Taking Turns is Hard to Do

Parents of toddlers, preschoolers, even school-age children sometimes feel there is no end to the task of getting children to share and take turns. It seems to be especially difficult—and embarrassing for parents—when the child is at a party or with “rivals” of their own age. The child’s own birthday party can be the worst, as he or she sulks, pouts, and makes every effort to prevent the party guests from touching any of the presents.

I suppose I needn’t point out how hard sharing and turn-taking is for us adults? We can’t see why there should such a fuss about a toy train, but we would not care for other people to expect to sleep in our beds or “take a turn” with our spouses. A whole lot of maturation and learning has gone into our adult capacity for sharing, such as it is. Yet, somehow we believe that it’s possible for a preschooler to have such a wonderful personality and such character that he or she will cheerfully share and take turns with the most precious toys in the toybox.

Well, guess what: it’s not possible. Whoever knows how to share, has learned to do it, with help and support from older people. It did not just happen, and what’s more, it did not happen in the moments of violent jealousy that are so conspicuous, but in various quiet events that took place along the way.

Looking through some papers the other day, I came across my notes from a lecture by Lisa Poelle, the author of the excellent book Chronic biting extinguished. Among other things, Lisa was considering the situations in which toddlers bite people, and thinking about ways we might make those situations less fraught and the children less easily frustrated. She had a number of suggestions about how we can prepare children for situations where we expect them to share or take turns.

One of Lisa Poelle’s suggestions was to find everyday situations where we can model taking turns by doing it ourselves and/or talking about how it’s being done, and by offering another person a turn doing what we have been doing. So, to take some of her examples:

1. “I’ve been stirring the batter for a long time. Would you like a turn?”
2. “Let’s play ball. My turn to roll it…  your turn to roll it… my turn.”
3. “Let’s put the puzzle together. I’ll do this piece… okay, your turn to do one. “
4. “You can have a turn with the truck after Sam has it for three more minutes” (N.B. one of those three-minute egg timers can be a big help on this one).
5. “I’m tying your sister’s shoes now. Next it will be your turn.”

A second suggestion is about helping the child know when a turn begins and ends. For example:

1.  “You put the doll down; that was the end of your turn. Jessica picked it up for her turn. When she puts it down it will be your turn again. “
2. Pointing out situations where characters in books or in videos take turns can also be helpful.

A third suggestion is to point out how often adults as well as children have to wait for their turn. For example:

1. “Let’s take a number at this counter. When the man is ready to wait on us he’ll call our number. We can look at these pictures while we wait.”
2.  “ All the cars are lined up to cross the bridge and each one gets a turn. We’ll wait for our turn before we go.”
3. “We’ll wait for the traffic light to change before we walk across the street. When we see the little green man on the sign, that means it’s our turn to go.”

One problem preschoolers have about waiting for their turn is that they don’t have a very good idea of time. When we tell them “wait just a minute”, we might mean a real minute, or five minutes, or we might forget all about what we said--  so they don’t get much of an idea about how long they have to wait. Again, an egg timer may help with the waiting, at least by providing some distraction. Distraction may also be helpful if the waiting child can be helped to find something else to do until her turn comes around.

Can we expect children not only to share and take turns, but to be cheerful about it? Eventually we get to be skilled at these social “white lies”, where we thank people for presents we hate, or smile cheerfully as someone takes the last two chocolates instead of one or spills red wine on our cream-colored carpet. But that takes time and practice, and perhaps some adult experience with how we feel when other people are grouchy about problems. There’s no harm in trying to work with a preschooler on how to be polite when cross, but we need to remember that their basic tendency at this age is to become incensed and flounce around in a towering huff, several times a day. There is no taker of umbrage like a four-year-old! Our job, perhaps, is to avoid having our own anger triggered by  the child’s ire—and to be sure that we do not respond angrily just because we are embarrassed in front of other adults. There’s more to model for the child than just turn-taking, and being calm when someone else is mad is something we should display to children if we can manage it.

Should an Eighteen-Month-Old Be Seen by an Autism Specialist? Yellow Flags

As we all know, various Internet sites proclaim “red flags”, or behaviors of young children that may be associated with a later diagnosis of autism. Unfortunately, these “red flag” sites usually neglect to explain the considerable overlap between typical and atypical behavior, or the fact that behaviors very typical of infants can closely resemble the behavior of older children diagnosed with autism. Worried young parents see one “red flag” behavior that is characteristic of their [usually quite young] infant and convince themselves that they must find treatment at once.

But in fact, for children under the age of two or three years, atypical behaviors are only “yellow flags “, or “caution” signs, and even that only if several of them are seen. A small group of “yellow flags” in a toddler simply suggests that the child should be observed and his or her development should be watched more carefully than might usually be needed. These “yellow flags” act as a screening device that helps to focus on a small number of children of whom some are going to need special help.

                        Quite a few years ago, the British psychologist Simon Baron-Cohen (yes, brother of you-know-who!) developed a checklist to help pediatricians screen for toddlers who should be seen by an autism expert. Now, let me point out once again that these children are EIGHTEEN months old or older when screened with this checklist. They are not 12 months or 6 months, and they certainly are not 4 weeks old!  Let me also point out that one or two or even three atypical responses does not mean a diagnosis of autism; this whole thing is about finding the small number of children whose diagnosis needs a highly specialized professional examination that can rule out this particular problem for many of the kids.

So, given all that, here are some questions that might be asked a parent of an 18-month-old:

Does your child enjoy being swung, bounced on your knee, etc.?

                        Does your child like climbing upstairs or up on other things?

                        Does your child enjoy peek-a-boo and hide-and-seek?

                        Does your child ever PRETEND? (Baron-Cohen uses the Brit example of pouring                         and drinking tea, but other examples might be stirring a spoon in an empty                                                    pot, or using an electric cord as a “stethoscope” after visiting the doctor.)

                        Does your child ever point a finger to ASK for something?

                        Does your child ever point a finger to show INTEREST in something?

Can your child play with objects by rolling a toy car or building with blocks, rather than just mouthing or dropping them?

Does your child ever bring objects to you to SHOW them to you?

Notice, by the way, that some of these questions ask whether the child EVER does certain things. The fact that he or she does not do them all the time is not important, but if they are never done, that may be important.

Baron-Cohen’s list then goes on to questions for the pediatrician and what he or she has observed about the child:

During the appointment, has the child ever made eye contact with you?

If you get the child’s attention and then say “oh look!” as you point at an interesting object, does the child look where you are pointing?

If you get the child’s attention and then give him or her an object that could be used to pretend (the teacup again--  but any toy can be used ), and ask if he or she can drink the tea, stir the pot, etc., does the child do so?

If you ask the child to show you a light or other object, does the child look up at your face and then POINT?

Can the child build a tower of two or more blocks?

Once again, the issue is whether the child does most of these things a lot of the time. If he or she does, the possibility of a later diagnosis of autism is remote. If the child does not do most of the things mentioned, there may still be reasons other than autism for the problem, but it would be a good idea to see a specialist who can make sense of what is going on. Whatever the trouble may be, it may be time to seek treatment and help to move the child along developmentally as much as possible.

That was EIGHTEEN months, remember! And those flags are yellow.  

   

   

Webinar for Parents Of Children with Disruptive Behaviors 6/17/2016

Hello everybody-- I want to call your attention to a webinar for parents that will be held by the National Center on Birth Defects and Developmental Disabilities on Friday, June 17, 2016, 1-2:30 PM Eastern time. To register, go to htpps://goto.webcasts.com/starthere.jsp?ei=1105300. There is no charge for participation.

This webinar is about learning to do a parent version of behavior therapy for children whose behavior is disruptive, perhaps because of ADHD.

According to the announcement I received:

During the webinar, parents and families will learn about:

·        What is behavior therapy for young children and why it is delivered by parents; the parents’ role in fostering a healthy and positive environment for their children;

·        What parent training in behavior therapy looks like (including what programs and interventions are effective for young children with ADHD and other disruptive behaviors);

·        What they can expect when being trained in behavior therapy (setting, number of sessions, activities during sessions, homework, time to see progress, types of skills addressed in the training);

·        When medication is recommended for children with ADHD;

·        Questions to ask their primary care physician or referring clinician;

·        Questions to ask a potential parent training provider before beginning training in behavior therapy;

·        How to monitor treatment progress to decide whether or not a provider and/or treatment is a good fit for your child’s needs.

This promises to be a very helpful experience for parents who are concerned about children's disruptive behavior!

Maltreated Toddlers in Foster Care: What Can We Do for Them?

A week or so ago I had an email from a CASA (court-appointed special advocate) working in Washington State. She asked a very reasonable question: So, you say not to send young foster children for Attachment Therapy. Well, what are our options? What should we do to help them?

In reply, I sent her a journal article and suggested that she read about the Attachment and Biobehavioral Catch-up  (ABC) program directed by Dr. Mary Dozier of the University of Delaware. Dr. Dozier has spent 22 years developing this program and has reported four randomized controlled trials showing its benefits to children who have experienced serious adversity. ABC is now being implemented in 15 states and is wanted in others, but Dr. Dozier is concerned about maintaining high fidelity to the original program and must thus move more slowly than we might like.

ABC is a 10-session program, done in the home by trained coaches, which targets key child issues resulting from experiences of adversity. The focus is on parenting behavior, not on underlying attitudes or motives, and the parents may be neglecting birth parents, foster parent of toddlers, or parents who have adopted internationally. Randomized controlled trials have supported the effectiveness of ABC as done by certified coaches, with long-term positive effects for children’s development. The coach does not interact with the children, but watches and comments on the parent’s behavior.

ABC teaches and increases three basic parenting behaviors: 1) nurturance, 2) following the child’s lead, and 3) non-frightening behavior. These behaviors are not all carried out at the same time, so a challenge for a parent is deciding which kind of behavior is suitable at a given time.

Nurturance, or comforting or helping when the child needs this, is especially important for children who have experienced early adversity. Their high rate of disorganized attachment behavior shows that they have no consistent strategy for deciding whether to approach or avoid an adult caregiver, so caregivers need to be able to recognize situations and subtle communications showing a need for nurturance. When toddlers are avoidant or resistant to nurturance, caregivers tend to respond “in kind” – to feel rejected and to avoid trying to comfort the child. To increase nurturance, ABC-trained coaches actively comment in the moment by making, once a minute, positive comments on a caregiver’s nurturing behavior, like going to a child who has fallen down or picking up a child who approaches the caregiver.

Increasing parents’ nurturing behavior helps to decrease the non-nurturing behaviors that are too easily resorted to when toddlers are perceived as avoiding caregivers. These behaviors include making fun of the child, acting on unrealistic expectations of the child, deliberately letting a child get into difficulty “so he will learn”, telling the child “you’re okay, you’re not hurt” or “you’re too big to cry”, ignoring the child, or distracting the hurt child by pointing to something interesting. These actions all tell the child that the parent is saying “you don’t need me”, whereas the fact is that the child does need a nurturing caregiver and needs to identify a specific adult as actually being such a person.

Nurturing behavior involves responding to the distressed child’s needs with minimum--  or perhaps, no—signals from the child.  This behavior is different from  following the child’s lead, in which the parent responds to a child’s interest signaled by speech, gaze direction, movement, or toy play. For example, if a toddler is banging two blocks together, a caregiver might follow his lead by banging two other blocks or by putting one block forward to join in the banging, or jut by saying “bang!” each time. A caregiver is not following the child’s lead if he or she takes one of the blocks and asks the child to say what the letter on it is, or takes the blocks and starts to build a tower with them.  These parent activities have their place, but ABC tries to increase the adult’s success in identifying the child’s interest and making use of it for pleasurable communication. 

Parent behavior that does not follow the child’s lead can be “teach-y” under the wrong circumstances, bossy, intrusive, or ignoring. Of course, there are many times when a caregiver appropriately does not follow a child’s lead, especially when limits need to be set or boundaries established. The ABC goal is to increase the caregiver’s ability to follow the child’s lead when doing so is appropriate--  not when the child’s lead will take the child or others into danger.

ABC-trained parents also learn to avoid frightening behavior that makes it more difficult for a young child to stay calm and regulated. This includes intrusive behavior like grabbing or tickling. For a child who has experienced severe adversity, typical “normal” parent-toddler games like “I’m gonna get you”, the threatened tickle with a finger that goes around and around near the child’s belly, or exciting chasing and hiding, may all be inappropriately frightening. The child who still struggles with knowing whether to approach or avoid a caregiver may interpret even play at frightening behavior as a signal that this adult should be avoided if possible.   

The ultimate goal of ABC is to improve the ability of the child to stay calm and regulated in the everyday circumstances of the home. This improved regulation allows the child to learn and communicate more effectively and to have more inhibitory control. One of the ABC outcomes is that children of ABC-coached parents later have more success than controls in a laboratory test where they are shown some fascinating toys and told not to touch them by an adult who then leaves the room.

When Internet sites for foster and adoptive parents tell parents that conventional treatment “just makes a child worse”, or when they advocate highly authoritarian, intrusive, managing methods that are supposed to make maltreated children “attached” and therefore obedient, they are badly mistaken (to put it politely). Evidence-based treatments like ABC and PCIT (Parent-child Interaction Therapy) can make enormous positive differences to the lives of children and families. I hope my CASA correspondent will pass along what I told her to others and help them understand this.

What Does Evidence-based Therapy for Children Look Like?

If you’ve never been in psychotherapy, the idea can be a pretty scary one. Revealing ourselves and our problems can seem so intimidating that we may think we’d rather just have the problems. Taking your child to psychotherapy is even scarier--  what will they do when I’m not there? What will they talk about? Will they say the problems are all my fault? Will my child learn to disrespect me? Will the therapist work against our family values? Parents may have to feel pretty desperate before they are ready to face some of the possible answers to these questions!

When people start talking about evidence-based therapies, that can be scary too. The term just means that these treatments have been systematically tested and shown to give good results, but many parents are not sure what’s evidence-based and what isn’t, or how these “scientific” methods look different from any other kind of treatment. (Maybe they even involve electric shock, some may fear.)

Fortunately, you can now have a good look at what happens in some evidence-based treatments for children, thanks to Dr. Cynthia Hartung of the University of Wyoming and her graduate students. They have made  a series of youtube presentations that describe and give examples of treatments for certain childhood problems—I found these not only informative but quite fun to watch. You will enjoy watching them yourselves, but I will give a little summary about each.

1. Cognitive-Behavioral Therapy for Adolescent Depression

by Brooke Merrow & Kendal Binion

https://www.youtube.com/watch?v=VXJy0X0OZtI

This presentation gives an excellent discussion of the basic ideas of cognitive-behavioral therapy (CBT). This treatment is based on the very real links between thoughts, feelings, and behaviors. Changing the way people think about situations or people (including themselves) can change the feelings they have, and that in turn can change their behavior. Or things can work the other way around--  if behavior can be changed, the result can be that people think and feel differently about some aspects of their lives. Depressed behavior (like staying in bed all day) can create negative feelings and subsequent negative thoughts about the world, for example, and changing that behavior can give someone a chance to experience better feelings and more positive thoughts.

2. Coping Cat to Treat Anxiety in Children and Adolescents

by Andrea Slosser & Shira Kern

https://www.youtube.com/watch?v=qE5QpJ_FaJ8 

This presentation discusses treatment for the debilitating anxiety some children and adolescents experience, anxiety that interferes with many of their normal behaviors and experiences. It affects school performance, sports, friendships, and family relationships. An important point is that children’s anxiety may not be shown by restlessness or a fearful expression as we might expect, but instead may show up as irritability. Sleep problems may also occur and are likely to make parents more irritable too, as their sleep is disturbed by the child’s disturbance.  

3. Parent Management Training for Childhood Behavior Problems

by Adam Ripley & Alejandra Reyna

https://www.youtube.com/watch?v=YMl8cKe9DD0  

This presentation focuses on way parents can learn to help children whose behavior is hyperactive, oppositional, or aggressive. These children may have been diagnosed as having Oppositional Defiant Disorder (ODD), Attention Deficit Hyperactivity Disorder (ADHD), or Conduct Disorder. The point of parent management training is not to blame parents or say they have caused a child’s problems, but to call to their attention how they can respond to the child’s behavior in ways that can make “good” behavior more likely.

The basic idea is that under certain circumstances (antecedents), an unwanted behavior may occur. The consequences or results that follow that behavior will help to determine whether the behavior will happen again if the same antecedents are present (for instance, a child being teased or frustrated). To help decrease unwanted behaviors and increase wanted ones, parents need to follow the wanted behaviors by a positive reinforcement. (The video gives an excellent discussion of rewards and punishments.) Methods like time-out try to ensure that children are not accidentally rewarded for unwanted behaviors.

Of course, for any of this to work, the child must be able to do what is wanted, or to stop doing what is unwanted.

4. What is Trauma-Focused CBT for Children & Adolescents?

by Kati Lear & Sarah Steinmetz

https://www.youtube.com/watch?v=JTcjMPoxUTM  

This treatment is aimed at reducing the distress and anxiety children and families experience after a child has been exposed to trauma--  an incident in which there is extreme fear and helplessness. A recent example of such a traumatizing event is the experience of the Cincinnatti family whose three-year-old slipped into the gorilla pit at the zoo during the Memorial Day weekend of 2016. A child who experiences a very frightening event may later have “flashback” memories as if re-experiencing the incident, may have family and other relationship problems and emotional outbursts along with difficulty in obeying rules, and these problems may last over some time, with impact on the family members’ states of mind and ability to help the child. The treatment helps child and parents identify and talk about the emotions connected with the event and eventually become able to talk to each other calmly about what happened.

 I hope that readers who are concerned about child emotional problems and who are hoping for effective treatment will look at these videos (thanks, Dr. Hartung and students!) and will also have a look at www.effectivetherapy.com for further discussion of evidence-based treatments for children. Do note that these treatments are not a matter of interminable psychotherapy--  generally, they involve fewer than 20 sessions, once a week.

Thank, Brian Allen, for Saying "Down With Attachment Disorders"!

A leading clinical child psychologist, Dr. Brian Allen of the Center for the Protection of Children, Penn State Hershey Children’s Hospital, has stood up to make an important statement. His recent article, still in early online form in the new journal Evidence-based Practice in Child and Adolescent Mental Health, is entitled “A RADical idea: A call to eliminate ‘attachment disorder’ and ‘attachment therapy’ from the clinical lexicon”.

Noting that those two terms are well entrenched in graduate education, parenting information, adoption work, and so on, Allen points out that “neither of these two concepts is empirically sound as commonly practiced”. In other words, the assumptions frequently made about the nature of attachment, even by well-trained and legitimate practitioners, are often unsupported by systematic evidence.  

One source of confusion about “attachment” as a clinical concept is that  attachment behavior and attachment theory are two very different things. Attachment behavior is observable and happens in the great majority of children between about 9 months and about three years of age. It involves responding to threats or discomfort by getting and staying close to familiar caregivers. Although most children do this, the manner and intensity of their behavior depends in part on individual  differences and on the caregiver’s response. Children who have experienced many changes of caregiver, or who have had insensitive or unresponsive  caregivers, will still show some attachment behavior in most cases, but (as Mary Dozier has shown) their behavior may be so subtle and understated that caregivers have trouble noticing it--  for example, they may just glance up at a caregiver who leaves the room, rather than bursting into tears and following him.

Attachment theory, like all theories, attempts to put observable attachment behavior into a framework that makes sense and helps us predict what kind of behavior may occur later. In John Bowlby’s first formulation of attachment theory, he proposed a framework that included the development of an internal working model (IWM) of social relationship. The IWM would begin with what a baby learned in the early relationship with a caregiver, including the valuable comfort of being able to get close to the caregiver in distressing circumstances.

The theory of the IWM, and its changes as a result of maturation and experience, provided an explanatory framework for the ways attachment behavior changes with age. As Allen points out, a basic fact about attachment behavior is that it alters as a result of a variety of experiences and goes on altering for many years. Later attachment behavior is not entirely determined  by early events, and the later events that affect this behavior do not always seem to have anything to do directly with attachment (e.g., mothers’ confidence). It is a great mistake to try to cherry-pick portions of attachment theory , such as the importance of early sensitive and responsive caregiving, but to neglect the message of this theory about the long-term changing and reshaping of attachment behavior as the result of a range of experiences. Unfortunately, terms like “attachment disorder” and “attachment therapy” have become shorthand for “early caregiving effects”, and their use often implies that the user is ignoring the larger picture of attachment theory.

With respect to the term Reactive Attachment Disorder, once thought of as encompassing two separate and somewhat opposed forms, Allen points out that one of those forms is now described as Disinhibited Social Engagement Disorder  and divorced in terminology  and otherwise from the attachment concept. The remaining use of the term Reactive Attachment Disorder is applied to a very small proportion even of  children with histories of severely neglect. What’s more, this disorder appears no longer to be present after children have been in family settings for a while, so presumably these children were not locked into the effects of their earliest caregiving experiences, but like anyone else are able to continue the development of their models of social relationships on the basis of maturation and new experiences. This means that the word “attachment” in the current name of this diagnosis has little meaning--  but it particularly lacks the very narrow meaning  so often ascribed to it.

Allen proposes that we stop using terms that incorrectly attribute behavioral problems to attachment difficulties, and that we stop saying we are treating attachment when in fact we are working with specific problems of parents and children. Not all relationship problems are attachment problems, and many behavior problems are not relationship problems  in any case. When we use terms that confuse the issues both of causes and of treatments, we make ourselves more likely to make serious mistakes.

What do we do then? How do we change the familiar names that make us think, wrongly, that we are actually talking about a specific aspect of attachment? Allen suggests a new emphasis on outlining the  problems a child or family is experiencing--  for example, aggressive behavior or callous/unemotional traits--  and adding to these what we know of a history of maltreatment. Then, treat the problems with well-established treatments, and, I would say, forget the popular belief that treating the problems successfully is wrong because  it ignores the “underlying” cause. 

Reactive Attachment Disorder and Attachment Disorder: Compare and Contrast

My colleague Linda Rosa recently sent me a link to an apparently highly commercialized organization called “The Adoption Exchange”. At https://www.adoptex.org/events/understanding-attachment-2016-april-18/, The Adoption Exchange announced a class that purported to explain the difference between Reactive Attachment Disorder and Attachment Disorder, as well as informing students about parenting methods that “heal attachment issues” in adopted children. The instructor was a licensed professional counselor. Nevada social work education units were said to have been requested for this class. A list of learning objectives was provided, but these were puzzling to me because rather than stating some active performance demonstrating mastery (such as being able to define certain terms or differentiate between two conditions), as such objectives ordinarily do, they simply referred to understanding as an objective. (But this is a problem for the Nevada social work association, not for the rest of us.)

I don’t know what the instructor said about differences between Reactive Attachment Disorder and Attachment Disorder, but I think I can guess, because of the very fact that she proposed to discuss a difference between one well-established diagnosis, and another that is essentially the invention of a group who are confused about the nature of attachment and of any problems that may result from a poor attachment history. The title of the course, “Understanding Attachment”, might be better stated as “Completely Misunderstanding Attachment.”

The term Reactive Attachment Disorder has been in the Diagnostic and Statistical Manual of the American Psychiatric Association since about 1980. It’s a term that has gone through various changes over the years, as has indeed been the case for a lot of other diagnoses as well. RAD was initially a term that shared much with nonorganic failure to thrive (NOFTT) as a description of poor weight gain and physical development in the first year or so of life. Because poor development can and does often result from physical disease processes (referred to as failure to thrive, FTT), RAD/NOFTT was a relatively new concept, suggesting as it did that poor growth and development might also result from disturbances of relationships with caregivers, such that a baby did not ingest enough food or was unable to digests and use what was provided. (I remember a lecture on this topic in the ’70s that gave as an example a mother who was so anxious that her baby would not eat enough that she attempted to entertain him after every bite by putting an umbrella up and taking it down again, which amused the baby but distracted him from eating.)  By the 1980s and ‘90s, the failure-to-thrive aspects of RAD had disappeared from DSM, and the term focused entirely on behavioral indications of infant-caregiver relationships. At that point, a spectrum of attachment relationships was envisioned, with normal attachment behavior in the “Goldilocks” position, and aspects of RAD on either side of that--  one side involving children who were did not seem to prefer one adult to another, and the other side including those who were excessively clingy and afraid of separation. The current, DSM-5, position has divided these possibilities into two separate categories, Reactive Attachment Disorder (involving aloofness, unresponsiveness, difficulty in engaging in relationships,  and difficulty in receiving comfort), and Disinihibited Social Engagement Disorder (lack of preference for familiar people, exploring without normal “checking back”, and willingness to go with strangers). Both of these begin before age 5 years (but after 9 months) and are preceded by poor caregiving experiences.

You can see that those two diagnoses, as currently defined, are based on different kinds of behavior . So, how are they different from attachment disorders? Given that the term “attachment disorder” is written all lower-case, they are not entirely different. “Attachment disorder” (all l-c) is a general term that can be applied to either RAD or DSED, and has been applied to disorganized/disoriented attachment behavior in toddlers.  “Attachment disorder” (all l-c) is not meant to indicate a particular kind of problem, any more than “childhood rashes” necessarily means rubella.

However, when people capitalize those words--  Attachment Disorder—they think they mean something specific. Even in the 1990s, proponents of Holding Therapy/Attachment Therapy, who claimed that childhood aggressive or noncompliant behavior resulted from attachment problems, had been told frequently that the things they were talking about were not Reactive Attachment Disorder. As a result, they proposed a new term, Attachment Disorder (with caps) that they claimed was characterized by failure to make eye contact on a parent’s terms, love of blood and gore, aggression toward small children and pets, etc. Elizabeth Randolph, a psychologist whose license had been revoked in California, self-published a test she called the RADQ (not Reactive Attachment Disorder, but Randolph Attachment Disorder Questionnaire [Randolph, 2000]). Randolph, felt that she could validate this questionnaire against her own diagnosis, because she was able, she said, accurately to determine which children had Attachment Disorder—for example, Randolph stated, they were unable to crawl backward on command. Randolph clearly stated that the RADQ did not diagnose RAD, but instead tested for  Attachment Disorder, a diagnosis that was “not yet” in DSM. Sixteen years later, AD is still not in DSM, and the reason is that no one has done any of the substantiating work to show that such a diagnosis differentiates reliably between a specific problem and other problems a child may have.

No one would deny that there are children who are highly (and dangerously) noncompliant, or who seem fascinated by aggressive acts, or who attack both adults and younger or weaker beings. What would be denied is that there is any evidence that such problems are associated with attachment history, or that they can be cured by treatments that focus on attachment. What would also be denied is that there is a need for an additional diagnosis to replace disorders like Obsessive Compulsive Disorder, Oppositional Defiant Disorder, early onset schizophrenia, and so on.

The Attachment Disorder (with caps) concept has been a money-spinner for a shadowy world of practitioners who have little training in either established theory or research facts about attachment. They have sold their views to adoption organizations, who in turn market them to confused and overwhelmed adoptive parents, for whom the idea of fixing previously-damaged attachment is most attractive.

I doubt very much that the instructor of “Understanding Attachment” made any of these points.

       

Are "Coaches" the Same as Psychologists or Psychotherapists?

Anyone can ask a friend for advice, and many friends will give it. The advice may be right or wrong, the friend may or may not know what she is talking about—but it is pretty certain that a friend will not ask for a fee or for agreement to a contract before she gives her opinion.

Today, quite a few people ask for advice from a “life coach”, a “parenting coach”, or one of several other recently-invented kinds of coaches. These coaches may or may not be more knowledgeable than a friend is, and their advice may also be right or wrong. But it is pretty certain that the coach will want a fee, and the coach may also ask for a signature to a contract that protects the coach’s interests. Psychologists, counselors, mental health professionals, clinical social workers, and other licensed sources of advice and help also get paid and often do use a contract to state agreed-upon protections for both parties.

So what is the difference between coaches and mental health professionals? I don’t want to suggest that every member of one group is vastly different from every member of the other, but I do want to point out that coaches may be people whose qualifications are far below those of even a low-level licensed mental health practitioner. I’ll give two examples--  again, I emphasize, not characteristic of all coaches, but showing the worst possibilities.

I’ll begin with Debra “Kali” Miller, an Oregon psychologist whose license was revoked by her state professional licensing board (see http://childmyths.blogspot.com/2015/03/license-revoked-become.html for further details and sources). Miller’s conduct was brought into the open when a boy she had been treating, and whose family she advised about how to act toward him, attempted suicide and was taken to a hospital. There, he told staff how he had been made to crawl on the floor, to be fed with a baby bottle, and to be isolated for periods of time, as advised by Miller’s mentor, Nancy Thomas, a foster parent and self-appointed instructor with a lucrative system of camps and family advice. The board objected not only to Miller’s unconventional and dangerous practices, but to her failure to diagnose the boy’s depression and her use of a highly unconventional belief system to attribute all difficulties to “attachment disorders”. But were Miller, or Nancy Thomas, impressed by this turn of events? No, indeed; instead, Miller now presents herself as a “parenting coach” and is welcomed as such on the Nancy Thomas website. The fact that she has been disciplined and may not practice her profession in Oregon because of her conduct is nowhere mentioned. Now she is a coach, and all that unpleasantness about the suicide attempt is left behind.

For a second example, let’s have a look at one Dorcy Pruter, inventor of a “treatment for parental alienation” (hard to know where to put the quotation marks here, as all the words are questionable). The statements I am about to make here are based on court documents on display at www.tsimhonirevisited.com. Pruter was sued in U.S District Court in Wyoming in 2015, by her former client Theresa Breen, who had hired Pruter to help with a high-conflict divorce and custody disagreement. Pruter states in the trial transcript that she was a high school graduate without any college education and took courses offered by various coaching companies. She started a business called the Conscious Co-parenting Institute. A contract between Breen and Pruter is available. In it, this high school graduate agrees to “provide consulting services to compile evidence, create timelines, and write scripts to provide to Clients (sic) legal team referencing her legal custody dispute between Client, her former spouse and other professionals in her specific custody case.” This was to be done to some extent “on spec”, with Pruter receiving 20% of any settlements or awards. The agreement also stated that Pruter and her company were held harmless financially against any claims arising out of the contract.

Now comes an interesting part. The agreement also covered an Acquisition of Life Story Agreement, wherein Pruter established claim to the use of Breen’s life information for academic research or any other purposes. Indeed, for Breen to use her own life story, she would have to ask permission of the Conscious Co-parenting Institute. Interestingly, in comments on this case, the psychologist Craig Childress noted that as Pruter was not a licensed psychologist, she did not need to conform to professional ethics as presented by the American Psychological Association.

These two examples show that it is quite possible for individuals to market themselves as coaches either without professional training or with serious disciplinary actions by professional licensing boards in their backgrounds.  As a result of these facts, professional psychologists and other practitioners are concerned about the quality of assistance given by coaches. Judith Gebhardt, writing in the American Psychologist, examined some of these issues in an article entitled “Quagmires for clinical psychology and executive coaching? Ethical considerations and practice challenges” (2016, 71, 216-325).  

Gebhardt noted that “Clinical therapists work under clearly documented governance rules and explicit ramifications for malpractice, including reporting of noncompliance and breaking confidentiality. In comparison, coaches operate in a nongoverned profession where the ICF [International Coach Federation] acts as a credential-granting and self-anointed entity, with no oversight body, for example, a state or federal regulator. … Although the coaching profession has taken steps to address ethical breaches, self-oversight and self-management merits attention. …it is still the words from Sherman and Freas  (2014) that seem most appropriate: ‘It’s the Wild, Wild West!’  for the coaching industry and practitioners…” (p. 226).  (Although Gebhardt does not mention this, the ICF seems to be functioning like other quasi-professional groups, e.g. the American Psychotherapy Association, which provide impressive-sounding diplomates and certifications for very little in the way of training or accomplishment.)

I have no doubt that some coaches are exactly the right source of help for some clients, and no doubt someone can provide two examples of excellent coaches to match my examples of two poor ones. I am writing this simply to say caveat emptor--  it’s a client’s responsibility to make sure of the quality of services sought, most especially if that client is making decisions on behalf of children or other vulnerable persons. Craig Childress’ statement that a coach does not have to conform to ethical guidelines tells us much about the possible outcomes of choosing a coach over a licensed mental health professional.

  

   

Swaddling and Sudden Infant Death Syndrome

A brief article in the Science Times section of the New York Times this morning was enough to strike terror into the hearts of young parents: it associated swaddling of babies with SIDS. The article reported a risk of SIDS increased by about one third for babies who were swaddled, with the greatest risk for those sleeping in the prone position.

For readers who haven’t come across this, swaddling is a traditional infant care technique that involves wrapping a baby, fairly tightly, from feet to neck. The head is free and sometimes the arms are too. Some Native Americans used to do this by binding the baby to a cradleboard. As I understand it, the Russian tradition was to use long strips of fabric and to keep the baby swaddled much of the time until a year of age. (These babies were frequently unwrapped to be fed and cleaned, of course.) According to some observers, swaddled babies were sometimes so thoroughly bound that they could be picked up by the feet without bending their bodies. The purpose of swaddling was described as keeping the babies warm, making them easy to carry, and calming them. In developed countries today, swaddling is infrequent except for very young infants who may be tightly wrapped in blankets as a soothing measure. Older babies are usually put into “sleep sacks” or “sleeper” suits to keep them warm while avoiding the loose bedding associated with suffocation during sleep.

So, what about this article that looks at swaddling as a cause of increased SIDS rates? The article, by Anna Pease and colleagues, is titled “Swaddling and the risk of Sudden Infant Death Syndrome: A meta-analysis.” It appears in Pediatrics, May 2016 (pediatrics.aappublications.org/comtemt/early/2016/05/05/peds.2015-3275).

Pease and her colleagues did a meta-analysis by examining data from four studies of SIDS cases, with each case compared to a control infant who did not die. The studies used had appeared over a period of 20 years and used cases from parts of England, from Tasmania, and from Chicago. About 35% of babies were swaddled in Tasmania in the 1980s when that study took place, while about 9% were swaddled in Chicago in the 1990s, about 10% in an English study ten years ago, and about 6% in a more recent English study. Across all studies, about 17% of the babies were swaddled for the sleep that ended with their deaths, and about 10% of the surviving, control babies were swaddled. However, only in the English studies was the difference between swaddled and unswaddled babies’ deaths a statistically significant one, and only in the more recent one did this statistical significance remain after adjustment for other possible causes of SIDS. Babies found dead in the prone position were more likely to have been swaddled, and older babies who were swaddled were more likely to die than younger swaddled babies, whatever their sleep position.

Pease and her colleagues did a careful job of stating the limitations on conclusions that could be drawn from their study, and especially noted that none of the four studies they worked with gave a careful definition of swaddling. They did not advise against swaddling young babies, but did note that there should be an upper age limit of about 4-6 months on swaddling.

For me, this study raises questions about other factors that could both encourage parents to swaddle older babies and increase the chances of SIDS. Why, for example, did any of the parents in these studies continue to swaddle an older baby? The reasons could have had to do with the baby’s own characteristics; when a baby still sleeps very poorly and is easily distressed at age 4-6 months, parents may try to soothe him or her by swaddling or other techniques that were recommended to them much earlier, but there may be developmental problems related to the poor sleeping that are the actual causes of SIDS. Or, the reasons could emerge from characteristics of the parents; parents who abuse drugs or alcohol or suffer from physical or mental illnesses may choose to continue to swaddle because of difficulty in thinking about their babies’ developmental status and needs, or because they are especially disturbed by infant awakening and crying, all situations that are associated with less adequate physical and medical care for infants. Finally, use of swaddling with older infants may be associated with living conditions; parents might choose to swaddle older babies to keep them from rolling off a bed or sofa where they were put to sleep in the absence of a crib, or because of demands of other household members that they try to keep the baby quiet, all of these suggesting the poverty and overcrowding that can compromise infant health and make SIDS more likely.

Factors that make SIDS more or less likely are complex, and it is difficult to pull out single factors that by themselves cause or prevent SIDS.   In addition, making changes—for example, in sleeping position—may pose some developmental risks as well as possibly being associated with a decreased SIDS rate. Babies who use pacifiers/dummies have been reported to have lower SIDS rates, but it is not clear whether rhythmic sucking has a protective factor or whether the parents who provide a pacifier have other characteristics that make SIDS less likely.

Is there a take-home message here? Am I saying swaddle or don’t swaddle, sleep prone or sleep supine? No, simply that we all need to take a deep breath and think carefully about SIDS information as it emerges. It will take a long time to understand this complicated and terrifying phenomenon, and it is not likely that there will be a single action that will save our babies. All parents can do is their best, and it’s an awful truth that sometimes that’s not good enough.

Worried Sick About Autism? Read This Mother's Letter

I have a one year old son who is an absolute delight. He smiles and laughs, and uses eye contact effectively to communicate and interact. I wanted to post because I visited read your page numerous times when I was feeling anxious and found your rational and informative responses reassuring. Up until about 9- 10 months I was incredibly anxious that my son wasn't interacting much or communicating well- particularly in terms of eye contact. I identified with so many of the concerns that people have posted, including fears about Autism even though I knew that such early diagnosis is not possible. I took him to the Dr a few times and despite their reassurance, my gut feeling was that something was wrong. I think parents with young children are faced with a lot of information and we also spend time around other babies who are developing different skills at different paces. Whilst this can sometimes be reassuring it can also be unnerving, depending on perspective at the time. On reflection I think I had some unhealthy postpartum levels of anxiety and seeking treatment for this helped me to shift my focus and start to enjoy my son again while his social skills continued to develop.
Thanks for all the work you do and the time you take to write replies. It’s a minefield out there and a lot of the other information I came across on the internet served to heighten, not allay my fears. 

This letter from "Anonymous" was so welcome to me. Naturally I like to be told that I'm doing a good job--but I also hope that posting her words will send a meaningful message to the many young mothers whose anxiety becomes overwhelming for them. Many women don't understand that perinatal mood disorders can include more than the classical postpartum depression. If they don't hear voices telling them to kill the baby, they think they are quite all right. They don't realize that their moods and concerns may be out of control, causing them to suffer, and interfering with their relationships with the baby and other people (including their husbands).

Of course I am not saying that every worry about a baby is a symptom of a mood disorder. Worrying is a part of being a parent and a painful but realistic reflection of the responsibility parents have. But when no amount of reassurance makes someone feel better, she and her family need to consider whether counseling or even some medication would help them all get through this period of their lives better. Gynecologists nowadays are supposed to receive some training in screening for perinatal mood disorders and making recommendations about treatment, and they are certainly the first people most mothers should contact when they have excessive worry or  concern.  Unfortunately, a number of state programs for education of the public and professionals about these problems lost funding during the economic recession and have not had support renewed. However, if your health insurance allows for some mental health visits, being very worried about your young baby may be a good reason to seek private care and use some of those visits.

I want to reiterate what "Anonymous" says above: comparing your baby to other babies you know is usually just a way to feed anxiety. They are really all different,  and if you are already anxious you will busily look for the things they do better than your baby, and you will ignore the things your baby does better than the others! It's just a shame that most parent education material tells about average development in various areas, but does not mention the very normal deviations from the average that are characteristic of any group of babies. "Average" and "normal" do not mean the same thing at all--  but when you're already prey to exaggerated fears, it's quite easy to think that anything about your baby that's not "average" is cause for terrible alarm.

Evidence-Based Treatment: What Is It?

I’ve had a number of annoyed reader comments lately, claiming that certain mental health interventions were evidence-based, and I should stop saying that they weren’t. I’ve been in various brouhahas in professional journals, too, when authors claimed that they were writing about evidence-based treatments (EBTs), and I (and other people too) pointed out that they were not.

Why is everyone so eager to say that they are using an EBT? First, there is considerable cachet nowadays to be gained by saying you have an EBT. Many professional organizations recommend EBTs as the first choice among psychological treatments, and in the interest of accountability, many funding sources require that EBTs be used if available for the needed work.  Second, most people don’t know what the technical term “evidence-based” means, so it’s not too hard to convince them that a treatment is an EBT when it is not.

Everybody knows what “evidence” is in the everyday and the legal senses. It’s information that comes from people’s direct observations or from expert interpretations of indirect factors--  like DNA on underwear or contacts on cellphones. If I tell you what I experienced during a mental health intervention, and whether it made me feel better or not, that’s evidence. But it’s not the “evidence” in “evidence-based treatment”.

“Evidence-based treatment” is a technical term, a “term of art”, or “jargon” if you like that better. It first came into use in the 1990s, when the evidence-based medicine movement began to discuss definitions of the kind of evidence needed to give acceptable support of the effectiveness and safety of a treatment. Soon afterward, psychologists and others began to discuss the idea of levels of evidence--  that the significance of supportive information depended on how the information was gathered. An anecdote or testimonial, for instance, provides a very low level of evidence, and  treatments should not be chosen on the basis of that kind of evidence. To be called EBTs, treatments must have been supported by two independently-done randomized controlled trials; the studies must also meet other requirements such as presenting measures of intervention fidelity (showing that the treatment was done the same way each time). In cases where a treatment cannot be randomized, clinical controlled trials with many restrictions can be used. If a study just looks at people’s conditions before and after treatment, that treatment can’t be said to be an EBT. There has to be a comparison (control) that takes into account the fact that people’s conditions may change spontaneously or with maturation, and it has to be possible to tell how much change occurred that way and how much was caused by a treatment. In addition to these requirements, nowadays there is increasing pressure to include in research reports any evidence that a treatment can be associated with harm, and EBTs need to be reported in ways that allow both potential benefits and risks to be calculated.

Unfortunately, as EBTs have been seen as more and more desirable, the term “evidence-based” has been thrown around ever more loosely. Sometimes this has been done by unethical practitioners who want to increase their business success and know that interesting anecdotes or testimonials will get people’s attention and interest. But sometimes it has been done, I think almost inadvertently, by organizations that aim to provide lists of EBTs for the information of both practitioners and the public.

Such organizations present lists of treatments, but the material must in many cases be read quite carefully before it becomes clear whether a listed treatment is or is not actually to be considered an EBT. Let’s look at two of these--  the National Registry of Evidence-based Programs and Practices; NREPP, www.samhsa.gov/data/evidence-based-programs-nrepp) and the California Evidence-based Clearinghouse for Child Welfare (CEBC; www.cebc4cw.org). Each of these uses a name suggesting that programs listed there should be expected to be evidence-based.

However, NREPP includes the New Age “tapping treatment” Thought Field Therapy on its list, in spite of clear evidence that this method is ineffective. NREPP lists 205 treatments that are primarily for children and adolescents, and mentions possible adverse events for only ten of them. Until 2015, NREPP used a rating and report method that made it easy for readers to assess adverse events and design problems, and it could be calculated that when design problems were assessed, the average rating for handling confounded variables was only 2.6 out of a possible 4.0. A new rating method (which is supposed to be applied gradually to all old reports) makes these and other aspects of studies much more difficult to see.

CEBC lists very few programs that are not aimed at children and adolescents. The website rates treatments from 1 (evidence-based by the definition given earlier) to 5 (concerning methods). But it also classifies some listed treatments as “non-responders” (when proponents did not provide requested material) or as Not Rated (when the material available was not sufficient for a numerical rating). Of 286 programs for children and adolescents, 26 were non-responders and 77 of the “evidence-based” treatments listed were in fact Not Rated. Only 21 of the listed programs were rated as 1, and none whatever were rated 5 (concerning), even though the list included Corrective Attachment Therapy and a “camp” managed by Nancy Thomas--  both associated with adverse outcomes for children.

“Evidence-based treatment” mustn’t be confused with the kind of evidence that we use for decisions in everyday life. The term has a very specific and important meaning--  even more important now that funding sources and third-party payers may reject anything that does not meet the definition of EBT. Unfortunately, even websites that were intended to help the public deal with understanding EBTs are not doing their jobs well, because treatments appear on their lists when they should not. Teachers of introductory psychology classes, listen up—you can help by making this issue a point for your students to understand!  

  

Flying Monkeys, "Parental Alienation", and... No Vivid Writing Please

Craig Childress, the proponent of non-evidence-based and intrusive treatments for children who reject contact with one of their divorcing parents, has a rather remarkable newsletter going (https://drcraigchildressblog.com/2016/03/01/the-flying-monkey-newsletter/). He uses the term “flying monkeys” to designate the various people who argue against his approach and who thus stand in the way of parents who want to pre-empt child custody and prevent children from communicating with their preferred parent. This vivid term is no doubt gratifying to Childress’ clients, but the American Professional Society on the Abuse of Analogies, an august body that I just made up, is taking exception and umbrage in response to Childress’ effort to demonize psychologists and lawyers who regard high-conflict custody battles as individualized, complex, and nuanced situations.

Childress’ persuasive and inflammatory language technique  is of course hallowed among PR and advertising groups, but is not acceptable in professional circles, where avoiding fallacious reasoning is everyone’s responsibility. Although psychological events are often best communicated through some use of metaphor, it’s necessary that two entities that are compared in this way  share many characteristics, and especially characteristics that are relevant to the predicted outcome under consideration. By using the term “flying monkeys”  Childress is not appealing to a useful analogy for better understanding of high-conflict divorce, but instead suggesting to his fans that those who oppose them are doing so only from vicious inclination, without foundations in fact or logic—and indeed that they do so at the behest of a Wicked Witch, not even for their own purposes. This is regrettably an excellent way to build a base of admirers and supporters whose emotional needs are met by this kind of thinking, but it is not a way to persuade professional psychologists that Childress’ claims are correct. The only way to do that would be by offering information from research that meets current standards for evidence-based treatment.

Let’s hold our noses and examine some other statements from the newsletter linked above. How about “these allies of the narcissistic/(borderline) parent provide support for maintaining the pathology involving the psychological abuse of the child…”? The “allies”, presumably, are people like me who are aware that Childress has not made his case, and ask for acceptable evidence to be provided. The “narcissistic/(borderline) parent” is the person less excitingly referred to as the child’s preferred parent, who is now classified by fiat as emotionally disturbed or even psychotic. The “pathology” would be more accurately described as the family dynamics. The “psychological abuse of the child” is at the very worst discouragement of a relationship with one parent by the other; not admirable in some cases, but not found in Garbarino’s discussion of emotional abuse--  and in addition, it’s the exact action that Childress proposes to “cure” the child’s rejection! So, in translation to a less inflammatory tongue, what we have is this: “ people who think Childress is wrong are helpful to preferred parents who do not want to change present family  arrangements and dynamics and support the child in his or her wish not to have contact with one parent.” So, it would appear that when the statement is stripped of its connotative language, it’s actually quite true--  but the implicit scariness written into Childress’ statement is not true.

Why do we monkey-allies say what we do? Well, it’s very simple, and anyone who has become familiar with pseudoscientific claims will know what I’m about to say, because there are only two reasons anyone ever argues with psychological pseudoscience. Here are the two reasons in Childress’ terms: “They likely do so because of their own ignorance or because of trauma histories in their own background that resonate with the false trauma reenactment narrative being presented in attachment-based “parental alienation” (a process called “countertransference” in professional psychology)” So, passing lightly over the actual use of countertransference, we see that we dissenters are perhaps More to Be Pitied Than Censured. We either just haven’t studied the right stuff, or we are Sick because of our own histories that blind us to reality. This familiar form of faux counterargument is one I’ve been hearing for years from Attachment Therapy and “Nancy Thomas parenting” advocates, who are sure that if I hadn’t had a severe attachment trauma I would certainly see the force of their arguments. Whereas science has ways of responding constructively to criticism, pseudoscience is confined to the arguments Childress uses.

Just one more thing and then I quit. Smack in the middle of the page linked above, Childress places this as a link:

“New APA Position Statement: Some children are manipulated into rejecting a parent.”

This is NOT, however, a new APA position statement, however it may appear to the casual reader. It is a petition that APA make a new statement, and one agreeable to Childress & Co. APA has refused since 1996 to become involved with “parental alienation” and its various treatments. The organization does not reply to letters from persons on either sides of the PA debate. Whether that is wise or not is arguable—but it is clear that Childress’ implication that there has been a new APA statement is not only wrong but profoundly self-serving.