups (treatment and
comparison) with equivalent age ranges, gender proportions, and severity of
problems. Assignment to groups is done by staff who do not have information that
identifies individuals. Treatment is done by staff who do not know which group
each child belongs to. One [treatment] group is given the treatment recommended
by Forbrain™ advocates. The other [comparison] group receives a “sham” program—they
wear headsets for the same amounts of time as the treatment group but hear
different things. At the end of the treatment period, all children are
re-evaluated by staff members who do not know which group a child was in.
Finally, changes seen in the treatment children are compared to changes seen in
the comparison children. If the changes seen in the treatment children are
positive, and are statistically greater than those in the comparison group,
then advocates of Forbrain™ and Soundsory® can say that they have evidence that
their treatments are effective.
Until this happens, caveat emptor!
I hear from concerned people in the Netherlands that a
new issue about “parental alienation” (PA) has arisen. Not only are some divorced
parents accused of “alienating” children who do not want to have contact with
the other parent, even though many factors other than alienating behavior are
likely to be responsible for the children’s attitudes, and not only is notional
PA argued to be a reason for prohibiting contact between children and their
preferred parents. Now, in addition, it has been proposed that policemen can be
trained to identify PA cases!
Let’s examine this proposal under a strong light.
The first question we need to ask is a simple but
critical one: can anyone identify PA? Is there any established, evidence-based
protocol that can be used to differentiate PA cases from other cases in which
children’s refusal can be based on a range of causes, from domestic violence
and abuse to dislike of a step-parent or step-sibling to situations where
contact with one parent interferes with sports or friendships?
No, there is no such method. Identification of PA
cases is a subjective process based on the opinions of PA proponents. In no
case does such identification involve observation or even corollary evidence
for alienating behavior by preferred parents. In a few cases known to me, the
PA identification did not even consider whether a child had refused contact. In
one I can think of, a girl actually asked to have contact with her father and
he refused on the ground that she would accuse him of molesting her if he saw
her; he stated that he planned to send her to boarding school if he got
custody. In another case, a 17-year-old who had for years been alternating
weeks at her mother’s and father’s houses said she needed more stability and
wanted to have a “home” at her mother’s house while continuing to visit her
father, and this was alleged to be a PA case.
Interestingly, Richard Warshak, a long-term proponent
of PA and supporter of the Family Bridges treatment, has written of his
concerns about false positive identifications of PA and about the need to
discriminate between PA and other causes of contact refusal. He appears to recognize that children have been identified
as PA cases when in fact they were not. (Although Warshak did not express
concern about this point, the consequences of PA identification can include
custody change and prohibition of contact with the preferred parent as well as
court orders for that parent to pay extravagant fees for PA treatment. As PA
proponents also argue that PA is child abuse, such parents are in danger of
being affected personally and professionally when mistakenly identified as
abusers.) However, Warshak did not mention false negative cases in which PA was
not identified even though it was present. I assume that this means that he
feels all PA cases—and then some—are being identified, and that only one kind
of mistake is being made: the mistake that has the most obvious and serious bad
consequences for the child and the preferred parent.
So it seems that nobody can clearly identify PA in a
way that would allow others to confirm the identification. On the contrary,
people are concluding that PA is present when even its proponents admit that
this may not be correct. Among the undesirable consequences of this situation
are possibilities that a child’s custody may be given to a genuinely abusive
parent—and research has already indicated that this has happened.
Let’s get back to these policemen in the Netherlands.
Can they be trained to assess PA? Well, it’s possible that they could, IF
anyone else was able to make this assessment. As there is no one who can
identify PA validly and reliably, with some known proportion of false positives
and false negatives, it would appear that we have nobody to train the
policemen. You can’t teach what you don’t know.
One more point: when child custody evaluations are
done, they are supposed to include information from corollary sources. What do
neighbors, teachers, grandparents, family friends think about the parents and
children? Has domestic violence formed part of the background for the child’s
refusal? Gathering this kind of information takes time and expertise. No doubt
policemen could be trained to do this, but it hardly seems like their job. Of course,
PA proponents are not doing this kind of investigation either, even though it
should be part of their job.
Perhaps the conclusion here should be that policemen
are just as capable as PA proponents of identifying PA: in other words, not
particularly capable at all, and possibly not particularly interested in doing
the job as they should.
I have been neglecting this blog so badly, because a
lot of my time in the last six months has been taken up by writing and talking
about “parental alienation” (PA) and I don’t suppose anyone wants to read about
that every day. But a few days ago someone asked me a question about a non-PA
issue and I think it’s one that may be of interest to a number of people.
My correspondent is a lawyer who works with an
anti-child-abuse non-profit organization. She wrote to me to ask if I could
recommend a psychologist who could diagnose a type of factitious disorder or “Munchausen’s
by proxy”. These terms are used to describe cases in which an adult, usually a
parent and often the mother, asks for medical treatment for her child but
secretly does things that would cause the child to seem to need treatment. For
example, the adult might substitute something else for the child’s urine for a
urinalysis, or more seriously-- and this
has been videorecorded—partially suffocate the child and then call for help
because the child has stopped breathing. These cases are obviously to be taken very
seriously. What if the child actually is sick but no treatment is provided
because it’s mistakenly thought that the parent is causing the symptoms? What
if the parent is causing the symptoms, this is not recognized, and the child
dies because of the parent’s actions? It’s no wonder that there is much concern
when such a situation is suspected.
Here is the
story my lawyer-correspondent gave me. (Readers with infant mental health
background will quickly see why I am bringing this up.) A woman of 40, who had
a 5-year-old child, began to make frequent emergency room visits when her
second child was about 2 months old. When I say frequent: she took the baby in
on 27 of 30 possible days. No medical problems were detected. A neighbor
reported that she had come into the house to find the baby turning blue and had
restored the airway; as far as I know, she did not see the mother causing this
Medical personnel were worried about this situation
and suspected factitious disorder. They moved to have the baby placed in foster
care and the mother has for at least a month had only supervised visitation. A
forensic psychologist, who may or may not have any infant mental health
training is to evaluate the mother. My lawyer-correspondent was concerned about
the extent of the evaluation, and that was why she asked me to recommend an
My response was that everyone was ignoring the most
obvious explanation of the mother’s behavior: a perinatal mood disorder (PMD). PMD, sometimes called post-partum depression,
is a state of anxiety and depression that sometimes occurs during pregnancy
and/or after childbirth. Mothers with PMD may feel incapable of caring for the
children and sometimes focus on the idea that there is something terribly wrong
with a baby. By far the largest number of comments and queries I have had on
this blog have come from mothers who were tortured by their beliefs that their babies were
somehow damaged; many of the mothers were convinced that a baby of a few weeks
of age might be autistic. When I answered these queries I usually recommended
that the mothers see their ob-gyns for PMD evaluation and receive the treatment
they needed, because the problem was in their own conditions, not in the babies.
Many of them subsequently wrote and said that they had done this and had been
helped a great deal.
PMDs have been known for quite a long time to be
identifiable and treatable. They are no one’s fault and although the mothers
often blame themselves, the rest of us should not blame or punish them. About
15 years ago, several states had innovative programs to educate people about
PMD. New Jersey, for example, had a program called “Speak Up When You’re Down”
that was sponsored very effectively by the wife of the then-governor. (I was at
that time part of the train-the-trainer program for that program.) Regrettably,
political forces cancelled funding for these programs and it appears that we
are back where we started on this issue.
Ob-gyn offices should be making regular use of a
screening instrument for PMD, the Edinburgh Depression Scale. This is quick and
easy to use and identifies women who may benefit from treatment for PMD. In
addition, I would argue that its use with every new mother benefits everyone,
not just those with mood problems, as it reminds everyone of the potential for
PMD in themselves and others. This is especially important as PMD symptoms may
not occur until later in the first year after childbirth, and women who were
screened early may realize later that new symptoms they experience are related
to what they were asked on the screening instrument. In the case brought up by
my lawyer-correspondent, the mother had apparently not been assessed for PMD,
and candidly I remain unsure whether this is happening at this point, although
I suggested some possible resources in addition to her ob-gyn.
I want to take a moment to talk about the experience
of the mother in this case. I’m basing my comments on the assumption that PMD
is at work here—I do not have enough details to know this, of course. The
mother’s anxiety about her baby, expressed by multiple ER visits, has not been
understood as an expression of her disordered mood, but instead has been
interpreted as highly abnormal maternal behavior that is a danger to the baby.
The obvious solution from that viewpoint is to put the baby in foster care. But
what if the mother’s behavior is symptomatic of PMD and is thus both
identifiable and treatable, but neither identified nor treated? In that case, the mother’s experience is of
validation of her abnormal mood. Yes, we say to her, you are right to be
anxious and depressed and feel that something is wrong, and we are taking your
baby away because something is so wrong with you that you cannot be helped.
The mother now sees the baby only under supervision,
and it is no longer “her baby”. The constant tiny maturational changes of the
early months go by between visits without the mother having any chance to learn
from them, and the baby at each visit is a somewhat different person than the mother
saw the last time. Her behavior toward the baby is bound to be out of synch for
exactly that reason, so she will be observed on each visit to be awkward and
uncertain with the baby and not to behave like a “normal mother”. This kind of
experience adds to her sense of anxiety and sadness, which apparently is not
being treated by appropriate medication and talk therapy. Who will step in to
help this family? When will anyone do anything to support the mother in her
fight with PMD and to facilitate her relationship with her baby? Or is the
solution seen to be indefinite foster care, even termination of parental
N.B. I should point out that there is a severe form of
perinatal mood disorder, sometimes called post-partum psychosis, and some
readers will recall the tragic case of Andrea Yates, who killed all her
children after repeated post-partum problems that were ignored by the children’s
father. But these horrible cases are very unusual, and most cases of PMD, when
identified, can be treated quite