Why Can't They Tell Which Patient Will Kill Somebody?

Recently, someone commenting on a post on this blog asked me to explain why I had said that diagnosis of mental illness in research did not have to be, or at least was not, as accurate as was needed in treatment of an individual. The writer pointed out that therapists may make a diagnosis not so much because it is accurate but because it allows particular treatments or services to begin. This is certainly true, and it’s also true that psychosocial treatments are often directed at specific symptoms that are troubling rather than at some underlying condition that has been diagnosed. That’s a good idea in many cases, especially when the proposed condition, like Reactive Attachment Disorder, does not necessarily have the causes that are posited for it.

My remarks were not about how things actually are, or about the best they can be in light of various social and political pressures. Instead, I was thinking about the kinds of questions researchers and therapists are asking, and the ways these questions differ from each other. Researchers are almost invariably asking whether one group of people is different from another, or about what will happen to a group given one treatment, as compared with a group given another treatment. They expect some variability within groups and would be surprised and even suspicious if everyone in a group acted the same way. They also accept the fact that diagnostic measures vary in their accuracy.

Therapists, on the other hand, want to know what will be the effect on a particular person of a treatment or experience. They have much less wiggle room than researchers do, especially in cases where a patient may or may not behave violently. We are all aghast every time we read that a formerly violent patient was allowed a weekend pass from a hospital, went home, and chopped up his mother with an ax. “Why didn’t they know that would happen?," we demand.

A useful article in Science (“What is the question?, by Jeffrey Leek and Roger Peng, 20 March 2015, pp. 1314-1315) provides some ways of thinking about these issues. Leek and Peng even give a great flowchart, and I am going to shamelessly follow their description of making decisions about the kinds of questions that are being asked by researchers, therapists, and lots of other people.

The first question Leek and Peng ask about how people think about information they have available is, “did you summarize the data?” If this hasn’t been done--  for example, if there are only anecdotes or testimonials in use—there is no data analysis, and no prediction can be done. (For example, about whether a particular treatment produced a better outcome than another did. )

If the information was summarized, but reported without any interpretation, this was a descriptive approach, but again no prediction can be done.

What if the information was not only summarized, but interpreted—but there was no attempt to decide whether the patterns seen would be repeated in other circumstances? Work of this kind is exploratory. Whatever patterns or connections exist between factors (like treatments experienced), they still need to be confirmed by more work.

Did the study quantify the differences observed and calculate the probability that they would be repeated? If so, there are further questions to be asked. The first one is whether someone is trying to figure out how the average of one measurement affects another measurement. If this is not being done, the next question is whether the goal is to predict measurements for individuals. No? Then the study is an inferential one, which just looks for relationships between factors. Yes? The study is a predictive one. It attempts to predict what will happen with a single individual--  but without being able to understand how or why effects occur, and therefore without real certainty.

Suppose there is an effort to find out how changing the average of one measurement changes another? This may be a study that is causal in nature. It can demonstrate that a group of people receiving a treatment do better on average than a group receiving a different treatment, but is not able to predict which people will do well or poorly—only the average change in risk or benefit is calculated. Leek and Peng give the example of smoking as a risk factor for lung cancer. As we all know, some people who smoke will be very badly affected, and others affected very little, but the whole group of smokers will be more likely to have lung cancer than the whole group of non-smokers (some of whom will get lung cancer too). To take a psychological example, we have the evidence that of depressed people taking antidepressants, many will do better than a matched group without the medication, but some in both groups may kill themselves.

The highest level of explanation involves a deterministic or mechanistic analysis. In this case, the evidence shows that changing one measurement is reliably and exclusively followed by a specific change in another measurement. As Leek and Peng put it, “Outside of engineering, mechanistic data analysis is extremely challenging and rarely achievable.”

When researchers are working on psychological changes in groups as a result of treatments or experiences, they may be working at anywhere from an inferential to a causal level, but their concern is still about average changes in groups. If therapists are trying to be predictive, they may not be able to do a good job of prediction if (as is common) they really do not understand how or why certain results are brought about. Without understanding what events lead to the patient chopping up Ma with the ax, predicting that event is hard; it may be right most of the time, and most weekend passes do not lead to mayhem, but the predictive failure makes it clear that the cause of the behavior is not well understood. However, the more accurate the information is—for example, the better the diagnosis—the better the chances that the individual prediction will be correct.

But human behavior rarely involves a single event that is always and exclusively followed by another specific event. Instead, a broad range of events work together to bring about most outcomes, even those that seem quite isolated, like an ax murder. In aeronautical engineering, factors like wing design can directly affect air flow, but human behavior probably has few factors that are the sole cause of an event. Predicting individual human behavior is much more like meteorology, in which a broad range of factors can determine thunderstorms (does that cold front keep moving or not?) or ax murders (does Ma take the opportunity to tell the patient who his real father is?).  Not all of these are known—or even can be known—at the time of the prediction.

PRETENTIOUSLY HAZARDOUS Treatments: A New Category, Courtesy of the Post Office

A piece in the Week in Review section of the Sunday Times today described how the writer visited a New York post office, and looking at the rubber stamps available, discovered one marked PRETENTIOUSLY HAZARDOUS. I can’t let this golden trouvaille go to waste. It is the perfect category description for the whole attachment therapy-holding therapy- Nancy Thomas parenting-industrial complex, as well as for more than a few other treatment methods.

Some years ago, the clinical psychologist Scott Lilienfeld introduced the term potentially harmful treatment (PHT), to describe therapies that were already known to have caused harm to patients, or which might logically be expected to do so. This term, of course, did not mean that every use of a treatment would end in harm to a patient, simply that there was a reasonable possibility that this would occur. The PHT concept stressed the fact that despite the etymology of their name, “therapies” might actually do harm—that safety as well as effectiveness could be issues for psychological treatments.  The idea of a PHT was not obvious to a Georgia attorney who cross-examined me in a holding therapy case; he argued that no harm had apparently been done, until I gave him the example of running across a busy highway and by some miracle not getting hit by a car--  he had to agree that this was a potentially harmful act that should be prevented, even though the runner came through unscathed this time.

The psychologist Michael Linden added to the PHT concept by pointing out that various types of harm could be associated with misconceived psychotherapies—for example, that the “emotional burden” of feeling distressed during treatment was harmful and should be avoided if at all possible.

So, why am I not content to call AT-HT-NTP potentially harmful treatments? Why not just point out the emotional burdens children experience when subjected to these methods? In fact, why not stick to the term “alternative psychotherapies”, which I have used myself to designate treatments that are without an empirical evidence basis, that are incongruent with established information about human development, and that are potentially harmful?

PRETENTIOUSLY HAZARDOUS treatments display problems in addition to those just stated as they retrofit theory and diagnosis to support treatment methods that are in fact derived from old ways of punishing children (perhaps even from the old German “black pedagogy”). Proponents of these treatments have spun out of straw a prosperous belief system which meets the definition of pretentiousness given by my big old Webster’s: “making claims, explicit or implicit, to some distinction, importance, dignity, or excellence”. The claims include the putting forward of an unfounded “attachment cycle” theory that states that attachment is affected by caregivers’ boundary-setting in the second year of a child’s life (such boundary-setting is important, but is not a factor in attachment). The “attachment cycle” concept is used to justify age-inappropriate actions like insisting on bottle-feeding a ten-year-old or hand-feeding sweets to a child. It is also used to justify intrusive and rigidly-controlling actions toward children that are defined as equivalent to boundary-setting.

The “attachment cycle” concept and related adult actions make the explicit claims to importance  mentioned in the Webster’s definition of  pretentiousness. But they in turn are based on an implicit claim that is all too easily swallowed by parents and other caregivers—in fact, that may be believed to a considerable extent by many adults. This is the claim of recapitulation, the repetition of earlier events, but it is not the old familiar but faulty idea that the development of the individual repeats events in the development of the species. This concept of recapitulation holds that it is possible to magically cause the recapitulation of past development, and to make it come right where it has gone wrong, simply by ritually re-enacting some past events that might be associated with the desired developmental change. For example, if a child is thought to have problems with attachment because she was not sufficiently cuddled as an infant, cuddling her now, feeding her with a baby bottle, and gazing into her eyes are thought of as ways to recapitulate and correct her early emotional life. If a child’s problems are thought to have come from failures of limit-setting in the second year, rituals of demanding that the child ask for everything he needs or sit motionless for long periods are considered to recapitulate and correct the earlier problems.

There are several problems that make such treatments PRETENTIOUSLY HAZARDOUS. One is that it is very unlikely that attachment does result from feeding experiences per se, and it is particularly unlikely that ingestion of sweet things is related to attachment in infancy. It is similarly unlikely that attachment is the aspect of development affected by boundary-setting. But suppose for the sake of argument we were to assume that those events did cause attachment in infancy? Why would we think that experiences characteristic of infancy would have the same effects on older children as they do on infants? To imagine that would be like thinking that an all-milk diet, healthy and appropriate for young infants, would also be suitable for older children with different nutritional needs and growth patterns. Magical recapitulation rituals cannot return children to the developmental needs and patterns of an earlier stage of life, and it is pretentious to claim that they do. In fact, one might well argue that it is fraudulent to do so.

It’s clear that AT-HT-NTP methods are PRETENTIOUS. Need I also argue that they are HAZARDOUS? Proponents of these methods have stated that they no longer lie down on top of children or do other things that have caused death by asphyxia in the past, and perhaps they do not. Nevertheless, the recent license revocation case of “Kali” Miller in Oregon has shown the suicidal response of a boy to treatments that did not risk suffocation but appear to have carried an unbearable emotional burden. In my opinion, this is hazardous enough to argue against use of any such methods.

These treatments are not prohibited, in spite of all we know about them. But there should be large PRETENTIOUSLY HAZARDOUS stamps on all their websites.  

That Reber Paper, Its History and Consequences

Periodically other people and I refer to an article purporting to discuss Reactive Attachment Disorder, published by Keith A. Reber in 1996 in a journal called Progress. This paper was cited as a foundation of the attachment therapy belief system by Chaffin et al in the 2006 APSAC task force report on attachment therapy and attachment disorders, a report that rejected the use of holding therapy and related methods. Reber’s paper used to be readily available on line, but is no longer easily to be found, and although I have it I can’t post it without exposing myself to complaints about copyright violation. However, I can write about the paper and about its author and his sources.

Let’s start by considering who Keith Reber is and what his professional history has been. He was at one time a marriage and family therapist and was associated in some way with the Phillips Graduate Institute in California (this institute was the publisher of Progress). From 1999 to 2001, Reber was a licensed MFT in Oregon, and in 2001 he was served with a notice of proposed revocation by the Board of Licensed Professional Counselors and Therapists for that state.  In 2003, his license was revoked. The explanation for this decision can be seen at www.oregon.gov/oblpct/BoardAction/Reber.pdf.

According to the Board’s statement, Reber had agreed not to use holding therapy (HT) with children referred to him by a state agency, but did indeed use HT with three children who were temporarily placed with foster or potential adoptive parents. To place this action in historical context, I should point out what is not mentioned in the license revocation material: Candace Newmaker had died at the hands of HT practitioners in 2000, and this fact was widely known and of considerable concern, but Reber continued to use this dangerous and unsubstantiated approach despite state agency warnings and his own agreement not to use HT. Reber’s methods, according to the Board statement, were not the “nurturing, cradling hold” often mentioned in more recent times, but included wrapping the child tightly in a sheet, lying on top of the child, and thrusting his fist up into the child’s rib cage. These techniques were used with a child who had been sexually abused as well as with others.

To quote the Board report directly: “Licensee treated SM and VM (from approximately 1999 through 2000) and used holding therapy including wrapping them in a sheet and blanket, laying (sic) with his body on top of the children, pushing his elbow into their abdomen and/or stomach area so hard at times causing vomiting, and occasionally required the children to try to gain freedom from the blanket wrapping themselves, despite the fact that they were wrapped tightly”. [Candace Newmaker died from suffocation while trying to escape from such a wrap.—JM]  In addition, Reber refused to release the children or stop the treatment when asked, but instead berated them.

The Board was also concerned that during its disciplinary proceedings, Reber, who had been given notice of a proposed license revocation, had applied for a MFT license in Utah and represented the license matter in Oregon as having been resolved, when it was not. (A curious bit of HT history intrudes here: Reber’s file was reviewed by David Ziegler, who stated that HT was not acceptable--  at almost the same time that he himself was publishing a paper that cited a number of European practitioners who were and still are strong supporters of HT! But--  am I just revealing that I have one of those small minds for which consistency is a bugaboo?)

So what happened next? The next part of Reber’s story is told at www.deseretnews.com/article/1001664/Orem-therapist-lost-license-over-controversial-methods.html?pg=all. Leaving the unappreciative state of Oregon, he went to Idaho and got a job as a counselor at a clinic associated with a child’s death through forced water drinking. Without his MFT license, Reber had claimed pastoral licensing through the Universal Life Church. Presently, it appears that Reber is licensed in Utah as a hearing aid specialist.

There we have a history of weak or nonexistent professional ethical standards—a background for the Reber 1996 paper itself. I will select some intriguing bits from that document.

Reber starts early in the paper to show that his assumptions are not those of conventional attachment theory, in spite of his attempts to use conventional terms and concepts. He cites Verney and Kelly, two APPPAH stalwarts, to the effect that “attachment begins with connectedness in utero”, starting before birth “on a neurological and emotional level”. He states that without critical interactions with the mother, the baby may “lose interest in the world, become ‘insecure’ or ‘anxiously attached’, or even die.” Even omitting the mistaken claim of prenatal attachment, we see here a peculiar list of problems. Insecure or anxious attachment, while not ideal, is well within the normal range and probably was the condition in early childhood of a large number of the people reading this. Losing interest in the world is a far more serious problem, but even maltreated children with disorganized attachment patterns do not show this. As for death—yes, emotionally-neglected children may die, but the causes of these deaths are much more complex than Reber implies. On the second page, we see the interesting statement that attachments “fall on a continuum between secure and insecure, with the normal child falling somewhere in the middle”. This seems to suggest that insecure attachment is really all right, even though it was ranked earlier along with apathy and with death.

But let’s abandon this entertaining journey through Reber’s ideas about attachment and move on to the specific misunderstandings this paper introduced into discussions of Reactive Attachment Disorder. After saying correctly that RAD is difficult to diagnose, Reber provides on his fourth page a table giving symptoms of RAD as collected from the files of the Family Attachment Center in Salt Lake City, Utah. Here we see the first claims in a supposedly peer-reviewed publication of the RAD characteristics that now turn up in newspaper articles. These include superficial engagement and charm, refusal to make eye contact, incessant chatter, fighting for control, indiscriminately affection with strangers but not cuddly with parents, destructiveness, cruelty to children and animals, stealing, lying, hoarding and gorging on food, preoccupation with fire, blood, or gore [I’ve always wondered what the difference may be between blood and gore—JM], lack of cause and effect thinking, lack of conscience, and abnormal speech patterns.

No doubt many children seen at the Family Attachment Center  did have one or more of these characteristics. But where is the evidence that they had Reactive Attachment Disorder, alone or in addition to some other diagnosis? Answer comes there none, it would appear. Reber’s paper provides no reason to think that any of the concerning symptoms were in fact indications of RAD. In fact, other authors associated with this belief system, like Elizabeth Randolph, have specifically said that these symptoms do not indicate RAD, but instead a posited “Attachment Disorder” which is different. Not only does this symptom list have no part in descriptions of RAD in DSM-IV, DSM-IV-Tr, or DSM-5—even other proponents of HT did not accept Reber’s association of the list with RAD. But this has not stopped the constant repetition of claims about RAD symptoms, right up to the present day. As an example, I can point to the 2014 doctoral dissertation by Vasquez  which I discussed earlier this month, a document that includes items from Reber’s list, and which gives a muddled in-text citation of Reber’s paper.

Where did Reber get his ideas? His table of information from an unpublished sources is one we can’t check on, but a look at his reference section tells a good deal. Here we see some errors suggesting that Reber is not on top of his material: the name of the psychoanalytic theorist Erik Erikson is spelled Erickson, suggesting that Reber has him confused with Milton Erickson, who advised sitting on recalcitrant children and feeding them cold oatmeal; even that ur-holding-therapist Robert Zaslow has his name misspelled. Other sources are Foster Cline, Rick Delaney (who needs discussion in himself, as he has “gone straight” but never really explained why), Jirina Prekopova, and Martha Welch--  all proponents of the most rigorous physical restraint techniques like those that got Reber’s license revoked. Finally, Reber quotes Robert Karen, the 1990s popularizer of attachment theory, and attributes to Karen the statement that in New York City there are one million children with Reactive Attachment Disorder--  this out of a population of 6 million!

Ordinarily, it might not seem very important to go over the mistaken statements of an obscure writer from 20 years ago, especially as his publication does not seem to be available on line any longer. However, the fact that Reber’s claims have been spread as factual through Internet and print journalism, and have been immortalized as checklists for diagnosis of attachment disorders, makes it necessary to trace those claims to their highly unreliable source. Even though, by a sort of psychological Gresham’s law, bad information remains likely to drive out good, it may be that a better understanding of background may help fight the misunderstandings that have spread and continue to spread.   

What's Up With That, Doc? A Disturbing Doctoral Dissertation About RAD

While looking for some recent comments about Reactive Attachment Disorder recently, I chanced upon a 2014 doctoral dissertation that gave me considerable pause. This was a dissertation written in fulfillment of requirements for a doctorate in social work at the University of Iowa. The doctoral candidate, Matthew Lorenzo Vasquez, titled his dissertation “The impact of Reactive Attachment Disorder on adoptive family functioning”.  This in itself was a bit attention-getting, because I would expect a dissertation done today to look at the effects of RAD and adoptive family functioning on each other, not to assume that the disorder was there to begin with, and it caused changes in family functioning. But I wanted to read the thing to see whether I was right to question the nature of the document.

You can read this dissertation for yourself if you have the stomach for it--  it’s at ir.uiowa.edu/cgi/viewcontent.cgi?article=5299&context=etd. I’ll just give you some high points that will no doubt resonate with aficionados of the attachment therapy/holding therapy belief system.

We get right underway in the abstract and the first page of the introduction. Here we are told that “[c]hildren with RAD are known to engage in self-destructive behavior, talk of killing others or themselves, [and] direct verbal and physical aggression toward peers and adults”. This is of course true, just as it is true that children with other diagnoses, or with no diagnosis, may sometimes do some of these things. What is not true is that children who engage in self-destructive behavior, talk of killing, etc., etc., therefore have RAD. Although Vasquez references the DSM-IV-Tr description of RAD, he appears to have some other, unnamed source of information about diagnosis of RAD--  perhaps the work of Wimmer et al which appears in Vasquez’s reference list and which certainly posits RAD symptoms that are not to be found in any conventional discussion of RAD diagnostic characteristics. Although he mistakenly cites Parker, Forrest, and Reber, a non-existent source, it is plain to those of us who have studied the AT/HT belief system that Vasquez really means Reber (1996), a problematic paper, hard to find on the Internet nowadays, that made a variety of unsupported claims about RAD and used to be quoted frequently by practitioners of alternative psychotherapies.

Vasquez collected information by interviewing members of five volunteer families, and some interesting information it was, I can tell you.  For example, in discussing the methods a family used to respond to a child’s “meltdowns”, he comments, “In an effort to find some relief from Adam’s rages, Nancy [adoptive mother] started to bring Adam into the bathtub [with or without water is not stated]  and would hold him there in the dark  while he continued to scream” [as who wouldn’t scream? J.M.]. Nancy states that she learned this technique when working in a nursing home with people who had transient ischemic attacks…and seizures and hoped it would help Adam. Nancy then explained:

‘That’s when the meltdowns got shorter, and shorter, and shorter. Because he lost all his power. He had no power. Because sometimes he would get me frazzled you know and I was overwhelmed, you know? You don’t want to go there but you would. So he lost all his power when it went to the tub. And they just got, I bet, six to eight months before his meltdowns were 10 to 15 minutes in length.’

Vasquez then speculates that the approach was “so effective” (a speculation in itself of course) because the child could consciously decide whether he preferred to tantrum or to be held in the bathtub; Vasquez is uncertain whether he always had this ability or was given it as a result of the bathtub treatment.    

Rather than considering the meaning from the child’s viewpoint of being immobilized in the dark (and possibly in water), Vasquez is concerned with what it all meant for the parents. “Personally, I found the image of a young child being held in a bathtub, in the dark, while he screamed uncontrollably for hours at a time both profound and moving. … It … shows… what lengths some of these parents went to provide these children comfort and solace. Undoubtedly, to sit in a bathtub for multiple hours a day, restraining a screaming child for 6 to 8 months shows an incredible level of devotion and commitment to the care and well-being of these children”. Although many of us would query whether this behavior actually shows an incredible level of ignorance or of sadism, Vasquez does not mention that alternative explanation. Instead, he stays with the AT/HT tenet that adoptive parents are loving and good, as well as able and determined to make the best choices for children.

This is very depressing, but let me mention one other topic Vasquez mentions. It’s the old Darkness Behind the Eyes (see www.attachmentandtraumaspecialists.com/attachment_disorder/symptoms and other AT/HT sources). Vasquez says “hearing numerous reports about how these rages can be seen in the eyes of their child, I began to see this attribute as a significant feature in discussing these rages. “ He inquired of one mother about the idea that her child’s eyes changed color. She said “Mmm-hmm. Her eyes change color. They all do. They go DARK.” Another parent made the following statement: “When he would rage… it would almost look like there’s a fire in the whites of his eyes. He wore the footed pajamas, and at bedtime sometimes I would have to hold him down, and he would kick, and with all the lights off there would be sparks everywhere, I mean he was raging that fast.” Vasquez did not question these reports of physical impossibilities, but did note that the parents did not seem to attribute the events they reported to demonic possession. He did not examine the possibility that alternative practitioners and support groups had told the parents these things would happen.

So, do I blame Vasquez for this piece of work that repeats without question or comment various tenets of the AT/HT belief and treatment systems? Yes, to some extent I do. The man is not a scholar, although he seems to think he is, and he has done a sloppy job at best, mismanaging citations and references. He fails to note the discrepancies between the DSM criteria for RAD and the symptom list he emphasizes. He notes his attempts to manage his own biases by journaling, but does not attempt to discuss alternative interpretations for some of his conclusions. He did not do this work with due diligence, and if I contemplated employing him, I would be most concerned that the same degree of bias and carelessness would contaminate his professional contributions.

On the other hand, though, I cannot say that all the fault lies with Vasquez. As a doctoral student, he had a supervisor and a dissertation committee, all of them apparently with doctoral degrees. Why did they sign off on this level of work? Did they not realize that a dissertation may be cited, quoted, and used as the basis for further claims? As far as I can see, none of the committee specialize in adoption issues or in childhood mental health problems. Why did they agree to support this work if they knew little about it? Given that a doctoral candidate temporarily knows more about what he or she did than anyone else in the world, why did they not at least insist that this student explore alternative explanations of his interview findings? Do they not think that the discipline of social work depends on adequate research, not just on sympathy with suffering people?

It’s my hope that this committee and others supervising social work graduate students will read the forthcoming book by Bruce Thyer and Monica Pignotti, Science and pseudoscience in social work practice (Springer, 2015). Meanwhile, the rest of us have to deal with the release of yet another AT/HT proponent armed with an apparently respectable doctoral degree.  

  

Stealing Words' Meanings for Fun and Profit: Floortime(TM) and Tummy Time

In the Alice books, Humpty Dumpty and Alice have an argument. H.D. says that as far as he is concerned “glory” means “a nice knock-down argument”. Alice counters that you can’t make words mean just what you want, but Humpty says he can, and refers to “Saturday night when they comes around to get their wages”.

For Humpty Dumpty, it was the words that profited by getting paid for expressing a meaning other than their own. But people whose mental health interventions are not characterized by a strong sense of professional ethics can and do profit from using familiar words and giving them new meanings. This is especially likely when the familiar words reference treatments or concepts that are generally respected—the “new meanings” benefit from the respect that actually belongs to the old meanings.

As I mentioned some time ago in this blog (http://childmyths.blogspot.com/2011/05/what-is-floortime-well-folks-it-isnt.html), Ronald Federici and Heather Forbes borrowed the term “floortime” and applied it to their practice of physically restraining a child on the floor for supposed therapeutic reasons. As some parents and mental health professionals already know, Floortime™ has a specific meaning and indeed has been trademarked by its originators. Floortime™ is a method used by practitioners trained in DIR™ (Developmental, Individual-difference, Relationship-based treatment). Practitioners who use Floortime™ do play and interact with children on the floor, but their methods involve following the child’s lead and encouraging verbal and nonverbal communication through play. Really, no two things could be much farther apart in meaning than the respectful, empathic, interactive methods used by DIR™ professionals and the intrusive, authoritarian, coercive techniques used by Federici and his few followers. What was the point of calling the coercive methods “floortime” when this word had already been used for many years by DIR™ practitioners? Was it simply ignorance, or was it an attempt to get under the more popular umbrella of DIR™ by adopting what was essentially a stolen word? Profit, or just fun? I can’t explain it myself, but it worries me greatly to see meanings muddled in a way that advantages the muddlers.

More recently, I came across the theft of the term “tummy time”. Now, this is an expression that has been well-known to millions of parents over the last ten years, the period when infants in the U.S. have been supposed to be put to sleep in the supine position, and when developmentalists had figured out that supine-sleeping babies were not achieving motor milestones as the old standards said they should. Tummy time, a period of prone positioning for play or at least non-sleep activities, was advised as a daily experience that would foster motor development. A large number of young parents during this period have not done tummy time, because the babies don’t like it right away, but this is not the point; they have heard about tummy time and how you are supposed to do it to encourage your baby’s development.

But--  along come some other people and steal “tummy time” for their own meaning and purposes. I encountered this first in reading about the case of Kali Miller (http://obpe.alcsoftware.com/files/miller.debra%20(kali)%20a.f._559.pdf), the Oregon psychologist whose professional license was revoked because her recommendation of Nancy Thomas parenting methods was followed by the suicide attempt of a 12-year-old boy who was the target of the intervention. Miller apparently used the term “tummy time” to mean having the child crawl on hands and knees—an activity inappropriate for a 12-year-old, and without the slightest known developmental benefit for anyone whose motor development had been typical until that age.

Searching for other uses of the stolen phrase, I came across this: www.bestpractices4teaching.blogspot.com/2013/03/tummy-time-for-10-year-olds.html. This blogger states,”[I] sometimes wonder if ‘tummy time’ would work for a 10 year old”. She then refers to an article given to her by her (or, her children’s?) occupational therapist-- https://mysweetchaos.wordpress.com/2010/01/24/neurodevelopmental-reorganization/. Here we find a mother of children she speaks of as “RADishes” (I haven’t come across that one for a while). And mysweetchaos provides a post jam-packed with misinformation--  not only misinformation, but misinformation with a strong tang of Attachment Therapy beliefs about it.

I hardly know where to begin here. Mysweetchaos has provided what Barbara Pym would have called “such richness”. Starting at the top: “When a baby is on their tummy and they turn their heads from left to right to left to right and so on, this is developing their brain for reading. READING! [caps sic] When a baby moves their head up and down, they are developing their brain for math. MATH! Makes sense when we read left to right and solve equations top to bottom.” What to say about this farrago of nonsense? (I always think a farrago should be a kind of porridge, but that would work here too.) Let’s start with the simple fact that a large part of the world’s population does not read left to right. As Lerner and Loewe wrote, “the Hebrews speak it backward, which is positively frightening”, though perhaps not as frightening as mysweetchaos’s assumption that she knows what she’s talking about. Then, let’s look at the idea that “equations” go from top to bottom. Yes, children are taught to do arithmetic in columns, because that enables them to line up ones, tens, hundreds, etc. in ways that would be more difficult if the numbers were placed horizontally. But the equation, the actual arrangement that takes into account the principle of equality, can be horizontal, vertical, or diagonal. What’s more, if anyone understands equality, they know that it does not make the slightest difference whether you start on the left or on the right.

Skipping a bit, let’s go down to where mysweetchaos’s source tells her that many familiar problems (cf. “attachment disorder” checklists), like lack of empathy, overeating, poor appetite, and picking at scabs and other people, being superficially charming, etc., are due to “pons dysfunction”. The pons is a part of the brainstem that has multiple functions, including carrying messages from higher to lower areas and contributing to sleep, breathing, and bladder control. According to mysweetchaos, the developing functions of the pons have to be guided by  appropriate movement experiences, and if they were not guided, they will not develop. However, re-enacting those experiences, including crawling, patterning (honest, she says this), and vestibular movements (there are some movements caused by vestibular stimulation, but I don’t know exactly what she means) can recapitulate development and rebuild the pons. Ergo, children will develop empathy and stop being superficially charming if made to crawl around, and this is a part of “tummy time” (presumably, as recommended by pediatricians all over the U.S.). Of course, this whole discussion omits to mention children who never crawled because of paralysis or atrophied limbs, but are well-developed intellectually and emotionally, and children of previous generations who slept prone and did plenty of crawling, but who still had some cases of lack of empathy and superficial charm.

Where did mysweetchaos get all this stuff? Yes, I’m sorry to say, it appears that we have to look to her occupational therapist as her source. I don’t want to attack the whole OT profession, because I appreciate very much the ways they do things like check out people to see whether they’re competent to drive, and teach premature babies to nipple-feed. But I am tired of waiting for some OT to get up on her (usually) hind legs and state that Sensory Integration theory has never been supported by systematic evidence, or that recapitulation of development by re-enactment of early experiences is simply primitive magical thinking. I think it’s probably true that the person who connected the pons with superficial charm was probably a rogue practitioner—although not the only one around. Nevertheless, ideas apparently supported by the whole OT profession are behind these extravagant claims and the continuing commitment to patterning three decades after it was summarily rejected by physicians and psychologists.

And to call these methods “tummy time”, using the familiar words as if pediatricians recommended making older kids crawl! Is this for fun or profit?  Is it ignorance, or just the  old human urge to benefit from others’ ignorance? I don’t know, but I for one find it “positively frightening.”

  

"Taming Tiny Tigers", by Kali Miller: A Tale Told With Trepidation

Let me note first that the trepidation I’m talking about is my own, as Kali Miller does not seem to experience any. And my trepidation is about two things--  first, whether by discussing this at all I’m simply offering some unintentional paid advertisement for a disturbing attempt at intervention, and second, how well I can untangle the ideas so well braided in a document that mingles established concepts with fantasy.

The document I’m referring to is called “Taming Tiny Tigers”, by Debra “Kali” Miller, whose psychology license revocation I described in a post a few days ago. As I noted at that time, Miller is becoming a parenting coach now that her license has been revoked for her role in the treatment that culminated in a 12-year-old’s suicide attempt. As a coach, she will still be in a position to use the advice she has given in “Taming Tiny Tigers” (http://c.ymcdn.com/sites/opa.site-ym.com/resource/resmgr/imported/E1%20Handout.pdf).

“Taming Tiny Tigers” is an excellent example of the Trojan Horse approach that brings unsubstantiated ideas into discussion under the cover of established information. For example, Miller provides some accurate (though not particularly relevant) material about brain development. She also quotes directly the diagnostic criteria for Reactive Attachment Disorder from DSM-IV; these have changed, of course, but what she uses was correct at the time “Taming Tiny Tigers” was written. She references the much-respected Dante Cicchetti in the documents bibliography. She also points out that physical and emotional abuse are not good for kids. All good stuff, right? She must know a lot about early emotional development and later mental illness--  or so you would think until you see what else is in there.

Now let’s look at what’s inside this handsome Trojan Horse (we’ll see that much of it is similar to something that’s inside real horses). I’ll just begin at the beginning and go on until I can’t stand it any more.

The first problem that comes into view is on pp. 3-4: the good old first-  and second-year bonding cycles. Once again, I will point out that these have no parallel in conventional, evidence-based views of the development of attachment. Naturally, if a baby is not fed or cared for regularly, both physical and mental development will suffer, but attachment develops as a result of pleasant social interactions with a caregiver, not because that caregiver feeds the baby. In real life, of course, chances will be great that a lot of pleasant interaction is mingled with feeding and other care routines, but it’s the interaction and not the care that brings about attachment (which, by the way, is a very robust phenomenon, and does not often fail to happen if a few adults regularly care for a baby). The “second-year attachment cycle” focuses on rage and capitulation as contributing to some unstated aspect of attachment, whereas established information focuses on sensitive, responsive parenting that helps the child tolerate the inevitable frustrations of  this period of development. A large but unstated difference between the “attachment cycle” approach and conventional thinking about early emotional development is that the “cyclists” equate toddler attachment with obedience and compliance, whereas conventional thinking focuses on attachment as a function that helps young children explore and learn. I’ve gone into some detail about this at http://thestudyofnonsense.blogspot.com/2012/08/parsing-attachment-cycle-fox-terrier-of.html.

Let’s move on to p. 7 of “Taming Tiny Tigers”, where we’re given symptoms that are supposed to let us know that a child has Reactive Attachment Disorder by looking at events that may occur before six months of age. Here we have an interesting hint that what is being talked about here is not attachment in the conventional sense at all, but something else (undefined).  It is quite remarkable to claim that a child’s recognition or nonrecognition of the mother in the first six months tells something about Reactive Attachment Disorder, as attachment is not indicated behaviorally until after that age. Be that as it may, the symptoms Miller lists are serious problems indeed, including withdrawal, difficulty with touch, poor muscle tone, delayed motor development, and decreased vocalization. Any baby showing these symptoms does need early intervention for both physical and cognitive problems, there is no question about that . However, what they do NOT need is treatment for Reactive Attachment Disorder, especially the types of treatment Miller recommends later in the document. To tell parents of developmentally delayed toddlers or preschoolers that these early symptoms showed that they had Reactive Attachment Disorder all along is in my opinion little, if at all, short of criminal.

Slogging onward, we come to pp. 11-13. Having listed the DSM-IV criteria for diagnosis of Reactive Attachment Disorder, Miller now turns right around and introduces the infamous checklists of Walter Buenning and Gregory Keck. These completely unvalidated lists include such items as poor eye contact, wanting to hold own bottle, and preferring Dad to Mom as indicating Reactive Attachment Disorder in infants and toddlers, and for older children list the usual Attachment Therapy-related group, such as being superficially charming, not making eye contact on parental terms, “crazy lying”, and abnormal speech patterns. These lists contain a number of items like lack of impulse control that are indeed of concern, but are not aspects of  attachment problems and are not likely to be treatable by the interventions Miller offers.

What are the interventions Miller recommends? On p. 15, she suggests “brain building activities” as suggested by Bruce Perry, and of course by Nancy Thomas. In typical Nancy Thomas fashion, the list of these activities is headed by the injunction that they must be led by the adult, not the child; this injunction reflects the belief that  displays of parental authority create attachment, and that a child’s obedience shows that he is attached to an adult. The activities include many that would ordinarily probably be fun for children, ping-pong, playing catch, and jumping on a trampoline. However, when these are to be done as recommended, five or six times each day, for ten minutes at a time, at the command of an adult caregiver, the “fun” aspects seem to be a good deal lessened.

To continue with the recommendations for intervention, we see on p. 14 of “Taming Tiny Tigers” a page that is startling in its simplicity. Without elaboration, and under the heading of “Therapeutic Continuum”, this page shows a line with the words “non-directive play therapy” at the left and “holding therapy” at the right. What can Miller mean? What is she recommending? She doesn’t come right out and tell, but a look at the bibliography shows publications by the heavy-duty masters of the intrusive and potentially dangerous holding therapy, Foster Cline and Martha Welch, and by Ronald Federici, who advises restraining adopted children in the dangerous prone position. And of course, it shows many publications by Nancy Thomas, the woman who recommends that foster children not be permitted to say grace at meals, “because you don’t know who they might be praying to.”

All in all, “Taming Tiny Tigers” is a pretty disconcerting package, but Miller doesn’t have to conform to any rules to be a parenting coach. What’s more, the First Amendment permits her to pass out all this disinformation. Fortunately, it also permits me and others to have our say about Miller and her “Tigers”.

  

Psychology License Revoked? Become a Parent Coach! (The Kali Miller Story)

Every state in the U.S. has a professional licensing board that can grant licenses to clinical psychologists, and can revoke or limit those licenses under certain circumstances. If you Google your own state’s licensing board, you will probably see that dozens of licensees have been disciplined during the last year. The online information given will state whether a license has been revoked, whether corrective action has been required (like further study of ethical issues), or whether supervision of the person’s work by another psychologist is needed. In most of the cases you’ll see, the problem has to do with personal relationships with clients, with financial or billing problems, with drug or alcohol use, or with criminal conduct.

 Only rarely are licensees disciplined because of harm done to clients as a result of incorrect diagnosis or choice of treatment, even when children or other vulnerable persons are in question. In this post, I will describe the events surrounding the revocation of a license in one such case, that of the Oregon child clinical psychologist Debra “Kali” Miller. I’ll also point out that, far from being impressed by the revocation, Miller is starting a new career as a parent coach—such people are not licensed, so she needn’t fear another loss. How do I know she’s not impressed? It’s that she is doing this coaching in association with Nancy Thomas, the self-styled foster parenting expert, and the very person whose methods led to the license revocation.

A lengthy document (http://obpe.alcsoftware.com/files/miller.debra%20(kali)%20a.f._559.pdf

--  kindly forwarded to me by Linda Rosa) describes the investigation of Miller’s actions by the Oregon Board of Psychologist Examiners, including an Order of Emergency Suspension of her license in March, 2014, and a final order for revocation in September, 2014. Miller appealed these findings, which were recently (March, 2015) upheld by two administrative law judges.

What events culminated in the license revocation? Because psychotherapy for children is confidential and known only to the therapist, the parents, and the children (who are in no position to complain), only the occurrence of real harm to a child is likely to bring treatment methods to the attention of a professional licensing board. In Miller’s case, the precipitating event was the arrival of a twelve-year-old boy (“Client A”) at an Oregon hospital following an attempt to kill himself by strangulation. At the hospital, the boy disclosed that as a result of Miller’s recommendations for treatment, and her diagnosis of Reactive Attachment Disorder, he had received distressing treatment: “Client A reported that his father and step-mother required him to engage in routines that were causing distress, to include being directed to sit in his father’s lap for directed feeding of milk from a baby bottle while maintain eye contact with his father, to crawl on the floor for 20 minutes a day, to urinate into a jar in his room, to be confined to his room for extended time periods with his bedroom door set up with an alarm, and being directed to address his step mother using the term ‘Queen’ before her first name.” Client A’s father said that their therapist had told them to use certain treatments, “having Client A drink from a baby bottle while  being held in his lap, having Client A engage in physical exercises to include crawling on the floor and doing jumping jacks, and directing Client A to in a specified way for time out (‘strong sit’).” In addition, investigation revealed, Client A was examined and recommendations for his treatment were made by unlicensed persons, and he was supervised by unlicensed persons as “respite” for various periods of time.

Client A was diagnosed at the hospital as suffering from depression and was placed in foster care.

Readers of material about Attachment Therapy will recognize in Miller’s diagnosis and recommendations a strong resemblance to ideas and methods promulgated by Nancy Thomas; other material (www.advancedparenting4kids.com ) shows that Miller had been for many years a volunteer worker at Thomas’s “camps” that are intended to cause attachment between children and their adoptive parents. These methods are based on two beliefs, neither one supported by evidence. The first of these is the claim that emotional attachment is brought about by a cycle of recurring infant needs and their gratification by caregivers. The second belief is that a failed step in early development can be created by imitation or reenactment of the needed early experiences. In addition to accepting Thomas’s basic beliefs, Miller also was committed to the idea that Reactive Attachment Disorder, rather than being characterized by the symptoms described in DSM, was a matter of frighteningly violent and angry behaviors, shown initially in disobedience and lack of affection toward adult caregivers. These beliefs of Thomas’s are exactly what led to APA cancelling continuing professional education credits for a presentation by Thomas that had been scheduled to earn CEUs.

The Board of Psychologist Examiners found that Miller had violated a series of ethical standards that licensees must comply with:

1. Immoral or unprofessional conduct or gross negligence in the practice of psychology
2. Practicing outside the boundaries of her competence (“Licensee relies upon her own methodology and unreliable sources in assessing whether a child has a diagnosis of reactive attachment disorder and then recommends treatment that poses the risk of harm to the child”)
3. Failing to use appropriate bases for scientific and professional judgment (“Licensee uses a methodology in diagnosing and treating reactive attachment disorder [RAD] that is not based upon established scientific and professional knowledge in the profession”)
4. Failing to avoid harm (“Licensee … made specific recommendations… that focus on establishing parental power over the child through psychological aggression and physically challenging demands, which when implemented exposed the child to  the risk of harm”)
5. Failing to use an appropriate basis for assessments (“Licensee diagnosed Client A with RAD without substantiating the diagnosis with clinical findings in the chart to support her conclusions and recommendations for treatment”)
6. Failing to obtain informed consent to therapy (“Licensee failed to inform Client A’s father that her methodology in diagnosing RAD and her recommended forms of treatment do not conform to recognized diagnostic criteria or practice recommendations…”)

It was as a result of these violations of ethical standards that Miller’s license was revoked. I congratulate the Oregon Board of Psychologist Examiners for their meticulous work in this investigation and their courage in declaring Miller’s methods improper.

But is the small fact of a revoked license stopping Miller? Not really--  as we see at www.advancedparenting4kids.com/oregon-trainers/kali-miller/ . The license revocation is not mentioned. Instead, Miller is said on this Nancy Thomas-related website to have “transitioned from clinical practice and [to be] bringing her heart for healing to parent coaching and providing consultation for other therapists”—activities that remain under the professional radar and without the restrictions of licensure for meeting ethical standards”. We won’t be finished with regulating potentially harmful child therapies until licensure for coaches and others is required; even then, of course, quacks will find a way to cheat.

I plan in a few days to add to this discussion by a look at Miller’s parent-education material called “Taming Tiny Tigers”.

    

Sundance Canyon Academy Requests Severe Criticism (Inadvertently)

Some days ago I received an e-mail from one, Justin Taylor, representing Sundance Canyon Academy, a residential treatment facility in Utah that appears to treat teenagers who are said to have Reactive Attachment Disorder. Justin said that since I had been trying to educate people about this disorder, I would like to embed in this blog the Sundance infographic describing Reactive Attachment Disorder. This suggestion led me to have a look at said graphic, and I was most interested to see the amount of mis- or dis-information that could be crammed into a few pictures. You can see it too, at http://www.sundancecanyonacademy.com/reactive-attachment-disorder-infographic/. (But I'm finding that I sometimes get an error message for this; if you go to the home page and scroll all the way down, you'll see a link to this thing.)

Let’s look at this display under the usual strong light. First, in an introductory passage plagued with writing difficulties, Sundance states that “Reactive attachment disorder is a serious condition that some children and teens must live with”. This claim ignores the fact that RAD is not a diagnosis used for children of school age or older, and no diagnostic method exists for assessing such a problem after the preschool period. In addition, Sundance seems to be uncertain about whether any treatment would be helpful, otherwise why say that the children “must live with” the problem?

To continue looking at the introduction and the infographic: it’s notable that Sundance seems to have ignored the publication of DSM-5 and the change in terminology that limits the term Reactive Attachment Disorder to what used to be called the “inhibited” type, a developmentally-inappropriate emotionally-withdrawn behavior combined with irritability, sadness, and fearfulness even during nonthreatening interactions with caregivers. What used to be called the “disinhibited” type is now categorized as disinihibited social engagement disorder (DSED), and this involves a lack of preference for unfamiliar people (note that some lack of preference for familiar adult caregivers would be quite developmentally appropriate for adolescents). Sundance still references the two types, disinhibited and inhibited. Be that as it may, they provide an interesting, though somewhat notional, list of symptoms for each, apparently having read a bit of DSM-IV and a bit of DSM-5--  though not very carefully.

Here’s what Sundance says about the disinhibited type of RAD (now known as DSED):  the symptoms are “being highly selective” (?), “readily interacting with strangers, rather than showing natural strangers anxiety” (copy editor to the rescue, please!), “seeking unnatural comfort from strangers” (whoa!), “exaggerating the need for help doing basic daily tasks”, “taking part in inappropriately childish behavior”, and “appearing overly anxious”. Nowhere does the infographic clarify how children of different ages might show such “symptoms” in different ways, or deal with the issue of developmentally appropriate practice and diagnosis. The “highly selective” part is a mystery to me, and certainly does not come from any edition of DSM. Ready interaction with strangers is something I would expect from any well-developed teenager, and woe betide the poor child who is sent to any residential treatment facility if he or she does not have that capacity. “Unnatural comfort”--  well, I’m sure that doesn’t mean what it might be taken to mean, but the use of the terms “natural” and “unnatural” is without meaning except as a way to scare parents. As for needing help in basic daily tasks, this “symptom” comes straight from Attachment Therapy, where it’s regarded as a way in which disturbed children manipulate and exploit credulous adults; it’s not in the DSM description. “Inappropriately childish behavior” depends on how old a particular child is, as well as on the possibilities the environment presents. Finally we have “appears overly anxious”, but wait, hasn’t the person been declared to lack “strangers anxiety” and to approach strangers, normally a source of serious anxiety for young children? Apparently the children are simultaneously anxious and not anxious (but from the Attachment Therapy viewpoint, that only shows how cunning they are).

All right, if you’re not too depressed already, let’s have a look at the statements about symptoms of the inhibited disorder (now the only type called RAD). Here we have “avoiding eye contact” (oops, is there some confusion with autism spectrum disorders?), “unresponsive or resistant to comforting”, “steer clear of physical contact” (never mentioned in DSM), “excessively holding back emotion”, “preferring to play alone”, and “detaching from others”. The DSM description considers children with this inhibited disorder as inhibited and emotionally withdrawn, with negative emotional response to interactions with others. Although eye contact might be interpreted as an emotional interaction, it is not a very useful measure because it is characteristic of  other disorders and can occur because of cultural restrictions on children’s looking directly at adults.

Sundance’s infographic goes on to inform parents that children of all ages may have Reactive Attachment Disorder (their definition) if they do the following: “cruelty to animals for no reason” (perhaps there are some good reasons Sundance could suggest?), “watching others closely, but not engaging in social interaction” (school, perhaps?), “destructive to self and others”, “impulsive negative behaviors”, and “abnormal eating patterns”. Some of these, of course are matters of extreme concern, and although they may occur in typical children in the toddler and preschool period, in older children and teens they would be evidence of a serious need for treatment. However, except for a tendency to hypervigilance, they are not mentioned in DSM in descriptions of either RAD or DSED.

As you can see, Sundance Canyon Academy either does not have a very good understanding of these disorders, or may see some benefit in offering confused material to parents. Certainly some parents who have been reading about Attachment Therapy on the Internet will find some of these ideas familiar and therefore acceptable.

It’s quite a labyrinthine process to find out what treatments are used at Sundance Canyon Academy, and what their basis in empirical evidence might be. They use a method described at www.whytry.org, whose website offers claims at evidentiary support, none of which appear to have been published in peer-reviewed journals, and most of which seem to be simple before and after studies. There are some other issues, too, but this post is getting too long already.

One more point of interest: a major figure at Sundance is described as having been the owner and operator of Odyssey Youth Transport, an organization that comes into the home at night to waken sleeping teenagers and to take them away to residential treatment facilities. How this outfit worked when owned by the Sundance staff member, I have no idea. However, at present  its website (www.odysseytransport.com) includes a parent handbook that speaks of transport workers as Guides and inquires whether the child knows that the Guides are coming and whether he or she has alternative or favorite routes out of the house. Parents are told that after they converse with the Guides on their arrival at the house, they are to awaken the son or daughter in his or her bedroom and introduce the Guides. They provide a letter to the child telling what is happening. They are then to leave the house and asked “Please do not return to the residence until the Guides contact you, or until the rental car has left the premises.” As I said before, I have no way of knowing whether this draconian approach was taken when the Sundance staff member owned Odyssey, but the possibility is an eyebrow-raiser.

In a second e-mail, Justin Taylor asked whether I could point out changes needed on the Sundance website. I think I’ve done so. Now let’s see whether they alter their infographic.

    

Trauma: The New Explanation for Everything, and a Bad Example

There’s no question that psychological as well as physiological trauma is very real and can have long-term ill effects. Infants and young children are not “too young to remember”, but can be harmed not only by their own experiences but by what they see happen to others. A trauma-informed approach is essential for understanding that children’s “naughty” behavior--  like roaming around in the night instead of staying in bed—can be the effects of earlier traumatic experiences and won’t be corrected by punishment.

There’s a big push on recently to make sure that caregivers are aware of the effects of trauma, especially in foster and adopted children. But as often happens, there seems to have been a good deal of “criterion creep” so that definitions of trauma and its effects have expanded dramatically. The same thing happened some years ago with ideas about attachment problems, and in fact it’s often those who used to focus on attachment as the cause of all difficulties, who now point to trauma as the great problem. (Or they may even link the two, as in the “Attachment and Trauma Network”.)

But, in spite of the ill effects trauma can have, it is not all about trauma. Claims that trauma is behind all kinds of behavioral and maturational difficulties should be regarded with suspicion and examined under a strong light.

Jessica Pegis and Lisa Sainsbury have passed on to me information about a Toronto organization, the Gap Academy (www.gapacademy.ca), which seems to have its major focus on children with learning disabilities or attention deficit disorders. However, their website also references Reactive Attachment Disorder and something they call “adoptee trauma” or “abandonment trauma” (www.gapacademy.ca/adopteetrauma.html. All three of these diagnoses are discussed on the same page and appear to be equated with each other, although the site notes that the term Reactive Attachment Disorder will not be used. (It’s not quite clear why this should be, as RAD is an agreed-upon diagnosis with “official” criteria, and the others are not--  or could that be the reason for their decision, which muddies the waters a good deal?) The site seems to connect all three categories with learning difficulties.

Having declared by fiat that Reactive Attachment Disorder is a matter of response to trauma, the Gap Academy site goes on to describe what that trauma must have been. The DSM description of RAD includes experiences of neglect and abuse, and the latter certainly can be associated with trauma, but these possible traumatic experiences are not sufficient for the argument that’s brought, and additional traumatic possibilities need to be introduced. According to the site, “Many psychologists now believe that the separation of an infant from its mother leads to immediate and permanent trauma.” Now, strangely enough, although I am a member of Division 37 of the American Psychological Association (child maltreatment section) and of the World Association for Infant Mental Health, I have never met any of those many psychologists or read any of their work in any peer-reviewed publications. Who may they be? Ah, here we have it: “One doesn’t have to go much farther than  Thomas Verny’s The secret life of the unborn child or… Neilson’s A child is born to clearly identify the primal connection. Psychologists and psychiatrists dealing with patients who exhibit the RAD set of symptoms have long ago identified a group of trauma related effects.” Later on the page, we see a link to a paper by Nancy Verrier, a marriage and family therapist (not a psychologist) and author of The primal wound, in which she argues that a child’s emotional attachment to its mother occurs prenatally, and separation from the birthmother leads to intense, traumatic grief and rage, even if it takes place immediately after birth.

In a few easy jumps, we seem to have gone from the existence of a diagnosis called Reactive Attachment Disorder, to the role of traumatic experiences in creating that disorder, to the idea that there are many more traumas at work than have ever been discussed before, and that these have may already have occurred shortly after birth. In other words, all adopted children have by definition been traumatized, and the effects of the trauma may be with them permanently, causing all kinds of problems, including (to return to the original focus of the Gap Academy) learning disabilities.

Why do I think this is probably not so? I have two kinds of reasons. First, there is what is well-known about early development; second, there are the sources of the ideas of Verny and Verrier.

Let’s look at what is known about early development. The first point is that babies in the first few months do not show distress when their care is transferred from one adult to another. They don’t show fear of any of the things that scare older babies, either.  They are capable of expressing distress and do so frequently, when hungry or when getting medical treatment, but they don’t seem concerned about separation from familiar people. By about 8 to 12 months, however, they show fear--  of falling, of loud noises, of people moving suddenly, but most of all of the approach of strangers and the movement away of familiar caregivers. This is the point at which we say that attachment has occurred; attachment is above all a way of finding comfort where there are threats to well-being.

So, why do I say that if a 2-month-old baby does not display fear or distress at separation, he or she is not feeling such feelings? Obviously I can’t know what is happening inside the baby,  I have nothing to go on except the behavior that lets me infer what may be inside. Verrier and other advocates of her Primal Wound ideas believe that they can know what the baby’s emotions are in spite of having no behavioral cues to support their guesses. There is no point arguing about this, because to do so would be to engage in the unwinnable battle between those who look for evidence to support their contentions, and those who “just know”.

This leads us to the second issue I mentioned. Given that research evidence does not support the belief that newborns are traumatized by separation from the birthmother, where did this idea come from? It dates back to some ideas suggested by a British theologian/psychologist, Francis Mott, who claimed among other things that prenatal development involved the pattern of a universal sexuality, including an erotic experience involving the connection of the umbilical cord with the placenta. His later colleague, Frank Lake, “confirmed” Mott’s views of the conscious and emotionally complex life of embryo and fetus by LSD experiments in which people reported what their prenatal experiences had been. Arthur Janov, the “primal scream” man, followed these two, and all of them provided the foundations for the Association for Pre- and Perinatal Psychology and Health, the organization that continues to advocate for Verny, Verrier, etc., etc. To my way of thinking, these beliefs do not provide evidence that unborn babies have emotional or learning experiences that are similar to those of older children or adults. LSD experiences, whatever they may be like, don’t show that newborn babies are traumatized by separation from their birthmothers.

One more issue I want to deal with here: what does the Gap Academy (which apparently employs three staff members) do to treat “adoption trauma”? First, they describe the symptoms they expect to find: “defiant behaviors, disconnectedness, stranger familiarity, lack of understanding of basic trust and familial responsibility, aggression, severe withdrawal, poor self-esteem, enuresis, inattention, and so on”. Except for stranger familiarity in preschoolers, none of these are symptoms or Reactive Attachment Disorder, so it’s clear that the Gap staff are on different ground here--  ground that they share with Attachment Therapists and their posited “attachment disorder”. What do they do about these symptoms? Like Attachment Therapists, they deny that any conventional treatment like behavior modification can be of help. They state, “We have found that treating these kids in a behavioural way…causes further deterioration”; considering that the three staff members could not have had many cases to “find”, one can only guess that they adopted this claim from one of many Attachment Therapy sites. They also say: “we use a collection of methods designed to break down their rejection-oriented impulses… We also believe in teaching the student directly about their problem, which in this case, translates into the teaching of a mini-course on the effects of trauma.” In other words, the treatment consists in part of pressing the children to accept the staff’s implausible view of the cause of their troubles, and indeed teaching them to expect themselves to be psychologically handicapped by past events that may in fact have had no developmental impact whatsoever.

When an organization claims to be trauma-informed, or to teach other people to be so, it’s very important to find out what they mean by trauma. Public funds should not be paying for the sowing of confusion and for potentially harmful interventions.