Russian Adoption: Trying to Talk About Maxim Shatto

I got up at 4 o’clock this morning to go to a TV studio and be linked to a Russian Channel 1 program (“Life with Mikhail Zelensky”) focused on the deaths of Russian children adopted by parents in the United States. As it turned out, the birth parents of Maxim Shatto, the three-year-old recently killed in Texas, were interviewed on the program, and told a rather sad and somewhat sordid story of having left two young children with a grandmother who may have been a poor choice of caregiver, with the subsequent taking of the children into care and placement for adoption. (I only know this because of the services of Alexander the simultaneous translator, who was speaking into my ear while shouting and periodic applause filled the Russian studio.) You can see this at http://www.youtube.com/watch?v=BcBXI2oTN6g&feature=share.

There is so little information available about Maxim’s death that I cannot possibly say what lay behind this event. I was asked to describe attachment therapy for the program, and did so, but I was not asked whether I thought Maxim had been subjected to any aspect of that unconventional treatment. Again, I cannot think either way about this until I know much more. I am curious as to whether the little boy had failed to gain weight in his adoptive home, because this suggests the use of parenting techniques advised by AT proponents. I was also asked about restrictions on prescription of Risperdal, the adult psychotropic medication that Maxim is said to have been taking, and I was able to say that there is little control over these off-label prescriptions.

But of course these are not all the things I would have liked the chance to say. Although I am very concerned about misinformation given to adoptive parents about attachment  and about appropriate mental health treatment for adopted children, and although such misinformation may be most directly responsible for mistreatment of children, the picture is obviously much bigger than this. The absence of other information may drive adoptive parents to over-reliance on questionable mental health advice.

Aren’t all adoptive parents supposed to have some hours of pre-adoption education according to the Hague convention? Yes, they are, but there is no clear statement about what those hours cover. I understand that some programs concentrate on “scrap-booking” about the children’s lives--  a fine thing to do together, but not a matter that takes long to explain. The change.org petition I mentioned recently wanted pre-adoptive parents to be told that children with Reactive Attachment Disorder were likely to be violent and dangerous, and this request suggests to me that perhaps some pre-adoption programs already hand out this inaccurate claim.

What would be some good things to include in pre-adoption education? One topic I’d like to see covered would be the problems that children adopted from institution abroad are actually likely to have. These include difficulties with attention and distractibility, as well as with the “executive function” that allows a person to make decisions about what to do, including stopping a course of action that was undertaken by mistake or judged to be wrong after it is begun. In addition, post-institutional children are likely to have language delays and to need speech therapy. (Language delays are the source of many behavior problems, because a child who cannot understand what he’s told, and who can’t explain his problems, is quite likely to be frustrated to the point of tantrums or other displays of distressed emotions.)

What is the purpose of telling pre-adoptive parents these things? One is to clarify for them that emotional or behavior problems displayed by an adopted child may have to do with more than his or her emotional development. They may occur in connection with cognitive or language delays that are not necessarily obvious to the casual observer.

A second point of giving this information--  and this, I think, is essential--  is to allow pre-adoptive parents to look for and arrange appropriate services in the area where they live, or to discover (better now than later) that getting such services may require extensive travel. For example, in how many parts of the U.S. can people find a bilingual, Russian/English, speech therapist to work with a child whose English is very limited and whose Russian may be delayed? In how many areas can people find a therapist who can do Parent-Child Interaction Therapy, an evidence-based treatment that helps parents and children communicate and decreases oppositional behavior? If the parents cannot get access to these post-adoption services, will they find themselves limited to practitioners who use heavy-duty medication to stop “difficult” behavior? Information given to the pre-adoptive parents early--  and given consideration by the adoption caseworker—can make the difference between desperation and good functioning in the months to come.

Let’s back up a bit, though. I’ve just mentioned that the caseworker should have some idea what resources are needed and will be available to the adoptive family. This brings up the likelihood that abusive adoptive parents (like abusive non-adoptive parents) are not just “bad people” who should have been screened out to begin with. Like many events in life, abusive behavior toward children is probably determined by the interaction of multiple risk factors, like an absence of resources. If there are few such factors, abuse is unlikely; with addition of factors, it becomes more and more probable. Adoption caseworkers need to look at a whole list of such risk factors, not simply a checklist that shows whether the parent candidates are acceptable.

If a child will have many needs for professional services, and the family lives at some distance from services, that is a risk factor.

If one or both parents have a history of depression and have limited access to treatment, that is a second risk factor. (Just as perinatal mood disorders can be a factor in a birth mother’s abuse or neglect of a child, parents with a history of depression may respond to adoption with depression and inappropriate behavior.)

If the family is socially isolated, this is a risk factor. Planning to homeschool may or may not indicate social isolation, but this should be considered as a possibility interpretation.

If there are already many children in the home, if the parents have fostered many children, or if the parents are adopting more than one child at a time--  counter-intuitively, these are all risk factors that should be considered by caseworkers, because they may indicate problems with individual relationships with children, rather than the “wonderful self-sacrificing nature” so sentimentalized by the mass media.

If the potential adoptive parents believe that their primary job is to make the children obedient, this is a risk factor.

Again, we are talking about identifying risk factors for abuse of adopted children. No single one of these or many other possible factors means that an adopted child will be mistreated. Even if they are all present, abuse or neglect will not necessarily be the outcome. But as risk factors are added, and as family stresses like illness or unemployment unpredictably occur, the results may be abusive treatment, of either the systematic kind advocated by some proponents of attachment therapy, or plain old, unsystematic, common or garden maltreatment.

We can make use of information about risk factors to do a better job of screening potential adoptive parents. We can improve matters by better pre-adoption education of those who are not screened out. But forgive my cynicism if I say that we probably won’t, as long as the adoption industry makes money both inside and outside the United States.

PLEASE NOTE: A longer  Russian TV discussion of the use of attachment therapy can be seen at http://www.1tv.ru/news/world/227626. You will need to type this in, not click on it here. 

Don't Sign the Petition About Reactive Attachment Disorder and Relinquishment

When those change.org petitions come around, it’s so hard not to sign them. They all sound good and deserving. But, of course, there’s nothing to stop petitioners from presenting inaccurate information and asking for help with a matter that is to their own benefit alone. Such seems to be the case with http://www.change.org/petitions/the-president-of-the-united-states-post-adoptive-support-for-children-with-reactive-attachment-disorder. The group posting this petition, Hopefor Healing (spacing sic), has made a series of inaccurate statements and in addition has implied that other wrong information is correct. I hope you will not sign this petition, no matter what its emotional appeal may be.

The basic ideas stated in the “RAD” petition are the following: 1) undesirable behaviors of adoptees may not be displayed until the adoption process is over; 2) these behaviors, referred to as Reactive Attachment Disorder, are highly disturbing and dangerous, and need highly specialized treatment from residential facilities that focus on RAD; 3) parents cannot afford to pay for treatment; 4) parents who relinquish custody of their children voluntarily may be prosecuted, but should be allowed to relinquish quickly;  5) pre-adoptive education should include warnings of the potential of the child for violent behavior; 6) post-adoptive services should include residential treatment for RAD (at least this is my interpretation of the words “escalated to the highest levels of care”).

Before examining these claims under a strong light, I want to refer to a related issue of genuine concern. As was pointed out in the Bazelon Center for Mental Health Law’s 2000 publication Relinquishing Custody, state laws vary on provision of mental health services for children. In some states, parents may be forced to relinquish custody of a mentally ill child to the state before treatment can be provided without charge--  a conclusion that most parents resist as long as they can. This very real problem does not appear to be what “Hopefor Healing” is talking about. They want children’s mental health interventions, as they define and desire them, to be provided at public expense, and they also want to be able to relinquish custody quickly and easily.

But let’s look at “Hopefor’s” points one by one. First, the idea that worrisome behaviors of adoptees are somehow concealed until the adoption is final. According to the long-term research done by Michael Rutter and the English-Romanian Adoptees project, children who had been in the worst of worst conditions as infants and toddlers improved gradually with time in the adoptive family, leading to the conclusion that adoption  is one of the most effective developmental interventions. Among the ERA children, even those who were seen as disinhibited and too ready to go with strangers were by their teens regarded as friendly, outgoing, popular kids. I should point out too that in the ERA study, the most common problem was delayed language development, which was certainly present when the adoption was initiated.

Second, what about the idea that the children are likely to show violent, even homicidal behavior, and that this is evidence of Reactive Attachment Disorder and should be treated as such? There are two separate issues here. Yes, of course, as is the case in any population, some adopted children may be callous and unemotional in behavior and/or may be violently aggressive. However, as Charles Zeanah, the eminent child psychiatrist, has made clear in his discussion of Reactive Attachment Disorder in preparation for the DSM-5 publication (www.dsm5.org/Proposed%20Revision%20Attachments?APA%20DSM-5%20Reactive%20Attachment%20Disorder%20Review.pdf) , in fact these characteristics are not associated with Reactive Attachment Disorder. Thus, even if there were an evidence-based treatment for Reactive Attachment Disorder, it would not be relevant to these cases--  and the fact is that organizations that claim to specialize in treating RAD do not use methods of demonstrated effectiveness. “Hopefor” is asking for children to be publicly funded for treatment that is probably inappropriate for them, as well as lacking in an evidence basis.

Third, it is no doubt true that parents cannot afford to pay for expensive, intensive treatment, and as the Bazelon Center document suggested, we as a society need to correct this problem. However, it will never be appropriate for parents to demand payment for an intervention chosen by them on the basis of their beliefs about the child’s diagnosis, nor will it be appropriate for anyone but an independent evaluator to make such a diagnosis. Caseworkers from an adoption agency and prospective therapists are not the right people to make these decisions. Even if resources were not scarce, we would need to require independent assessments and avoid the apparent confusion of “Hopefor” about the nature and treatment of Reactive Attachment Disorder.

Fourth, although parents who abandon their children may be prosecuted, those who relinquish legally are not (although they may be called upon to repay funds that have been used to care for the child). States have procedures for legal relinquishment that may involve counseling and discussion of possible consequences, as well as providing simplified procedures and “safe havens” for relinquishment of young babies. In practice, also, voluntary relinquishment may be made very simple. In one case in which I testified, a couple adopting from Russia had been persuaded to take a girl as well as the boy they wanted. They did not like the girl much, placed her in attachment therapy, and often sent her to a respite home for periods of time. Finally, they decided they wanted to disrupt her adoption, and the respite family was willing to adopt; this exchange was maneuvered by the caseworkers without the usual formalities. When the girl was apparently mistreated in the new home and the authorities were notified, the family sent her to a boarding school in another state, a school that has been investigated for the use of restraint with children and has argued that this is permissible. There she remains, probably until she ages out at 18, and there has been no prosecution of the original adoptive parents.  

The fifth point, the demand that pre-adoption counseling include the claims about violent and abusive behavior as a part of Reactive Attachment Disorder, may be the real focus of this petition. According to the Hague convention, to which the U.S. is a signatory, candidates for adoptive parenthood must receive a number of hours of pre-adoption education. At this point, the nature and provision of those hours are up to the adoption agency involved. Even the Russia-U.S. adoption agreement of last year (now in abeyance) did not outline the pre-adoption education required.  This means that--  as most agencies do not have the time or resources to write their own curricula--  it would be much to the advantage of any interested person to seize the opportunity to write and market educational material. And if this material informed prospective adoptive parents that their children might be dangerous, that the danger was due to RAD, and that only specialized RAD treatment centers could help--  why, so much the more advantageous for the whole group that pushes misinformation about adoption and attachment.

And, sixth, as above--  the petition essentially presses the claims that there is only one set of problems, one diagnosis, and one treatment that must be part of post-adoption services--  the treatment apparently being the complementary-and-alternative, non-evidence-based approach often called Attachment Therapy, an intrusive, time-consuming intervention that is not reimbursed by third-part payers, and for good reason. But what could be better for its practitioners than being able to do an end run around public and private health insurance and have public funds support them in style?

Enough said, I hope?  

If It Isn't Attachment Disorder, What Is It? If We Don't Do Attachment Therapy, What Can We Do?

Many posts on this blog have been dedicated to explaining that Reactive Attachment Disorder does not include various disturbing traits described on websites such as www.attachmentdisorder.net. Whereas Reactive Attachment Disorder includes unusual behavior with respect to other people, including both clinging to caregivers and failing to prefer caregivers to strangers, the characteristics often incorrectly attributed to RAD include control battles, defiance, refusal of affection to caregivers, frequent temper tantrums or “rages”, physical attacks on others, cruelty to animals and smaller children, and so on.

Although some anxious caregivers easily interpret any noncompliance as pathological, of course there are a small number of children whose behavior really is disturbing, uncontrollable, and violent. Not only are adults afraid that these children will harm others (including the adults themselves), they also worry that the children’s apparent lack of empathy for others will continue into adulthood, causing them to be a danger to society and eventually to receive serious punishment for their actions.  The adults’ beliefs about the causes and solutions of these behavior problems makes them look for treatments like Attachment Therapy, and like the associated Love & Logic program, that are presented as appropriate therapies for unruly children.

But if violent and disturbing child behavior is not caused by problems of attachment—is not really any form of “attachment disorder”—trying to treat attachment is not likely to have much effect on them. Is there a more constructive way to think about the child who is described at www.attachmentdisorder.net? And can thinking in a different way guide us to more suitable treatments?

One useful approach has been to look at children who have callous-unemotional (CU) traits. Children classified in this way are described as lacking guilt and empathy, being very egocentric, making use of others for the child’s own gain, and lacking normal emotionality, especially normal anxiety (Herpers, Rommelse, Bons, Buitelaar, & Scheepers, Social Psychiatry and Psychiatric Epidemiology,2012, 47, 2045-2064). There is no clear agreement about whether these characteristics should yield a diagnosis in themselves or whether they cross the lines of various other diagnostic categories, but it is potentially very valuable to define these problems by themselves and to move away from the idea that all such troubles stem from attachment difficulties and can be cured by improving attachment. (It’s interesting, by the way, that in 9 or 10 recent professional articles on CU traits, although there was discussion of CU as a part of Oppositional and Defiant Disorder [ODD] and of other diagnoses, no author considered whether CU was part of RAD,and only one referred to an attachment status, disorganized attachment in early life, as a factor in bringing about CU traits.)

In looking at mental health issues, it is often constructive to think about mood and behavior problems transactionally. This means that mood and behavior of an individual are shaped by factors in the individual and also factors in the environment, certainly including the attitudes and actions of other people; it also means that as an individual matures and learns, the effects of transactions with other people can also change. Taking a transactional point of view, we can look at some characteristics that are thought to be typical of children with CU behavior (as discussed in the Herpers et al paper). Such children may have less anxiety than most people do, and may focus more on rewards they get from their behaviors than on possible punishing consequences, as well as having more trouble than most people in recognizing others’ emotional expressions, especially fear. The transactional approach suggests that, given the CU children’s unusual characteristics, they may respond differently to parenting methods than more typical children would. Parent training programs may be the best approach to treatment for children with CU behavior. Significantly, research on use of restraint and seclusion in child psychiatric programs suggests that reducing these methods is followed by a reduction in violent behavior (Stellwagen & Kerig, Journal of Child and Family Studies,2010,19, 588-595), and this may generalize to parenting practices as well.

One such program, Collaborative Problem Solving, developed by R.W. Greene  and described  in his 2008  book Lost at school, emphasizes the importance of taking a proactive approach to child behavior problems and to making the child an active partner in this endeavor. Rather than focusing on consequences for undesirable behavior, Greene’s CPS approach has child and adult working together to set priorities for what needs to happen, to identify and develop needed skills before the next time they are needed, and to consider situational and trigger factors that make it difficult for the child to control impulses. Attachment is not mentioned—but working together toward shared goals is one of the most important ways for human beings to create social bonds, so a developmentally-appropriate form of attachment may come in the back door as this method is put to work.

Greene stresses two important issues: the need for the adult to exercise genuine empathy and understanding of the child’s needs, and the fact that children who do not do as they are told most often cannot do as they are told, at least not at that time and place. Adults who assume that they must force a child to obey because the child is simply oppositional are missing a real empathic understanding of the child’s experience, and thus they create a transactional process with the child that takes both of them in an unwanted direction.

In Lost at school, Greene answers some questions about comparisons to other parent training programs directed at helping with oppositional or CU behavior. One comparison is between CPS and “Love & Logic”, the commercially-successful program sold to hundreds of school systems and other groups. Foster Cline, one of the forces behind “Love & Logic”, was of course an early practitioner of Holding Therapy/Rage Reduction Therapy/Attachment Therapy. In commenting on “Love & Logic”, Greene says “The Love and Logic program does place an emphasis on empathizing with kids, but the empathy utilized in this program is primarily of the emergent and perfunctory variety, isn’t aimed at gathering information or understanding kids’ concerns, and is typically a prelude to Plan A [this is Greene’s term for responding to a problem by imposing the adult’s will]. The problem-solving that takes place between kids and adults in this program isn’t aimed at reaching mutually satisfactory solutions. And the Love and Logic program relies heavily on adult-imposed consequences” (p.200)--  consequences, as I noted earlier, that may not be responded to by children with CU tendencies. Incidentally, although Greene does not mention this, Love & Logic has not been subjected to outcome research, whereas CPS has.

Kafka Again: More on Capture of Child Custody Proceedings by Attachment Therapists

I have more to tell about “Eve Innocenti”, the mother whose struggles for contact with her children I discussed at http://childmyths.blogspot.com/2012/12/the-attachment-therapist-wears-two-hats.html and elsewhere. I think now I should have named her “Josefine K.”, because her situation is becoming more and more reminiscent of The Trial, with its unstated accusations, empty courtroom, and efforts to make the protagonist punish himself.

As some readers will remember, Eve had two sons while living in Colorado. The boys had different fathers, but only one of the fathers was in the picture, and he and a new partner offered occasional care to both boys. Several years ago, Eve left the children with that couple while traveling--  and when she returned found that they refused to let her take the boys home. (Note, by the way, that while the older boy was the son of the man caring for him, the  younger boy was not biologically related to either of the caregivers.) Eve remained in the state of Colorado for some time, during which period she sought legal and judicial help that would allow her contact with her children, and preferably physical custody--  but without much success.

Eve married and moved out of the state with her new husband. She continued to try to work with Colorado authorities and found that she was being accused of having neglected and abused the boys earlier. She was assigned an attorney to represent her interests, but found and still finds that this person does not return calls nor apprise her of court dates. Meanwhile, the children’s “stepmother” (not legally, but for all practical purposes) enlisted the help of a local practitioner of Attachment Therapy, who began to serve not only as the children’s therapist but as an evaluator communicating with the court—an ethically questionable combination.

In Attachment Therapy, a stated goal is to remove attachment to a previous caregiver, and to establish attachment to a new adult. The tenets of AT suggest that this is to be accomplished in part by requiring a child to agree with and repeat statements about the abusive or neglectful treatment of the early caregiver, and to express rage against that person as instructed. Through this procedure, any child cooperating with AT will say that a caregiver was abusive. Statements made in this way by Eve’s children were the apparent source of abuse accusations against her—the accusations that are being used as an argument in favor of preventing her from having contact with the children, and eventually of terminating her parental rights. (Eve has never been told what the accusations against her actually are, so she cannot defend herself; instead of telling her, Colorado authorities suggested that she make a list of all the bad things she had done, and they would check those against what the boys were reported to have said.)

Paradoxically, when AT practitioners wish to foster an attachment between a child and a new caregiver, one of their tools is to separate an uncooperative child from the current caregiver and to send him or her to “respite care”, where treatment is austere and minimally enjoyable. This treatment has been used with Eve’s older son, in contradiction to the conventional view that attachment is encouraged by increased pleasurable social interaction with an adult caregiver. He apparently disliked this treatment very much.

A month or so ago, Eve came to the conclusion that for her own sake and that of the children, since the termination of her parental rights seemed to be unavoidable,  she might do well to relinquish her rights. This action would make the children both adoptable by their stepmother, and enable the father of the older boy able to adopt the younger one. Eve and her husband have spent all their savings, but their income is too large to make them eligible for legal aid, and without counsel they have no idea how to pursue the matter any farther.  Relinquishment could reduce the difficulties the children are presently going through, Eve thought.

But no! A telephone call from the Colorado authorities has advised Eve that she cannot relinquish. To do so, she would have to be available for counseling about relinquishment, and as she lives in a different state, this is not possible. The children’s caseworker has said that it is only a matter of time until her parental rights are terminated, in any case. In addition to its Kafkaesque features, this makes the case take on aspects of the judgment of Solomon--  if Solomon had said, “All right, this mother gives up, but let’s cut the child in half anyway”, but instead of cutting, subjected the child to abusive practices labeled as psychotherapy.   

What does the law actually say about this situation? According to S.N. Katz’s book Family Law in America (Oxford University Press, 2011), “Federal guidelines [the Adoption and Safe Families Act of 1997] mandate that a state make reasonable efforts to prevent the removal of children from their families except in the most aggravated circumstances of abuse. The goal is to insure that parental rights are respected, on the one hand, and the best interest of the child is served, on the other.”

The law [Child Abuse Prevention and Treatment Act, amended 1996] also requires that in child protection proceedings the child must have independent counsel. An attorney representing the child is not the same as a guardian ad litem (GAL). As Katz notes, “The difference between an attorney for the child and a GAL is… that the attorney represents the child whereas the GAL represents the GAL’s opinion as to the child’s best interests.”

Neither of these two legal requirements has been met in Eve’s children’s case. Of course, it is an awkward case because of the different relationships of the two children to their present caregivers. In the case of the older boy, he is living with one biological parent, and the only question about the situation is how his relationship with his birth mother is to be handled. In the case of the younger boy, neither of the present caregivers is biological kin, so the roles of both of them, in addition to the connection with the birth mother, require legal examination.  

Eve and her children need legal counsel, but they appear to be captives of the Attachment Therapy belief system as it has taken over a county’s practices. They will not get the counsel they are entitled to from the county, nor will they get any explanations or opportunities to deal with accusations.  I have suggested that Eve contact the American Civil Liberties Union for help in a situation where government is interfering with citizens’ rights.

Russian Adoption: Letter to Senator Mary Landrieu

Dear Senator Landrieu:

I am writing to you because of your involvement with the congressional adoption coalition and because of your recent attempts to communicate with the Russian authorities about the adoption ban. I want to comment on some issues that have rarely been mentioned in connection with the ban. Sad though the Russian decision was for some American families and some waiting children, it may offer us an opportunity to examine factors affecting the success of  both foreign and domestic adoptions in this country.

The Russian legislation was named for Dima Yakovlev, a toddler adopted from Russia who died a tragic but purely accidental death. It would more appropriately have been named for children like Viktor Matthey and Nathan Craver, or others who died as a result of systematic maltreatment of a type advised or countenanced by some adoption caseworkers and educators.

Popular sources of information about adoption and Internet sites such as www.focusonthefamily.com  and www.attach-china.org have to a considerable extent been hijacked by an unconventional, non-evidence-based view of emotional attachment and treatment of mental illness. This perspective claims that all emotional disturbance derives from poor attachment experiences, and that adoptive parents can cause children to become attached to them by displaying their power and authority. In order to display authority, parents must make children completely dependent on them and obedient to them; children may eat and drink only as parents allow them, must not use the toilet without asking, and may be kept in cold or uncomfortable sleeping arrangements, including cages. Such treatment is physically as well as mentally unhealthy and accounts for the frequent findings of malnutrition in deaths of adopted children.  

Because Internet sources present these types of maltreatment as appropriate for adopted children, adoptive parents may have become convinced of this misinformation before they ever receive the pre-adoptive training required under the Hague Convention. Whether their pre-adoptive education contradicts or confirms their beliefs may make the difference between mistreatment of adoptive children and appropriate treatment. Unfortunately, evidence from education of social workers, CASAs, and GALs suggests that in some cases the mistaken beliefs may be confirmed rather than contradicted.

How can the U.S. alter this situation so that adopted children from all countries are safer? As I suggested in a letter to Pavel Astakhov two years ago, an important step would be to review pre-adoption training materials. I would like to see this done for all pre-adoption education, but in light of the Russian ban this may be the time to begin with materials from agencies that work with foreign adoptions. I don’t believe that such a process can constitutionally be created by Federal legislation, and I believe that state legislation would be strongly resisted by groups like the ones I mentioned earlier. However, it should be possible for a congressional committee to request co-operation from agencies that deal with foreign adoptions and to have their materials vetted by independent scholars.

What I suggest here would obviously be only a first step,  but it may be an essential one both toward improving the outlook for adopted children and toward convincing the Russians that the ban is unnecessary.

Sincerely yours,

Jean Mercer,Ph.D.

Professor Emerita of Psychology, Richard Stockton College

NOTE: Senator Landrieu's office answered this the day after it was sent, with a form letter in which the Senator deplored the conditions of children in Russia.

I was recently interviewed on this issue by the Russian magazine Za Rubezhom. Perhaps Senator Landrieu's staff will read about the matter there.    J.M.

False Positives, False Negatives, and Standardized Testing for Reactive Attachment Disorder

When tests are developed for medical or psychological disorders, the idea is usually this: There is a disorder that can be identified. However, it may be difficult and complicated to identify it in the usual ways, or it may be desirable to identify it when only a few vague symptoms have appeared, in order to treat it early and keep it from getting worse. A medical or psychological test is a way of measuring a sample of behavior or biological functioning that will help predict whether a disorder is developing, or that can be an effective substitute for difficult, intrusive , and time-consuming examination of other kinds. Effective tests are very useful in ruling out problems that the symptoms might suggest but that are not really present, and thus allowing appropriate treatment to be chosen without waste of time.

But the tricky part about tests is that even the good ones are not always right. They may result in false positives and indicate the presence of a problem when there really is none. They may also result in false negatives and show that there is no disorder—but later events demonstrate that the disorder was actually there. Even the best tests show some false positives and some false negatives. The practical goal is not to get rid of all of these, but to be able to state how often they occur, and to interpret results in the light of that information.

Test development is a complicated and tedious matter in which small errors may ruin the value of extensive efforts. For example, an imprecise or erroneous definition of a disorder can result in an ineffective test. Test developers must work hard to exclude sources of bias, especially if diagnosis of the disorder has more than a small reliance on subjective opinions. Persons who perform or even know the diagnosis given to a participant must not also be the ones who perform or score the test, for fear that their beliefs will inadvertently influence the ways they administer or interpret the test. If a diagnosis depends on the examiner’s opinion rather than an objective measurement, it’s important to have several examiners make independent assessments, and to ascertain the extent to which they agree. If a test has not been developed following these and other guidelines, it cannot be trusted. Tests should be regarded with suspicion if they have not been published in peer-reviewed journals, whose expert reviewers will have done some of the work of assessing the test’s credentials. Transparency of reporting is the key to test selection; tests that are published privately by their developers, and whose background is not available to the reader, should be approached warily.

How does all this relate to the issue of testing for Reactive Attachment Disorder? There are presently no thoroughly-validated tests for this disorder--  and one reason is that the condition remains only incompletely defined, and has somewhat different descriptions in DSM (the standard U.S. listing of mental disorders) and ICD (the European manual).

Nonetheless, some American practitioners, especially those who advocate the use of “holding therapy” for children diagnosed with Reactive Attachment Disorder, choose as a diagnostic test the Randolph Attachment Disorder Questionnaire (RADQ), an instrument self-published by Elizabeth Randolph. The validating information claimed for the RADQ by Randolph has never been published in any peer-reviewed journal, and the one related article in a peer-reviewed journal (by Cappelletty et al) concluded that scores on the RADQ did not correlate with any validated test for childhood emotional disturbance. Beyond that, however, it is notable that Randolph herself stated plainly in her self-published work that the RADQ was not intended as a test for Reactive Attachment Disorder, but instead was an assessment of a different, suppositious disorder never described in any peer-reviewed publication. Whatever Randolph intended to test, in any case, she failed to guard against bias in her results by herself doing both the job of subjective diagnosis and that of performing and scoring the test. Although her publication includes a report of an analysis of variance on the test results, it does not state how many false positives or false negatives occurred. This raises the question whether there were no such false results, simply because both the original diagnosis and the test result were in each case formulated by Randolph, who agreed with herself strongly in her assessment of each child; this of course is a far cry from having test scores that are validated by their agreement with an independent diagnosis.

The RADQ should be excluded as a possible diagnostic tool for Reactive Attachment Disorder  first on the showing of its own developer, who did not intend it to do that job, and second on the basis of its complete lack of conformity to normal guidelines for test development. That neither false positives nor false negatives have been reported is a statement not of the effectiveness of the test, but of a failure to consider a basic testing issue.

What then? Are there any standardized tests for Reactive Attachment Disorder? Helen Minnis, a Scottish psychiatrist, has been working for a number of years to try to develop such an assessment, but although she has created evaluative methods, she has no standardized brief test. In a 2009 paper with a group of colleagues (An exploratory study of the association between reactive attachment disorder and attachment narratives in early school-age children. Journal of Child Psychology and Psychiatry, 50(8), 931-942), Minnis described the complications and difficulties of this work, beginning with the lack of clarity in descriptions of the disorder: “Although the concept of RAD is encapsulated in psychiatric classification systems… the research base is scant, particularly in relation to school-age children… In this paper, we use the term RAD as in DSM to cover both the ‘inhibited’ and the ‘disinhibited’ phenotypes… The DSM and ICD systems both define RAD as being associated with early maltreatment and characterized by disinhibited behavior (indiscriminate sociability) or inhibited (withdrawn, hypervigilant) behaviors.” Minnis goes on to point out that there is not much consensus about the effect of changes with age on RAD, and that one system includes attention-getting and aggression toward self and others among the symptoms. Minnis pointed out that research has indicated that children may show symptoms of RAD and also be evaluated as securely attached to caregivers. (Does this suggest that in fact Reactive Attachment Disorder has nothing to do with attachment? See below—J.M.)

Children in the Minnis study were referred because of symptoms noticed by social workers and mental health teams, but not because of evidence of pathogenic care. Thirty-three children  diagnosed with RAD on the basis of interviews and observations were compared to 37 children matched on age and sex but not diagnosed with RAD.  Working with an extensive protocol rather than a brief test like the RADQ, Minnis looked for shared characteristics of children diagnosed with RAD. Minnis and her colleagues concluded that their findings “reinforce the conclusions from other literature that RAD is a phenomenon different in kind from attachment specific behaviors…. RAD can perhaps be seen as one of the pervasive disorders of social impairment…”.  

Minnis’s work suggests that a brief test diagnosing RAD is not going to be possible in the near future. Beyond that, Minnis and her colleagues point out the possibility that RAD is not about attachment in any ordinary sense of the term. I would note that this finding implies that efforts to destroy or create attachments are essentially irrelevant to treatment of  RAD--  in contradiction to the belief systems of persons who currently use the RADQ.

Book Review: Eileen Gambrill's "Propaganda in the Helping Professions"

As you might expect, people in the helping professions want to help. Physicians, nurses, social workers, psychologists, occupational therapists—although they may have other motives too, they probably won’t stay in those professions long unless one of their goals is giving help. And because they really want to help others, they may be quite vulnerable to propaganda in the form of attempts to persuade them that certain methods are safe and effective. Even if there is no good evidence to support such claims, helping professionals may accept persuasive material  enthusiastically and unsuspiciously, to the unfortunate detriment of their clients’ conditions. This situation is especially problematic if propaganda is generated by pharmaceutical companies or by proponents of alternative methods, who stand to profit if they can persuade the helping professional to use their proffered techniques.

In Propaganda in the helping professions (Oxford University Press, 2012), Eileen Gambrill, a social worker with a long history of concern about methods in her own profession, warns patients and practitioners of the potential dangers of persuasive messages about treatments, and describes at length some necessary skills for identifying and resisting propaganda. Densely informative, with 500 closely-printed pages of information and argument, Gambrill’s book presents ideas and methods which most people in the helping professions have been exposed to--  but did not necessarily catch. Like many abstractions, these ideas are easily forgotten, and most of us benefit from periodic reviews of material we recognize but don’t easily recall. Gambrill’s almost encyclopedic book will not be read straight through by many, but can be dipped into frequently with benefit to professionals and to patients who want to take some control over their treatment. Readers will find the extensive bibliography helpful, the endnotes both entertaining and informative, and the entire publication characterized by personal, opinionated, and even pejorative views (Gambrill refers to the American Psychiatric Association as “fellow travelers” of the pharmaceutical industry, for example).

An important section is one that restates a point discussed frequently over the last several years: that both practitioners and patients understand risks and benefits of events better when statements are in “natural” terms (e.g., 3 cases of breast cancer out of 1123 women) rather than in proportions or percentages. The ratios are the same, however they are stated, but the medium influences the reception of the message. Gambrill works out several problems using natural statements of numbers and shows how intuitive responses to reports of percentages may be quite different from responses when specific numbers are provided, with possible effects on our conclusions about the effects of treatments.

Several sections of the book focus on rhetorical or logical factors as they influence a message’s persuasiveness. For example, Gambrill discusses fallacies of irrelevance and the frequency with which they are used in propaganda about medical and psychological treatments. Indeed, defense of statements with comments that are ad hominem (about a speaker) rather than ad rem (about the topic) is a technique that is almost diagnostic of propaganda in the helping professions and elsewhere. For myself, I find it useful to review types of fallacies from time to time--  remembering the names helps me to identify examples that I read or hear, and assures me that others would find the statements fallacious as well. Gambrill’s book presents a thorough review, and includes a warning against the possibility of “self-propaganda”, the tendency to persuade ourselves of beliefs that in fact we cannot support.

Propaganda in the helping professions is a book full of good things, but it is not precisely a “good book”; there is more to a good book than a series of good sections. Gambrill’s book would have benefited greatly from an experienced editor who could have tightened up the text and revealed an underlying structure that is presently obscured by details. In addition, the production phase seems to have been skimped, leaving the text sprinkled with puzzling uncorrected typos of the kind that spell-check either caused or failed to fix. These include sentences where punctuation seems to have gone agley, leaving the reader to figure out what happened to the shoots and leaves.

I was left with unresolved concern about a point in Gambrill’s book. As she has done elsewhere, she refers to the Citizens Commission on Human Rights as a “watchdog group”, together with  the American Civil Liberties Union and Advocacy (sic) for Children in Therapy. Overleaf (not her fault, of course), Gambrill notes that the CCHR was established in 1969 by the Church of Scientology. It can’t be denied that the CCHR is indeed a watchdog group---  but its Scientology affiliation surely raises questions about who should be watching the watchmen. Here, where I would have expected one of the references to “fellow travelers” found elsewhere in the text, I see no comments at all. Does Gambrill presently consider the CCHR and the ACLU to be equivalent in roles and purposes?  Or is this simply a result of cutting and pasting of an unwieldy mass of material? I’d like to know, and I’d like this flaw to be corrected, so it doesn’t steal attention from the rest of Gambrill’s valuable contribution.

Focus on the Family Buys Into Attachment Myths

Attachment theory, as formulated decades ago by John Bowlby, is a framework for understanding how human social interactions and relationships develop from infancy onward. Any theory works to pull together observations or other data on a topic and to suggest how they are connected with each other. Attachment theory deals with observable aspects of social relationships such as the apparent indifference of infants in the first months to contact with strangers, the quickly-developing preference for familiar people and fear of separation or strangers as infants  reach the end of the first year, the use of contacts with familiar people to help toddlers explore and learn, and the associations between early social experiences and adult attitudes toward other people.

Attachment theory, as it is conventionally understood, has been tested and revised as thousands of empirical studies have examined it. This is not the case, however, for an “alternative” view of emotional development that also uses the term attachment, but is in fact a matter of attachment myths.

The organization “Focus on the Family” appears to have bought into prevalent attachment myths. Although materials on its web site reference John Bowlby and attachment theory, it is in fact the myths that are repeated. Advice to parents  given by “Focus on the Family” is based on attachment myths, not on attachment theory.

Here is one example, taken from http://www.focusonthefamily.com/parenting/adoptive_families/attachment_and_bonding/new_definition_of_attachment-regulation.aspx. . The FoF author, Debi Grebenik, says this: “Children (biological or adopted) who do not get their needs met as babies and small children typically do not form a strong attachment with their parents. Even when adopting a baby, it is important to consider that the removal of a child from his or her biological mother creates a traumatic event in the life of the child.” Grebenik provides a diagram of the so-called “attachment cycle” that is solely a part of the attachment myths system and in no way a part of attachment theory.

Grebenik’s statements vary between the deceptive and the false. Certainly, young children are helpless to feed and care for themselves, and for good development must have caregivers who will do these jobs and do them well. However, it is a mistake to conflate good caregiving with the social interactions that are the actual cause of emotional attachment to caregivers. This aspect of attachment mythology adopts Sigmund Freud’s belief that children become attached to familiar people because those people provide food, an idea that was contradicted by Bowlby’s report, and the position of attachment theory, that pleasant social interactions with an adult are the actual cause of a child’s attachment to that adult.

Ordinarily, of course, caregivers who are neglectful or abusive are also likely to fail in providing pleasurable social interactions, and those who are attentive, sensitive, and responsive are also likely to create pleasant social interactions with their babies. It is easy to confuse these issues and to jump from care experiences to the social events that create attachment. If Grebenik is going to write about these issues, however, she should realize that it is deceptive to focus on satisfaction of needs as a cause of attachment, when in fact social interactions are the important factor here. Although events depicted in the “attachment cycle” diagram are usually accompanied by the important social interactions (which go unmentioned), the two are not the same things. This may seem like nitpicking--  except for the fact that attachment mythologists often recommend treatment of older children by attempts to re-enact the notional attachment cycle, such as spoon- or bottle-feeding. Buying into attachment myths in this way encourages parents and practitioners to choose forms of treatment that are neither plausible nor demonstrably effective.

In referring to the removal of a child from the biological mother as traumatic, Grebenik is again deceptive in her omission of important details. Of course, separation from a familiar caregiver (biological relative or not) is likely to be traumatic when two circumstances are present. The first is that the child has already formed an attachment to a familiar person, an event that does not occur before 6 months of age at the earliest. The second is that the new caregiver is unavailable, insensitive, and unresponsive. (I should note, by the way, that Bowlby did not consider, the second factor to be important, but his colleague John Robertson demonstrated that it was.) If the child is under 6 months old and is moved to a situation where a small number of attentive adults give good care and are socially responsive, this does not appear to be traumatic. Even an older child who is given sensitive, comforting care will adjust well over time. However, a child old enough to have formed an attachment, but too young to have developed good cognitive and language skills, is likely to be traumatized if placed in the care of a busy, unavailable, insensitive, and unresponsive caregiver. Children between 6 months and two years of age are most likely to have the reaction that Grebenik appears to ascribe to all children.

Let’s look at another FoF statement, at http://www.focusonthefamily.com/parenting/adoptive_families/wait-no-more/attachment-problems-up-close-and-personal.aspx. Here, in a piece by Kelly and John Rosati, we see the advice that emerges (logically but incorrectly) from the attachment myths described by Grebenik. Here’s what they say about the advice given to adoptive parents of a baby, whose age is not stated, but who was at the crawling stage. The adviser (an adoptive parent, not a professional ) inquired whether the baby held his own bottle, and whether when crawling toward an interesting object he looked back “to show it to you”. When the parents replied Yes and No, respectively to these questions, their adviser looked grave and announced that they were “in for trouble” if they did not work to overcome these attachment deficits.

[Let me take a moment here to point out two things. The first is that because there is no evidence that the “attachment cycle” described earlier actually exists, there is no reason to think that holding or not holding a bottle has any relevance to attachment. As for the second, the adviser appears to be confusing two developmental steps. At about 10-12 months, well-developed babies display “joint attention” by looking back and forth from an interesting object to a caregiver, until they get the caregiver to look at the object “with them”.  This is not usually considered a measure of attachment. The step this seems to have been confused with is secure base behavior, in which a child exploring a strange place or situation will occasionally make contact with a familiar person, by coming back to the adult, by “checking back” with a look, or by calling to the adult.  Unless an interesting object was also frightening, no one would expect a baby in a familiar setting to do much secure base behavior as he or she explored. ]

What did the adviser then suggest? “…only John and I should hold Daniel, and only I should feed him (not even John!). She told us that we should never let him hold his own bottle; he needed to depend on me to provide him with what he needed. … And then came the kicker: I needed to hold him and be face-to-face with him for almost eight hours a day!”

This mother recognized the implausibility of the advice--  although she apparently did not think of the interference with Daniel’s normal mastery motivation and with the eight hours of normal activity he would be missing, or of the training in passivity that was being given here. Scared of the dire predictions of the adviser, she did as she was told. “After several months of this therapeutic parenting…Daniel began to make good eye contact… and was more engaged and more emotionally connected with us”. The mother attributed the change she perceived to the treatment given--  although in fact one might well expect several more months in an adoptive family to be accompanied by increasing maturity and attachment to the new caregivers. (Indeed, I would ask whether those changes were actually slowed by the “therapeutic parenting”!)

There you have it. “Focus on the Family”, an outfit that draws many readers because of its religious and social positions, has bought into a mythology of attachment that contradicts  conventional attachment theory and that culminates in diagnoses and treatment that are inaccurate and inappropriate. How about it, FoF? Isn’t it time to replace the attachment myths with evidence-based material about attachment---  and help rather than hinder parents?

  

Preschoolers and "Shooter Drills"

An e-mail last night from a friend who is on the staff of a day-care center brought up a question that I have not seen addressed until now: should we try to train preschool children to follow instructions to escape from a shooter in the building? Elementary and high school kids are drilled on what to do, and the cooperation of some of the children at Sandy Hook seems to have saved their lives. Why not do the same for preschoolers? My friend’s center is proposing to do this, but as she said, the idea does not seem to “sit right”. And I had to agree with her about that.

Like all teachers and parents nowadays, day care providers and preschool teachers have been forced to think about the impact of events like the Newtown killings on the children they work with. The National Association for the Education of Young Children—the primary standard- setting and accrediting body for early childhood programs—has provided a list of suggestions for helping young children feel more comfortable as they hear about kids being hurt or killed (see www.naeyc.org/content/coping-school-shooting). As far as I know, however, neither NAEYC nor any other organization has proposed that young children participate in “shooter drills” that involve running away and hiding, on cue.

Why is my friend’s center considering such drills? It’s not a freestanding center, but operates under the administration of a larger institution. The larger institution is responding to Newtown and other events by developing plans for dealing with a “shooter”, and in the course of this a member of the security staff--  father of a child at the day care center—has been assigned to develop a plan and educate the staff and children. But I am afraid that like many people who know little about early development, he has with the best of intentions simply seized a method used with older children and “pulled it down” to be applied to preschoolers. By doing so, he may be proposing a step that will not only be ineffective in an emergency, but that may in itself be harmful and disturbing to young children.

Let’s consider first how likely it is that a school shooting will occur at all. Just over 80 school or mass shootings between 1996 and 2012 are listed at www.infoplease.com/ipa/A0777958.html and this is the worldwide list. It  includes shootings in malls, religious buildings, and theaters as well as in schools. In other words, although constant repetition on the news gives us the impression that school shootings occur over and over, they are in fact quite unusual events, and a child is a good deal more likely to die in a car accident --  or by being shot at home-- than in a school shooting.

This doesn’t mean that we should not plan what to do in all emergencies, but we need to balance the good we can achieve by any move against the ill we may unintentionally cause by the same move. Just as it’s wrong to think that “any psychotherapy is better than no psychotherapy”, it’s a mistake to forget that our attempts to protect children can  have unwanted side effects, especially if they are not developmentally appropriate.

It seems hard for many people (including some parents) to remember this, but preschool children are as different from school-age kids as they are from infants. Preschoolers can seem very grown-up and often “talk a good game”, using big vocabularies and doing a good imitation of adult attitudes. But that’s when everything is going well. Let a 3-to-5-year-old feel sick, get hurt, or feel threatened, and it all comes apart. Young children’s natural response to distress is to hurry to a familiar adult and cling there. If there’s no adult, other children are the goal. Overcoming that tendency with drills is not very likely to be achieved. The more serious and intense the adults are, the more the children want to stay with them, and the more the children are likely to cry and become confused if pressed.  Loud noises and screaming would increase their tendency to stay close to their teacher rather than run away.

This suggests that “shooters drills” with preschoolers are not likely to be effective in the very unlikely event of a shooter appearing. And what would their probable side effects be? The essential characteristic of a good day-care center or preschool is that the children feel it to be a safe place. Feeling safe helps them overcome the well-known anxiety that accompanies separation from parents even at this “advanced” age. Unless young children feel secure in the presence of a familiar adult, their ability to explore and learn is diminished. What happens then when we face them—either with or without explanation--  with the idea that they must run away and hide rather than staying where they feel safe? If we explain the problem and introduce them to the idea that someone might come and shoot them right here in their own classroom, we can certainly expect repercussions, not only at school but in the form of fearfulness and sleep disturbances at home. If we don’t explain, but just run them repeatedly through a drill that will create concern and anxiety in the adults, the outcome can be similar--  especially if the children are not developmentally ready to do what the adults are urging them to do.

Expecting preschoolers to act to save themselves in a shooting attack is somewhat like expecting them to recognize what a child molester is doing and tell him “no”. Trying to teach young children these things may make adults feel better, but that’s all the good it’s likely to achieve--  and it may do harm.

I have an idea, though. If we want to protect young children from being shot—at school, in their homes, or on the street—why don’t we enact some serious gun control laws? It’s just a thought, but ya know, it’s so crazy it just might work.

  

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Guest Post by Jane Bongato: Helping Your Adolescent Cope with Pressures

Adolescence is a difficult time in any child’s life, no matter how well adjusted they may be. With their bodies changing and an increased self-awareness, most young people struggle with a number of age-related issues such as peer pressure, sibling rivalry, body image, self-esteem, depression, relationships and anxiety over their future career and education.

As parents, it is our job to guide them through this challenging period in their lives and make their transition from childhood to adulthood as easy as possible.

Following are some tips and advice on ways to mentor your teen and help them cope with all the pressures that come with growing up.

Be there for them

The best thing you could do as a parent is to be there for your child when they need someone to talk to or even just a listening ear. Make sure that your teen knows that you will always make time for them and encourage them to share their hopes, dreams, worries and problems with you.

Be quick to praise but slow to judge, and always remind them that they are valued and loved. Even teens who don’t seem too interested in bonding with you once they reach a certain age will appreciate the fact that you are making an effort to communicate and spend time with them.

Communication shouldn’t only happen when you are disciplining them or when you think there may be a problem. It should be a daily occurrence, even if it’s just a friendly chat about how their day went.

Try to connect on a regular basis by doing simple things together, whether it’s preparing a meal, watching a TV show you don’t particularly care for or agreeing to listen to their music in the car during a long trip.

Don’t smother them with your own expectations

It’s fine to encourage different hobbies, educational achievements or career paths, but take care that you don’t weigh them with your own expectations. Remember that the most important thing is for your child to be happy and have the ability to express their individuality, even if it means that they choose a style, boyfriend/girlfriend or career that you would not have.

Most teens naturally rebel against their parents’ way of doing things, and trying to force them down a certain path will likely only cause them to run in the opposite direction.

Instead of smothering, allow them the freedom to choose their own hairstyles, clothing, friends, education and career (unless, of course, these are in some way unhealthy for them). 

Don’t downplay their problems

It’s easy to forget what it was like to be a teen once we grow up and start dealing with other problems that we perceive to be more “real.” However, as parents, we must be able to put ourselves in their shoes and think back to what it was like to be a teenager; when a bout of acne before a school dance seemed like the end of the world or the end of a two-day relationship meant you would never love again.

It is important to acknowledge their problems and struggles, no matter how small they may seem to us. Laughing it off or telling them that “it’s not so bad” or that “it could be worse” is not helpful and will only heighten their sense of being misunderstood.

Respect their privacy

It can be extremely tempting as a parent to meddle in every aspect of your teenager’s life and justify such behavior by telling yourself that you are doing it to keep them safe. However, not respecting your teen’s privacy will prevent them from trusting you and could breed anger or resentment later on in life.

There is a fine line between looking out for your child’s wellbeing and snooping through their private life. Things like reading diaries, logging into their social media accounts or listening in on private conversations should be avoided at all costs.

If you are concerned about them or believe they are getting involved in something dangerous, the best way to deal with it is to approach them directly and ask them about it. Don’t be afraid to step in if need be, but don’t go to unnecessary lengths to spy on them either.

Teach them what they need to know

As awkward as some things may be to bring up with your teen, it is important to make sure that they have all the information they need on important topics like relationships, safe sex, STDs, eating disorders and drugs and alcohol.

Yes, they may cringe or tell you they don’t want to talk about it or that they know all there is to know, but ignoring these issues or assuming they will learn about it in school or from a friend could leave them open to serious problems down the line.

If you don’t feel comfortable talking about these things with them yourself, you may want to consider enlisting help from someone else, like an aunt, uncle or close family friend, as teens often feel more comfortable discussing such issues with someone who isn’t their mother or father.

Providing them with educational material is also a good way to ensure that they are well-informed, without having to sit them down for “the talk”.

About the author:

Jane Bongato is part of the team behind Open Colleges ( http://www.opencolleges.edu.au/)
 Australia’s provider of child care courses (http://www.opencolleges.edu.au/childcare-certificate-and-diploma-courses.aspx).  She is an early childhood educator  with a background in psychology and for the past six years has worked closely with special needs children. She enjoys reading, painting or meeting friends during her spare time. (Find her on Google+ )

More on the International Problem of Holding Therapy: Nancy Thomas in Russia

Yulia Massino, a Russian blogger, has called my attention to the visit of Nancy Thomas, an advocate of Holding Therapy, to Russia in 2012. Yulia is especially concerned about the possible influence of Thomas because little of the  U.S. criticism of Thomas’ methods has been translated into Russian. Unless Russian parents are fluent in English and have access to professional and other publications, they are unlikely to be aware of the existence of serious concerns about Thomas’ claims.

Thanks to Google translate, it’s possible for non-Russian-speakers to have a good look  at http://attach2me.ru, a web site offering material by Nancy Thomas and other proponents of Holding Therapy to a Russian audience. Like other advertisements for the Holding Therapy belief system, this one begins with an unusual definition of attachment as a desire and ability to prolong emotional intimacy with another person, rather than one of the more common definitions, like a preference for being near a person when uncomfortable or threatened. It proceeds to describe a mental health diagnosis called Reactive Attachment Disorder as including failure to make eye contact except when lying and an interest in blood and gore---  none of which are part of Reactive Attachment Disorder as defined by DSM-IV-TR or by ICD-10.

In a move typical of Holding Therapy proponents, http://attach2me.ru lists a peculiar mixture of books that are all said to be “about attachment”. These include an important volume by John Bowlby, the major theorist of attachment, and one by Bowlby and Mary Ainsworth, his collaborator  and creator of the idea of differing  qualities of attachment. (Articles listed in another section are also primarily by Bowlby.)  In addition, however, the book section includes translations of works by the Holding Therapy advocate Nancy Thomas and by Gregory Keck and Regina Kupecky, authors well-known to support a belief system that shares with Bowlby’s conventional system no more than a handful of vocabulary words. Also listed is a translation of a book whose senior author is Foster Cline, the erstwhile leader of the “rage-reduction therapy” movement of the 1980s and 1990s, and like his colleague Thomas a promoter of an attachment theory quite unrelated to Bowlby’s.

Two questions present themselves: What are the differences between the Thomas/Keck/Cline view of the attachment and the conventional attachment theory formulated by Bowlby? And, given that the two approaches are mutually contradictory, why would proponents of one want to mention the other approvingly?

The first question requires more details but is in fact simpler to answer than the second. Here are some basic differences:

1. The basic nature of attachment. For the Holding Therapy (HT) group, attachment is an emotional transformation something like religious conversion. Once done, it is difficult to undo or change, but shapes relationships through life by determining not only trust and intimacy, but obedience and gratitude to others. Disturbed attachment results in psychopathic behavior, serial killing, and sexual inappropriateness.

From Bowlby’s viewpoint, attachment is the formation of an early preference for familiar caregivers and sense of security in their presence. As cognitive and emotional development proceeds, existing attachments change toward  more mature relationships, and new attachments are formed. Early attachment experiences are one of several factors that determine later social relations.  Bowlby argued that poor early attachment can result in delinquency, but did not relate early experiences to later severe behavior problems.

2. The timing of attachment processes. The HT group considers attachment to exist prenatally as a result of some form of communication between birth mother and unborn infant, but also to continue to develop later. Newborns are thought to have a strong attachment to their birth mothers and to suffer grief and rage if separated (e.g.by adoption).

Bowlby’s theory of attachment focuses on social interactions with a small number of caregivers in the second half of the first year as critical to attachment, but assumes that new attachments can develop in the second year and later. Newborns (that is, infants in the first month after birth) are not thought to have attachment or to experience suffering if separated from their birth mothers.

3. How attachment occurs. The HT theory of attachment holds that this emotional commitment of the child increases through the first year insofar as caregivers can satisfy the child’s needs. (Infants with serious health problems are thought to fail in attachment if caregivers cannot comfort them.) The experience of need followed by gratifications presented by caregivers is referred to as the “first-year attachment cycle”, a concept absent from conventional views of attachment. Attachment is thought to be advanced and perfected during the second year of life when caregivers set limits on children’s behavior.

Bowlby’s theory of attachment focuses entirely on pleasant social interactions with familiar caregivers as the cause of attachment and the related sense of security with familiar people. Attachment is more difficult if caregivers are indifferent or unpleasant, or if the child has too many changes of caregiver.

4. How attachment problems are thought to be treated. The HT approach is based on the assumption stated in the last paragraph, that attachment occurs because of satisfaction of physical needs and because of limit-setting. HT methods, especially those sometimes referred to as “Nancy Thomas parenting”, aim at re-enacting the events HT advocates believe are responsible for early growth of attachment to caregivers. In order to satisfy a child’s physical needs, it is essential to be sure that these needs exist and can only be gratified through the intervention of the caregiver or proposed attachment figure. Children are forbidden or prevented from efforts to help themselves in age-appropriate ways like preparing food or using the toilet at will. The child’s diet is limited in amount and variety (one Russian adoptee in the U.S., Viktor Matthey, was apparently fed on uncooked grains), leading to malnutrition and weight loss; he or she may be made to sleep in a cold room; and toilet use is available only with the stated permission of the caregiver. Along with actual “holding” treatment, these methods are thought to prepare the child for a new attachment, which is cemented by means such as extended mutual gaze, rocking and cuddling of older children as well as younger, and hand-feeding of milky sweets in apparent imitation of the provision of  milk from the breast. As all behavior problems are thought to be based on poor attachment, these methods are expected to help with all difficulties.   

Conventional child psychotherapies based on Bowlby’s theory, such as Robert Marvin’s “Circle of Security”, focus on increasing parents’ and children’s communications with each other, so parents become more aware of children’s cues showing that they need comfort and security, and children in turn have improved social experiences. Specific problem behaviors  like speech delays are treated in conventional ways and are not linked particularly with attachment history.  

5. Safety and effectiveness. A number of cases of harm to children have been associated with HT and “Nancy Thomas parenting”, but no such association has occurred with conventional treatment. HT methods have no foundation in systematic evidence, but several conventional methods are evidence-based.

It is abundantly clear that the HT approach is vastly different in its assumptions about attachment than the conventional attachment theory developed by John Bowlby. Why, then, would http://attach2me.ru list together a series of books that contradict each other? The best explanation appears to be that the HT group wish to gain acceptance by “riding the coattails” of a major conventional psychological theory and associating themselves with a name that has been heard by every introductory psychology student for the last 40 years or so. Not guilt, but respect, by association is the goal of the promulgators of http://attach2me.ru. They’ve tried the same thing in the United States, but here they have met again and again with critical rejection by major professional groups. What a new frontier Russia must be for them--  a Promised Land where few have yet heard about the reality of HT, and most can’t read the endless criticisms of the method! Let’s hope that Pavel Astakhov takes note of what may be happening to Russian children in their own country.

N.B.  I believe I’ve heard that Jirina Prekopova is also making some approaches to Russia. What a Battle of the Titans that might be---  NT versus JP--- which can restrain the other longer?