This is a little over an hour long:
Monday, June 22, 2020
ADHD, FDA, and Video Games
Recently the Food and Drug Administration approved a video game that is purported to be helpful as a treatment for attention deficit hyperactivity disorder (ADHD). Parents and teachers are often concerned about kids whose behavior indicates ADHD, as their inattentiveness and high activity level combine to cause problems for their learning at school and at home, and serves as distractions to their teachers and parents as well as to other kids. The adults are bound to find attractive the idea that having the children play a video game can help improve their focus and self-control.
I’m not going to state the manufacturer or name of the specific game that was approved by the FDA. It doesn’t really matter, and I’m not in the business of telling people what to buy or not to buy. What is important is that people always need to find out certain things before they decide to put their resources into a treatment.
An important question is, who paid for the research? Obviously, research funding can come from neutral, objective sources who have no reason to want one outcome or another. But it can also come from highly interested parties—and in this case that’s what happened. The manufacturer paid for the research and got the outcome they wanted. When we say that a treatment is evidence-based, however, we ask for two independent researchers both to show the beneficial effects of the treatment. If someone unconnected with the manufacturer got the same results as the people funded by the manufacturer, that would be something to encourage us to use the treatment.
A second important question is, what does the outcome have to do with the original problem? Lots of treatments have effects, and it can be seen that they make a difference of some kind. The question is whether the difference they make is relevant to the problem everyone was worried about. In this case, that has not happened. The kids played one video game and their attentiveness was measured. Then they played another game 100 times, went back to the first one, and their attentiveness had improved—voila, a desirable outcome. However, none of the ratings by their parents, of attentiveness and so on, were improved. If the wish had been to create a treatment that would help the kids play video games better, this one would be good, but of course that was not the point of treating ADHD.
Just because we (in general) always hope for a pill or a potion to “fix” problems of development and behavior, rather than to have to do any difficult work, there will always be offerings of this kind. I mentioned one a while ago: “Forbrain” , which according to its website “energizes” the brain when you speak using a bone conduction headset. How you know whether your brain has or has not been energized is not mentioned. That’s typical of devices offered to treat autism, speech and hearing problems, and attention difficulties—even some that seem highly plausible and were created by very knowledgeable people.
The difference between the ADHD video game and the others is that in the ADHD case the FDA has approved, suggesting that the game has been found both safe for use and effective. That last part is questionable, as I have pointed out. And this is a prescription game, sounding very impressive and encouraging parents and teachers to see it as worth a try, whatever it costs.
It all amounts to caveat emptor. Ask the right questions!
Wednesday, June 17, 2020
The "American Psychological Association Review"
A colleague recently called my attention to the website https://americanpsychologicalass.com/. This is one of many Internet sites that argue in highly personal terms against “parental alienation” and claim that a former spouse and a judge have interfered with the author’s relationship with his [usually] children. Kenneth Gottfried was told he could not have contact with his children following a psychological evaluation. The two teenage girls had stated that they did not want to see him, a situation that Gottfried attributed to “alienation” on the part of the girls’ mother.
This is a sad and all too common situation, and I would say nothing about it except for the fact that the unfortunate Gottfried has become a megaphone for spreading the questionable views of the “parental alienation” advocate Craig Childress. I think I am right in assuming that Gottfried has not spent his time studying the various aspects of psychology he mentions, but that he has picked up his claims from Childress, either directly or via Internet.
The thrust of Gottfried’s statement is that the American Psychological Association is responsible for “countless” deaths associated with judges’ decisions not to give custody of children to one of their parents. The deaths he refers to are said to include a case of what he apparently means to call “self-immolation”. Gottfried claims that he has personally witnessed 30 deaths of separated parents in the last 4 years, but does not provide any evidence for this statement. He also appears to think that such deaths would not occur if APA were to recognize “parental alienation”; he does not say how such recognition would affect courts or parents. It may be that Gottfried confuses the American Psychological Association with the American Psychiatric Association, both confusingly referred to as APA. The latter is responsible for DSM, the Diagnostic and Statistical Manual of Mental Disorders, and in preparation of the 2013 edition declined to include “parental alienation” as a diagnosis. No actions by the American Psychological Association would determine inclusion of a disorder in DSM.
Gottfried uses a letter written by APA to argue that the organization knows it is contributing to causing deaths. The letter, however, is on the subject of separation of immigrant children from their parents, and refers to suicides in that group. Although abuse of analogies is common in arguments about “parental alienation”, to conflate families where children avoid one parent with parents and children involuntarily separated (and poorly treated) is surely the achievement of a new rhetorical low.
I am a member of APA (the psychology one) but hold no particular brief for the organization and would like to see quite a few changes in it. However, although I see no way APA can or should make the moves Gottfried proposes, I think I can guess why he thinks what he does. His positions stem from those of Craig Childress. It’s my opinion that these Gottfired charges against APA stem from the events two years ago when Childress and some of his adherents delivered a petition to the APA headquarters in Washington, DC. Childress had made excited announcements on the Internet about how they were going to do this and what APA might do in response. I wasn’t present at the delivery, but what I have gathered is that someone in the office took the petition and said “thank you” and the Childress group then left. That was, not surprisingly, the end of that. But Childress has been muttering about this for two years. He has also been muttering about the events involving his presentation at a conference of the Association of Family and Conciliation Courts group, which culminated in having APA cancel the continuing professional education units that had been planned for presentation attendees. This led to even more fulmination against APA, and more recently against AFCC, with some special personal remarks about the AFCC head Matthew Sullivan.
What do I see on americanpsychologicalass that makes me so sure that Childress is behind this? For one thing, there is the very fact that Childress is referred to. He is barely mentioned in the literature about “parental alienation”, although Jennifer Harman (not Harmon, that’s someone else) in 2018 said she thought there should be some empirical research into his ideas. Gottfried did not come across Childress by picking up a professional journal article, but by seeing and being drawn into Childress’s and his followers’ large and noisy Internet presence.
I also see Childress in a number of references made by Gottfried. Anyone who has read Childress’s self-published work will recognize the tireless repetition of certain names: Bowlby, Bowen, Minuchin, Madanes--- and then more recently, van der Kolk and Tronick. The connection of specific ideas to Childress’s work is not elaborated anywhere, and connections are made by jumping rather than step by step. For example, citing Bowlby’s discussion of attachment, Childress arrives quickly at the conclusion that a child who avoids one parent has had his or her attachment system suppressed.
There’s more Childress in this site, but I’ll just point to the lengthy and meaningless discussion of APA ethics guidelines by Gottfried. Childress rather specializes in describing how unethical other professionals are, especially with respect to the use of the best science. Those who disagree on various points with the “parental alienation” approach are said to be outside the boundaries of their competence and therefore in violation of ethical guidelines.
It would be easy to look at americanpsychologicalass and conclude that it was the work of an individual angry and frustrated man, and of course it is. But there is more to it than that. On that site we see an amplification of the views of a psychologist whose claims about parents and children are recognized as concerning by many professionals but few laypeople. These views are potentially harmful to children and families because they encourage courts to order unnecessary separations and ineffective treatments. Please, readers, if you find yourselves confronted with the Gottfried site or anything like it, understand that there is more here than fury and goofy ideas. These arguments have the power to do harm and need to be countered.
Attachment and "Parental Alienation"
When thinking about parental alienation (PA) issues in the United States, I usually think it makes sense to consider a child age range of about 9-17 years. It’s rare in the U.S. to have a child less than 9 who is claimed to show PA when he or she avoids one parent. This narrow age range is one in which issues about attachment—if any—are much different from those we see in infants and toddlers. Some PA advocates, like Craig Childress, propose that when a child avoids a parent this means that something has damaged her attachment to that parent, or even “suppressed” her whole attachment system [don’t ask me, I’m just reporting the news here], but this is hardly likely for 9-17-year-olds, whose social focus is less and less on their parents and more and more on their peers.
However, it does seem that in some cases PA concepts are applied to much younger children. My first introduction to PA occurred when I was contacted by the grandmother of two preschoolers who had been taken from the mother on the grounds that she had caused their avoidance of their father. Those children were certainly at ages when attachment to a familiar caregiver is the focus of a child’s life and when abrupt, long-term separation from that person causes deep distress, grief, and lethargy that may last for months.
Some European colleagues are also telling me that they see PA allegations in situations where toddlers and preschoolers are concerned. They express concern over the impacts on young children of being forcibly removed from a familiar parent and placed in the custody of one whom they essentially do not know (their biological relationship being of little import here). Others have argued, to the contrary, that one parent may prevent the child from having contact with the other on the grounds that their attachment will be harmed if that happens.
I want to comment on these highly fraught situations where parents are in enormous conflict over the custody or parenting of a preschool or younger child. First, though, I want to say that I am going to talk only about the role of attachment in parenting decisions when all else is equal. I mean: this is not about situations where there has been domestic violence, or physical or psychological child abuse, or child sexual abuse. Those all create their own unique dangers. I am going to talk only about situations where one parent wants more contact with the child , the child seems reluctant, and the other parent is resisting the change in contact-- but nothing else is wrong.
Point 1: How the child acts, and how parents can handle this, depends largely on how old the child is.
A baby under 6 months of age is usually quite ready to socialize with whoever comes along and has not yet formed an emotional attachment to any individual. The young baby may object if handled clumsily by someone, or if someone fails to pick up on cues about what the baby needs, but this is not about attachment or about fear. However, even at 4 months or so, the baby may be quite distressed if someone stares blankly at her and does not change expression or move in response to the baby’s social signals.
After 6 months, but usually before 12 months, babies begin to form emotional attachments to people whom they see frequently and who behave toward them in sensitive and responsive ways. They often indicate that this developmental change is occurring by showing fear of strange things and even by being startled and frightened by some things that have happened before (noisy garbage trucks, jumping dogs). They try to stay near familiar people and avoid strangers—often, they will not look at a friendly stranger who approaches them, and will even cry if the person keeps looking at them. If left in a strange place without a familiar person, they cry and will not look around with interest or try to explore, even though they will explore the same place if a familiar person is there.
Babies of 10 or 12 months and toddlers also show a behavior called “social referencing”. If they meet a new person or a new kind of object, they look at the face of a nearby familiar person. If that person looks frightened and seems to be looking at the new person or object , the baby backs off and will not approach the unfamiliar thing. If the familiar person smiles and looks relaxed, the baby goes ahead to explore the new person or object.
As toddlers get to be two or three years old, and as they learn to understand and use language, they can cope much better with unfamiliar situations. They may go to child care or preschool, encounter new babysitters, and develop better social skills. If they are tired or hungry or sick, however, they still seek familiar people and reject everyone else. (Of course, when sufficiently cross they may reject a familiar person too!) If they cannot find the familiar person, or if their separation goes on for a long time (weeks), they may show serious distress and take many weeks to recover; even if reunited with the familiar person become clingy and anxious.
Some children are much more intense in their negative reactions than others. They have temperamental differences that are biologically determined. A child who takes a long time to adapt to child care or who is predictably seriously frightened of clowns or masks or large groups of people is also likely to show more intense reactions than others to separation or to strange people and places.
Point 2: Can knowing about attachment behavior help people?
Yes, knowing these things helps parents know how to handle the distress of young children as they visit a parent they do not live with—if the parents give it some thought. The awareness that such distress is natural may (I hope) prevent suspicions or allegations that one parent is causing the child to hate or fear the other. Let’s look at possible things to do for different ages.
For the youngest babies, under 6 months, if the baby is getting distressed about clumsiness or a withdrawn expression, the solution is for the adult to learn to behave differently. More contact and more daily care will help the adult learn to engage the baby in care routines to the satisfaction of both. “Staring” or looking withdrawn is a different problem. Some adults can do better if they know they are looking a certain way, but others may be depressed, anxious, or distracted, and those things are harder to handle. It will be helpful to everyone to know that the baby is responding to the facial expression and not to the individual, however.
For older babies and toddlers, there are a lot of issues that may need work by the adults. If one parent is actually frightened of the other, a toddler doing social referencing may quickly catch on to this and also be frightened, even though the frightened person has no wish for this to happen. An older baby or toddler may also be frightened and resist a parent who is not often present and may become distraught when approached—and even more so if taken away from home. These are normal behaviors of typically developing children and are not taught or caused by one of the parents. There can be improvement if both parents behave calmly and give the child plenty of time to warm up; there can also be worsening if people are hasty, argue, or are demanding or rough. Toddlers are most comfortable in familiar places, so if it is possible for the child to stay at home and the parents to switch places for a time, the child will be more comfortable and will more quickly come to accept both parents as familiar attachment figures.
Times of transition, including bed time, are always the most difficult for toddlers and preschoolers to handle, even if there is no family separation or conflict going on. In perfectly happy families, young children may respond to a transition by pushing away one parent and saying they want the other; the next day they may reverse who they want. It’s the transition that’s the problem. So, when transferring a young child from one parent to the other after divirce, it would be surprising if everything always went smoothly. Crying when going from father to mother probably does not mean that father abused the child. Crying when going from mother to father probably does not mean that the mother has brainwashed the child to make her afraid of father.
The very difficult problem here is that in a few cases these things have happened, and it can be difficult to know what is distress caused by bad events and what is normal transition complaining. But following the “black swan” rule, our first assumption should be that things belong to the more frequent category of events. If parents are prepared to deal calmly with times of transition, knowing that they are likely to include child crying and distress, everyone will be able to do better—to the advantage of the child, who is not helped if adults feel and show their own upset. If this does not help, it's time to explore carefully to see whether there is something one or both parents are doing to distress the child.
It’s true that one of the real difficulties of divorcing parents is the attachment-related reaction of young children. They cry, they cling, they demand attention, they avoid unfamiliar people even more than usual, they need a lot of emotional support as they struggle to feel secure with both parents. This is all occurring at a time when one or both of the parents may be completely stunned by what is happening and want nothing more than to pull the covers over their head and hide for a month. One of the natural problems of being a parent is that the less you want demands placed on you, the more demands your young child will place. You have “gone away” from your usual availability, and the child wants you back.
It's tough on everybody. But let’s be careful about interpreting normal child separation behaviors as “parental alienation” or thinking that somehow the child’s internal working model of attachment has been smashed by a visit or the lack of a visit. Jumping to those conclusions only makes things worse in the long run.
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