The New York Times has announced the recent death of J.M. Tanner, an extraordinary figure in the field of child development. This was the man who established the scientific study of children’s physical growth and thus opened the door for further research and for practical applications of this information. It was Tanner’s work on rates of growth and development that made possible the study of changes in the age of puberty and that helped neonatologists discriminate between babies who were born prematurely and those who were simply very small for their stage of development. When I needed to evaluate the status of a poorly-nourished child a few weeks ago, I went straight to my well-used copy of Tanner’s book Foetus into man and looked at the appropriate growth chart, which showed proportions of children of a certain age at or below given weights. Indeed, almost every parent has seen his or her child’s height and weight marked on growth charts derived from Tanner’s work.
A part of Tanner’s contribution was simply a matter of meticulous measurement of large numbers of cases. He recorded heights, weights, and other details of growth for large numbers of children of known ages, and dealt with issues like the differences between measurement of height for infants (lying down) and for older children (standing up),with the problems these presented for accuracy. A particularly important question involved tracing the events of development before and during puberty; Tanner established a set of data based on photographs and measurements of changes in girls’ nipples and breasts, in pubic and axillary hair, and in boys’ penis and scrotum characteristics. This information allowed him to establish ways of predicting menarche and spermarche with some accuracy, an important step in deciding how to provide suitable sex education for older children as well as establishing standards for precocious puberty.
Of course, a set of data alone is not much help for understanding or decision-making. Tanner treated his collected data as the normal distribution they were, and was able to use related statistical concepts to help identify abnormal growth patterns that needed treatment. With a large set of data from children of various ages, Tanner could establish the statistical average heights and weights at specific ages by adding all the figures from an age group and dividing by the number of children. This helped to characterize particular children’s growth as being above or below average, of course, but it accomplished something still more important: a way to decide when growth was inside or outside a normal range, and thus whether a child did or did not need treatment. Most of the children in any group will have heights or weights that are above or below the statistical average, so that comparison is not a very useful one-- but knowing how far away from the average someone is can be extremely helpful when it comes to identifying problems.
Tanner did the statistical work that allows us to look at a growth chart and to decide how far a given child is from the average height or weight for his or her age. Like others making statistical comparisons, he usually considered a “normal range” within which children did not need help. To establish the normal range, he calculated the weight or height than which only 10% of an age group were smaller (the 10th percentile, the number below which 10% of the heights or weights fell), and the weight or height than which only 10% were larger (the 90th percentile, the number below which 90% of the heights or weights fell). Children whose measurements were in the top or bottom 10% groups were outside the normal range, and the other 80% of children were within the normal range. Children who were bigger or smaller than that normal range might be in need of treatment; for younger children, being unusually small was of greatest concern because the condition might be associated with other problems.
Establishing a normal range for children of different ages was especially important for care of premature babies. Tanner’s work included measurement of fetuses whose gestational age (time passed since conception) was known. Babies who were small at birth could then be classified as small, average, or large for their gestational ages, rather than all being considered simply premature even though some might be full-term births. This kind of classification made it possible to understand and treat the differing problems associated with different ages and relative sizes, rather than trying the same general treatment for all very small babies.
Tanner’s enormously useful and influential work seems to have been related to the maturationist descriptive research of Arnold Gesell, who in the 1930s provided detailed information about early changes in functions like grasping and handedness. The matters that Gesell studied were, of course, much less easy to measure and analyze statistically than height and weight were, and no one has been able to establish the same types of comparisons to a normal range that Tanner achieved with his studies of growth. However, Tanner’s work has set a standard for the study of development that may inspire investigation of more complex events, perhaps some day allowing for much earlier diagnosis of problems like autism.
Wednesday, August 25, 2010
Thursday, August 5, 2010
Book Reviews: Alternative Therapies for Children
Two books published by Jessica Kingsley Publishers will be of interest to students of complementary and alternative treatments for disorders of childhood mental health or educational progress. Dyslexia and alternative therapies, by Maria Chivers (London: Jessica Kingsley, 2006) focuses on treatments for reading problems, but includes a variety of CAM approaches covering a spectrum of methods from physical manipulation to stress reduction. Understanding controversial therapies for children with autism, Attention Deficit Disorder, and other learning disabilities, by Lisa A. Kurtz (London: Jessica Kingsley, 2008) reviews a much broader range of problems and treatments, as its title suggests.
The Chivers book is notable for its completely uncritical consideration of an extensive list of dyslexia treatments. The author concedes that “tried and tested teaching methods should not be replaced, and… alternative approaches should be treated as complementary”. She asks readers to judge for themselves but notes that “it will pay dividends to keep an open mind”. She applies this approach even to “distant healing” methods, about which she remarks that “some people are skeptical about therapists who state they can cure them without touching or even seeing the clients themselves. But as with many therapies in this book they may be worth trying.” About one method, Chivers says, “This definitely works for me.” She advises that “it is healthy to maintain a critical faculty and to question what you are told, but equally make sure this does not prevent you from being open to some of the valuable treatments that are out there.” Clearly, Chivers is not one to concern herself with the evidence basis for a practice.
Chivers provides no discussion whatever of issues concerning research design or the concept of evidence-based practice, but simply presents a list of CAM treatments and summarizes the claims made by their proponents. She includes a bibliography with a small number of articles from peer-reviewed journals, a very few of which report randomized controlled trials; most of the resources listed are non-technical or even speculative in nature. The book also features a list of organizations whose websites offer either general information or advocacy for specific methods such as chiropractic treatment.
Chivers’ book is not a resource for those who are interested in evidence-based practice, but it does provide a lengthy and sometimes surprising list of CAM methods that have been put forward as potential treatments for reading disabilities. These include acupuncture, hypnotherapy, and nutritional supplements as well as “visual” treatments like the use of colored overlays. The suggested treatments resemble each other, not only in the absence of empirical support for their usefulness, but in their complete lack of plausibility. Curiously, the one highly plausible, although little-supported, method of treating dyslexia, FastForWord, is omitted from the list.
The Kurtz book makes a somewhat better effort to deal with the issue of evidentiary foundations for CAM therapies. One reason for this may be the fact that Kurtz is looking at treatments for psychiatrically-diagnosed conditions as well as for educational problems. The higher cost and insurance-related decisions of the former suggest the need to focus on efficacy, whereas the effectiveness of educational methods is less frequently subjected to serious evaluation. Kurtz presents reference lists for treatments, including outcome research in some cases, but providing only occasional and cursory guidance about conclusions to be drawn; much more space is devoted to methods for training practitioners than to the evidence bases of these treatments. As was the case for the Chivers title, plausibility is not mentioned as a concern, and the completely implausible “Bach flower remedies” receive the same attention as the quite plausible but weakly supported FastForWord.
Kurtz’s discussion of several methods involves notable omissions. The reference list for the Doman-Delacato “patterning” technique includes a reference to the 1999 policy statement of the American Academy of Pediatrics on this method, but the text does not note that this statement was the second of two by this group, both rejecting the use of “patterning”. The discussion of Facilitated Communication refers in passing to the possible influence of the practitioner on this method, but does not discuss some of the serious accusations families have suffered as a result of the assumption that the technique yields accurate information about a child’s intention.
Kurtz’s discussion of Holding Therapy is problematic in that it describes only one of the several approaches that would be categorized under that label. In addition, the description fails to explain the length or frequency of sessions, a point that would do much to communicate the intense experiences characteristic of the specific treatment described (the Welch method). Kurtz does not mention that Holding Therapy has been classed as a potentially harmful treatment.
It was a surprise to this reader to see DIR/Floortime listed as a CAM treatment by Kurtz. DIR (Developmental, Individual-difference, Relationship-based therapy ) is indeed lacking in an established evidentiary foundation, and it uses some of the problematic methods associated with Sensory Integration. However, DIR has a highly plausible theoretical basis and there is ongoing work aimed at outcome evaluation, so DIR would seem to stand in considerable contrast to other methods discussed by Kurtz.
Like some other Jessica Kingsley publications, the Chivers and Kurtz books give the reader a certain sense of incompleteness, as if no reviewer or copy editor had acted to jog the authors’ memories and remind them to include or elaborate on various points. As simple lists of treatments, or as compilations of resources for further study, however, they provide well-organized though unevaluated information for the interested researcher.
The Chivers book is notable for its completely uncritical consideration of an extensive list of dyslexia treatments. The author concedes that “tried and tested teaching methods should not be replaced, and… alternative approaches should be treated as complementary”. She asks readers to judge for themselves but notes that “it will pay dividends to keep an open mind”. She applies this approach even to “distant healing” methods, about which she remarks that “some people are skeptical about therapists who state they can cure them without touching or even seeing the clients themselves. But as with many therapies in this book they may be worth trying.” About one method, Chivers says, “This definitely works for me.” She advises that “it is healthy to maintain a critical faculty and to question what you are told, but equally make sure this does not prevent you from being open to some of the valuable treatments that are out there.” Clearly, Chivers is not one to concern herself with the evidence basis for a practice.
Chivers provides no discussion whatever of issues concerning research design or the concept of evidence-based practice, but simply presents a list of CAM treatments and summarizes the claims made by their proponents. She includes a bibliography with a small number of articles from peer-reviewed journals, a very few of which report randomized controlled trials; most of the resources listed are non-technical or even speculative in nature. The book also features a list of organizations whose websites offer either general information or advocacy for specific methods such as chiropractic treatment.
Chivers’ book is not a resource for those who are interested in evidence-based practice, but it does provide a lengthy and sometimes surprising list of CAM methods that have been put forward as potential treatments for reading disabilities. These include acupuncture, hypnotherapy, and nutritional supplements as well as “visual” treatments like the use of colored overlays. The suggested treatments resemble each other, not only in the absence of empirical support for their usefulness, but in their complete lack of plausibility. Curiously, the one highly plausible, although little-supported, method of treating dyslexia, FastForWord, is omitted from the list.
The Kurtz book makes a somewhat better effort to deal with the issue of evidentiary foundations for CAM therapies. One reason for this may be the fact that Kurtz is looking at treatments for psychiatrically-diagnosed conditions as well as for educational problems. The higher cost and insurance-related decisions of the former suggest the need to focus on efficacy, whereas the effectiveness of educational methods is less frequently subjected to serious evaluation. Kurtz presents reference lists for treatments, including outcome research in some cases, but providing only occasional and cursory guidance about conclusions to be drawn; much more space is devoted to methods for training practitioners than to the evidence bases of these treatments. As was the case for the Chivers title, plausibility is not mentioned as a concern, and the completely implausible “Bach flower remedies” receive the same attention as the quite plausible but weakly supported FastForWord.
Kurtz’s discussion of several methods involves notable omissions. The reference list for the Doman-Delacato “patterning” technique includes a reference to the 1999 policy statement of the American Academy of Pediatrics on this method, but the text does not note that this statement was the second of two by this group, both rejecting the use of “patterning”. The discussion of Facilitated Communication refers in passing to the possible influence of the practitioner on this method, but does not discuss some of the serious accusations families have suffered as a result of the assumption that the technique yields accurate information about a child’s intention.
Kurtz’s discussion of Holding Therapy is problematic in that it describes only one of the several approaches that would be categorized under that label. In addition, the description fails to explain the length or frequency of sessions, a point that would do much to communicate the intense experiences characteristic of the specific treatment described (the Welch method). Kurtz does not mention that Holding Therapy has been classed as a potentially harmful treatment.
It was a surprise to this reader to see DIR/Floortime listed as a CAM treatment by Kurtz. DIR (Developmental, Individual-difference, Relationship-based therapy ) is indeed lacking in an established evidentiary foundation, and it uses some of the problematic methods associated with Sensory Integration. However, DIR has a highly plausible theoretical basis and there is ongoing work aimed at outcome evaluation, so DIR would seem to stand in considerable contrast to other methods discussed by Kurtz.
Like some other Jessica Kingsley publications, the Chivers and Kurtz books give the reader a certain sense of incompleteness, as if no reviewer or copy editor had acted to jog the authors’ memories and remind them to include or elaborate on various points. As simple lists of treatments, or as compilations of resources for further study, however, they provide well-organized though unevaluated information for the interested researcher.
Wednesday, July 21, 2010
Potentially Harmful Therapies: Don't "Misunderestimate" the Problem
I was taken aback by a question I was asked a few days ago. This surprising question emerged in the course of my testimony as an expert witness in a juvenile court matter that focused on Holding Therapy, the physically-intrusive “complementary and alternative” treatment for childhood mental health problems. My interlocutor, the attorney representing one of the parties involved in the matter, first asked an ordinary question: was I familiar with a journal article from 2007 that discussed potentially harmful treatments? I asked whether he mean the article by Scott Lilienfeld (the man who has been called the Ralph Nader of psychology, but we can count on him not to be a third-party candidate for president). Yes, that was the one (Lilienfeld, S.O. [2007]. Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70). Lilienfeld had listed Holding Therapy as one of a group of potentially harmful treatments (PHTs).
Now came the surprising question. Well, said the attorney, what was the problem if the treatment was only potentially harmful? Lilienfeld had not said it was actually harmful; didn’t that mean he thought Holding Therapy was all right? My off-the-top-of the-head answer was that walking into the street in the face of heavy traffic is only potentially harmful to the individual who hasn’t done it yet, but it’s still inadvisable. And someone who tells you it’s potentially harmful does not mean it’s all right.
What does it mean to say that a treatment is potentially harmful? The dictionary definition says “potential” refers to something that hasn’t happened yet; it’s not “actual” (presently happening, or presently showing the effects of having happened.) “Potential” is “power”-- the power to have a certain effect. But how would we know that potential exists? What facts suggest that a treatment has the potential to do harm?
There are a couple of ways we would be likely to tag a therapy as a potentially harmful treatment or PHT. One is by making a comparison to the known outcomes of similar actions. Knowing other outcomes, or using logic, can we conclude that it is plausible that a treatment will be safe? For example, how about “compression therapy”, a CAM treatment that involves having an adult lie down on top of a child? What do we know that is relevant to the safety of this kind of treatment? We certainly know that it’s possible for a person to be crushed or asphyxiated by a heavy weight on the chest and abdomen. Crushing of this kind was even used as a method of execution in the past (see Arthur Miller’s play The Crucible for a dramatic example). Using the outcomes of similar events, and knowing that not everyone with heavy weights on the chest has died, we can legitimately label “compression therapy” as potentially harmful. It has the power or possibility to do severe harm, although it does not always do so.
But what if there is no comparable event that we can use to assess the potential for harm in a treatment? We are left with the more difficult task of watching for adverse events from the treatment and collecting that information. Given that psychotherapies are not expected to have harmful effects, one or two adverse events are enough for us to point out the potential for harm associated with a treatment. Where any such events exist (and some have occurred), we need to investigate them carefully. This is no time for what a formerly-prominent political figure used to call “misunderestimation”.
What sort of adverse events are we talking about here? The obvious ones are death or serious physical injury, but we should also pay attention to incidents like weight loss or inadequate growth. Emotional trauma is less easy to ascertain unless a concerned adult calls attention to a child’s condition, or unless an adult is able to complain of the effects of a treatment in the recent or distant past.
Adverse events can be less obvious, as well. PHTs may do harm by interfering with a child’s education, thus limiting his or her options in adulthood. They may limit social interactions and prevent the development of normal social skills. And, of course, they may use up a family’s energy and resources and prevent the use of safe and effective treatments. All these problems may emerge from the social pressures of a cult-like network in which a family becomes intensely committed to participation in a treatment that should properly be called “potentially harmful”.
Most people are still getting used to the idea that psychotherapies can have real potential for harm. But no one should assume that “potential” mean “unfounded speculation” or “fantasy”.
Now came the surprising question. Well, said the attorney, what was the problem if the treatment was only potentially harmful? Lilienfeld had not said it was actually harmful; didn’t that mean he thought Holding Therapy was all right? My off-the-top-of the-head answer was that walking into the street in the face of heavy traffic is only potentially harmful to the individual who hasn’t done it yet, but it’s still inadvisable. And someone who tells you it’s potentially harmful does not mean it’s all right.
What does it mean to say that a treatment is potentially harmful? The dictionary definition says “potential” refers to something that hasn’t happened yet; it’s not “actual” (presently happening, or presently showing the effects of having happened.) “Potential” is “power”-- the power to have a certain effect. But how would we know that potential exists? What facts suggest that a treatment has the potential to do harm?
There are a couple of ways we would be likely to tag a therapy as a potentially harmful treatment or PHT. One is by making a comparison to the known outcomes of similar actions. Knowing other outcomes, or using logic, can we conclude that it is plausible that a treatment will be safe? For example, how about “compression therapy”, a CAM treatment that involves having an adult lie down on top of a child? What do we know that is relevant to the safety of this kind of treatment? We certainly know that it’s possible for a person to be crushed or asphyxiated by a heavy weight on the chest and abdomen. Crushing of this kind was even used as a method of execution in the past (see Arthur Miller’s play The Crucible for a dramatic example). Using the outcomes of similar events, and knowing that not everyone with heavy weights on the chest has died, we can legitimately label “compression therapy” as potentially harmful. It has the power or possibility to do severe harm, although it does not always do so.
But what if there is no comparable event that we can use to assess the potential for harm in a treatment? We are left with the more difficult task of watching for adverse events from the treatment and collecting that information. Given that psychotherapies are not expected to have harmful effects, one or two adverse events are enough for us to point out the potential for harm associated with a treatment. Where any such events exist (and some have occurred), we need to investigate them carefully. This is no time for what a formerly-prominent political figure used to call “misunderestimation”.
What sort of adverse events are we talking about here? The obvious ones are death or serious physical injury, but we should also pay attention to incidents like weight loss or inadequate growth. Emotional trauma is less easy to ascertain unless a concerned adult calls attention to a child’s condition, or unless an adult is able to complain of the effects of a treatment in the recent or distant past.
Adverse events can be less obvious, as well. PHTs may do harm by interfering with a child’s education, thus limiting his or her options in adulthood. They may limit social interactions and prevent the development of normal social skills. And, of course, they may use up a family’s energy and resources and prevent the use of safe and effective treatments. All these problems may emerge from the social pressures of a cult-like network in which a family becomes intensely committed to participation in a treatment that should properly be called “potentially harmful”.
Most people are still getting used to the idea that psychotherapies can have real potential for harm. But no one should assume that “potential” mean “unfounded speculation” or “fantasy”.
Wednesday, July 14, 2010
Partnering With Parents: Difficult Decisions About CAM
In a calm and reasonable discussion in the Brown University Child and Adolescent Behavior Letter, Dr. Margaret Klitzke has commented on the difficulties pediatricians and child psychiatrists encounter when parents want to use CAM (complementary and alternative medicine) treatments for their children’s mental health problems. In this article (“CAM in child mental health: Partnering with parents”, CABL, August 2010, p. 1, pp. 5-6), Dr. Klitzke defines CAM as “those healing modalities that provide supplemental treatments in addition to conventional treatments”, but she suggests that parents may consider CAM out of concern that conventional treatments are ineffective or have too many side effects, which impliess that the CAM treatments in question are seen as alternatives, not actually as “complementary” additional methods.
Dr. Klitzke’s discussion focuses on dietary supplements like flax oil and herbal remedies like St.John’s wort as well as on melatonin. She also notes the use of special diets, for example a gluten-free casein-free diet, and points out that the findings on the effectiveness of any of these are “equivocal”. With respect to these treatments, Dr. Klitzke suggests that practitioners need to be informed, be open to families’ inquiries, cultivate a partnership with families , and know their professional limitations.
It’s clear that practitioners are worried that apparent rejection of CAM treatments may cause parents to abandon conventional methods and commit their children to exclusive CAM care. As a result of this worry, they are inclined to seek ways to stay on good terms with parents, and to follow the methods parents want as far as they can ethically and scientifically justify this. And there would be little reason to criticize this approach as long as the CAM treatments are harmless, and as long as conventional treatment is also ongoing. (With respect to harmlessness, by the way, Dr. Klitzke points out the lack of FDA supervision of dietary supplements and herbal remedies, and the related issues of possible contamination or dosage problems.)
But what happens when CAM treatments for child mental health problems are demonstrably harmful? Not just ineffective, not just fraught with side effects, but potentially harmful treatments in and of themselves? A number of CAM treatments for child mental health issues come into this category. For example, there have been examples recently of parents advised to make their children’s food largely contingent on desirable behavior, and associated weight loss, in some cases producing permanent physical effects. I recently had a conversation with a young woman who as a four-year-old had been subjected to almost daily “holding therapy” over the course of a year; she is now being treated for serious anxiety, a reaction that may well be based on that early “therapeutic” experience. Child deaths have been associated with physically-intrusive treatments such as forced consumption of food or liquid, claimed by CAM practitioners to be effective with Reactive Attachment Disorder or any behavior problem of an adopted child.
At a more obviously physical level, avoidance of immunization, argued by CAM practitioners to prevent autism, does not prevent autism but does make children vulnerable to potentially fatal diseases. Chelation, a treatment with oral or infused medication, can have minor or occasionally serious side effects, and has not been shown to be an effective method of treating mental health problems.
How can conventional practitioners “partner” with parents who have committed to these types of treatments? No doubt criticism of dangerous CAM techniques is likely to cause some parents to leave conventional treatment and never come back, or to withhold accurate information about CAM treatments from a psychologist or pediatrician. (Because CAM treatments may in some cases interact with conventional treatments such as anti-depressant medication, the absence of accurate information may in itself create a dangerous situation. ) Nevertheless, there are several real problems that can result from failing to criticize CAM methods when it is appropriate to do so. One is that lack of criticism may be read by parents as actual approval of methods that are known to be dangerous, or ineffective, or both; parents may pass on to others this piece of “information”, thus making it more probable that other families will become engaged with CAM. Another is that it is conceivable that parents’ commitment to CAM is shaky. Criticism by a knowledgeable person might carry enough weight to alter a decision that would be maintained if left uncriticized. Finally, there is the point that professions involving responsible stewardship of others’ lives all have some ethical requirement for active engagement to prevent harm.
No one expects practitioners to partner with parents and facilitate abusive or neglectful treatment where it is not defined as part of a CAM treatment. Why is this “partnering” expected when harmful treatments are given the CAM label? It seems to be time for professionals working with children and families to re-think this matter and to differentiate between tolerating the harmless and encouraging the harmful.
Dr. Klitzke’s discussion focuses on dietary supplements like flax oil and herbal remedies like St.John’s wort as well as on melatonin. She also notes the use of special diets, for example a gluten-free casein-free diet, and points out that the findings on the effectiveness of any of these are “equivocal”. With respect to these treatments, Dr. Klitzke suggests that practitioners need to be informed, be open to families’ inquiries, cultivate a partnership with families , and know their professional limitations.
It’s clear that practitioners are worried that apparent rejection of CAM treatments may cause parents to abandon conventional methods and commit their children to exclusive CAM care. As a result of this worry, they are inclined to seek ways to stay on good terms with parents, and to follow the methods parents want as far as they can ethically and scientifically justify this. And there would be little reason to criticize this approach as long as the CAM treatments are harmless, and as long as conventional treatment is also ongoing. (With respect to harmlessness, by the way, Dr. Klitzke points out the lack of FDA supervision of dietary supplements and herbal remedies, and the related issues of possible contamination or dosage problems.)
But what happens when CAM treatments for child mental health problems are demonstrably harmful? Not just ineffective, not just fraught with side effects, but potentially harmful treatments in and of themselves? A number of CAM treatments for child mental health issues come into this category. For example, there have been examples recently of parents advised to make their children’s food largely contingent on desirable behavior, and associated weight loss, in some cases producing permanent physical effects. I recently had a conversation with a young woman who as a four-year-old had been subjected to almost daily “holding therapy” over the course of a year; she is now being treated for serious anxiety, a reaction that may well be based on that early “therapeutic” experience. Child deaths have been associated with physically-intrusive treatments such as forced consumption of food or liquid, claimed by CAM practitioners to be effective with Reactive Attachment Disorder or any behavior problem of an adopted child.
At a more obviously physical level, avoidance of immunization, argued by CAM practitioners to prevent autism, does not prevent autism but does make children vulnerable to potentially fatal diseases. Chelation, a treatment with oral or infused medication, can have minor or occasionally serious side effects, and has not been shown to be an effective method of treating mental health problems.
How can conventional practitioners “partner” with parents who have committed to these types of treatments? No doubt criticism of dangerous CAM techniques is likely to cause some parents to leave conventional treatment and never come back, or to withhold accurate information about CAM treatments from a psychologist or pediatrician. (Because CAM treatments may in some cases interact with conventional treatments such as anti-depressant medication, the absence of accurate information may in itself create a dangerous situation. ) Nevertheless, there are several real problems that can result from failing to criticize CAM methods when it is appropriate to do so. One is that lack of criticism may be read by parents as actual approval of methods that are known to be dangerous, or ineffective, or both; parents may pass on to others this piece of “information”, thus making it more probable that other families will become engaged with CAM. Another is that it is conceivable that parents’ commitment to CAM is shaky. Criticism by a knowledgeable person might carry enough weight to alter a decision that would be maintained if left uncriticized. Finally, there is the point that professions involving responsible stewardship of others’ lives all have some ethical requirement for active engagement to prevent harm.
No one expects practitioners to partner with parents and facilitate abusive or neglectful treatment where it is not defined as part of a CAM treatment. Why is this “partnering” expected when harmful treatments are given the CAM label? It seems to be time for professionals working with children and families to re-think this matter and to differentiate between tolerating the harmless and encouraging the harmful.
Thursday, July 8, 2010
To Bed Without Supper
Being sent to bed without supper as a punishment--- this old-fashioned idea seems to have a certain charm. It’s much less violent than spanking, but still conveys a strong sense of adult authority. Doing it every now and then is not likely to do much harm to a healthy child. Nevertheless, we don’t hear of many ordinary parents using this punishment nowadays. They might deprive children of dessert, or “ground” them, or take away a toy or a week’s allowance, but meals are provided regularly, no matter what. And although those ordinary parents may get annoyed at children who won’t eat something, it’s rare for them to attempt to force eating. Withholding or forcing food or drink are not part of most families’ child-rearing or discipline methods.
Unfortunately, what I just said is true only of “ordinary” parents. The Philadelphia Inquirer this morning described the conviction of a Baltimore cult leader who had advised a mother not to give her toddler son food or drink because he was “rebellious” and did not say “Amen” after meals (www.philly.com/inquirer/local/20100519_Cult_leader_gets_50_years_in_child_death.html#axzzOoNjtuU5x) . The child died of hunger and thirst after a week of deprivation. The child’s mother, who still believes he will be resurrected, is in a residential treatment program for young women.
The conviction of the cult leader on second-degree murder and child-abuse charges may be a breakthrough in this area. People who practice as therapists or parenting coaches or educators have advised parents to limit food and have not been held liable for child injuries or deaths; it was the parents who were convicted. For example, in the death some years ago of Viktor Matthey in New Jersey (http://dartcenter.org/content/short-life-Viktor-Matthey-8), Viktor’s adoptive parents were convicted and sent to prison for the child’s death from multiple causes. Among other things, they had “punished” Viktor by forcing him to eat a mixture of uncooked beans and barley; if he did not finish it in time, he was not allowed to drink. Did the Mattheys invent this punishment for themselves? It seems unlikely, because punishment by means of forcing or limiting food is suggested in various publications advocating unconventional child-rearing or discipline methods. But no advisors were charged in the Matthey case.
Similarly, Cassandra Killpack’s mother was convicted after she forced the 4-year-old to drink a large amount of water, causing brain swelling and the child’s death (www.deseretnews.com/article/1,5143,515037467,00.html). Mrs. Killpack said that this punishment for having “sneaked” some of a sister’s fruit juice had been advised by a therapist she consulted. The therapist denied this, saying he was only there to support the parents. The therapist , who had lost his license in another state because of inappropriate practices, was not charged.
Why do I suggest that unconventional therapists advise withholding or forcing food, rather than thinking that parents invent these practices for themselves? After all, most of us are aware of the “bed without supper” tradition, and some people may convince themselves that serious deprivations are really no worse than that. But what makes me think that therapists (like that Baltiomore cult leader) may be giving this advice is that there are published materials that suggest food deprivation as part of the “treatment” for Reactive Attachment Disorder or other problems. This idea goes back to the generally-respected psychologist Milton Erickson [N.B.not Erik Erikson!) who advised a diet of cold oatmeal, and periods of physical restraint, for a disobedient boy, and noted with approval that after a time on this regimen the child trembled when his mother spoke to him ( Erickson, M.H. [1962]. The identification of a secure reality. Family Process, Vol. 1(2), pp. 294-303). The parenting “educator” or “coach” Nancy Thomas has more recently advised limiting of food to peanut butter sandwiches and milk for weeks at a time, with a more nourishing diet dependent on pleasing the parents (Thomas, N. [2000]. Parenting children with attachment disorders. In T.M. Levy [Ed.], Handbook of attachment interventions. San Diego: Academic Press). (Thomas, incidentally, claims that feeding caramels to children fosters attachment, because caramels contain milk, etc., etc.-- you fill in the rationale.) There is no evidence that such treatment is either safe or effective as a way of dealing with discipline or mental health problems, but there the advice is in print, and the First Amendment protects it.
Although I believe it would be highly appropriate to charge therapists and other advisors whose counsel encourages parents to harm children, I recognize the legal complications here. If I tell someone to shoplift, that other person has the responsibility for recognizing that the action is wrong and refraining from doing it. However, the conviction of the Baltimore cult leader suggests that authorities are beginning to see the importance of the roles played by givers of advice, whose words may encourage parents to perform acts that they would otherwise only have considered. In the Baltimore case, the judge described the cult leader as a manipulator of lost souls. Perhaps we are on the way to recognizing that such manipulators may appear in professional or quasi-professional guises, and that harmful advice from such people merits punishment as much as if they were leaders of cults.
Unfortunately, what I just said is true only of “ordinary” parents. The Philadelphia Inquirer this morning described the conviction of a Baltimore cult leader who had advised a mother not to give her toddler son food or drink because he was “rebellious” and did not say “Amen” after meals (www.philly.com/inquirer/local/20100519_Cult_leader_gets_50_years_in_child_death.html#axzzOoNjtuU5x) . The child died of hunger and thirst after a week of deprivation. The child’s mother, who still believes he will be resurrected, is in a residential treatment program for young women.
The conviction of the cult leader on second-degree murder and child-abuse charges may be a breakthrough in this area. People who practice as therapists or parenting coaches or educators have advised parents to limit food and have not been held liable for child injuries or deaths; it was the parents who were convicted. For example, in the death some years ago of Viktor Matthey in New Jersey (http://dartcenter.org/content/short-life-Viktor-Matthey-8), Viktor’s adoptive parents were convicted and sent to prison for the child’s death from multiple causes. Among other things, they had “punished” Viktor by forcing him to eat a mixture of uncooked beans and barley; if he did not finish it in time, he was not allowed to drink. Did the Mattheys invent this punishment for themselves? It seems unlikely, because punishment by means of forcing or limiting food is suggested in various publications advocating unconventional child-rearing or discipline methods. But no advisors were charged in the Matthey case.
Similarly, Cassandra Killpack’s mother was convicted after she forced the 4-year-old to drink a large amount of water, causing brain swelling and the child’s death (www.deseretnews.com/article/1,5143,515037467,00.html). Mrs. Killpack said that this punishment for having “sneaked” some of a sister’s fruit juice had been advised by a therapist she consulted. The therapist denied this, saying he was only there to support the parents. The therapist , who had lost his license in another state because of inappropriate practices, was not charged.
Why do I suggest that unconventional therapists advise withholding or forcing food, rather than thinking that parents invent these practices for themselves? After all, most of us are aware of the “bed without supper” tradition, and some people may convince themselves that serious deprivations are really no worse than that. But what makes me think that therapists (like that Baltiomore cult leader) may be giving this advice is that there are published materials that suggest food deprivation as part of the “treatment” for Reactive Attachment Disorder or other problems. This idea goes back to the generally-respected psychologist Milton Erickson [N.B.not Erik Erikson!) who advised a diet of cold oatmeal, and periods of physical restraint, for a disobedient boy, and noted with approval that after a time on this regimen the child trembled when his mother spoke to him ( Erickson, M.H. [1962]. The identification of a secure reality. Family Process, Vol. 1(2), pp. 294-303). The parenting “educator” or “coach” Nancy Thomas has more recently advised limiting of food to peanut butter sandwiches and milk for weeks at a time, with a more nourishing diet dependent on pleasing the parents (Thomas, N. [2000]. Parenting children with attachment disorders. In T.M. Levy [Ed.], Handbook of attachment interventions. San Diego: Academic Press). (Thomas, incidentally, claims that feeding caramels to children fosters attachment, because caramels contain milk, etc., etc.-- you fill in the rationale.) There is no evidence that such treatment is either safe or effective as a way of dealing with discipline or mental health problems, but there the advice is in print, and the First Amendment protects it.
Although I believe it would be highly appropriate to charge therapists and other advisors whose counsel encourages parents to harm children, I recognize the legal complications here. If I tell someone to shoplift, that other person has the responsibility for recognizing that the action is wrong and refraining from doing it. However, the conviction of the Baltimore cult leader suggests that authorities are beginning to see the importance of the roles played by givers of advice, whose words may encourage parents to perform acts that they would otherwise only have considered. In the Baltimore case, the judge described the cult leader as a manipulator of lost souls. Perhaps we are on the way to recognizing that such manipulators may appear in professional or quasi-professional guises, and that harmful advice from such people merits punishment as much as if they were leaders of cults.
Why Not Withhold Children's Food As Discipline?
I’ve had a lot to say recently about suggestions that children’s food supply should be contingent on their behavior. Many parents may feel a little uneasy about this topic, because most of us have used dessert as a negotiable item in efforts to get children to stop dawdling or to use reasonable table manners. Of course, when I refer to withholding food as a way to discipline children,I’m not just talking about whether they get a piece of lemon meringue pie tonight or not. I’m talking about reducing the available food to a small number of items and a smaller number of calories than the child usually consumes, with normal types and amounts of food given only if the child complies with parents’ wishes, and continuing that regimen for weeks or months. The effects of this kind of food withholding come on gradually but are very real.
If a child misses some food on one day-- as a punishment or because of a tummy-ache-- he or she generally makes up for it the next day. There’s no real need for food, or food intake, to be “balanced” over a 24-hour period, and there’s no long-term effect if it isn’t.
But a long period of time with less food than normal, as well as fewer nutrients than normal, is a different matter. This condition has been referred to as semi-starvation by some nutritionists. The starving person does not die within a week, as would be the case if all food and liquids were withheld, but gradually experiences both physical and mental effects.
Understanding the effects of gradual starvation is a matter that requires some tricky research approaches. Although all too many people in the real world are suffering from being underfed, most of them have other health problems-- contagious and chronic diseases, parasites, untreated injuries--- all of which may affect them physically and mentally in ways that are easily confused with the effects of lack of food. There are few circumstances in which experimental work can be carried out on the impact of semi-starvation; only adult volunteers could be used in this kind of investigation. The most famous experimental investigation of semi-starvation took place toward the end of World War II and used volunteers who were conscientious objectors to the war (Keys, A., et al. [1950] The biology of human starvation. University of Minnesota Press; Kalm, L.M., & Semba, R.D. [2005]. They starved that others be better fed: Remembering Ancel Keys and the Minnesota experiment. Journal of Nutrition, Vol. 135, pp. 1347-1352). These healthy young volunteers agreed to be subjected to months of calorie restriction and continuing physical exercise. They became emaciated, irritable, apprehensive, and moody, and were preoccupied with food; some ended up eating garbage or items like raw rutabagas, even though they were strongly committed to the program in terms of what its data could do to help people who were involuntarily starving in war zones. Not only were their bodies affected in complex ways beyond simple weight loss, but personality changes appeared.
Of course no experimental work of this kind would be done on children. But there is some related information which was secretly collected in the Warsaw ghetto, again during World War II. A lecture by Myron Winick on this sad topic can be found at www.columbia.edu/cu/epic/winick_lecture_2005.pdf. Winick reports the studies of what was called “hunger disease” in Jewish children confined and semi-starved in a section of Warsaw. Obviously, weight loss and growth failure resulted from their experience, but there were other effects as well. Low blood pressure and other cardiovascular effects were a consequence of slow starvation, as were cataracts (changes in the lens of the eye that prevent light from entering). The children reported being always cold.
It’s well known that infants, toddlers, and preschoolers, if subjected to poor nutrition for a period of time, are likely to be badly affected. Kwashiorkor, a nutritional deficiency disease resulting from lack of protein, causes slowing of brain development, among other things. Malnourished young children are reduced in stature and brain size.
These physical effects are all excellent reasons for avoiding the use of serious, long-term food withholding as a technique for disciplining children. But let’s consider the mental and personality effects in addition. Parents who consider using these techniques are usually concerned with what they consider to be serious behavioral problems. They may be dealing with an emotionally disturbed child whose irritability, aggressiveness, or tantrum behavior are trying or even frightening. They may begin a regimen that makes a normal amount of food dependent on behaving well-- but if the child is really not able to improve, or if other aspects of the environment reward the behavior, semi-starvation may go on for many weeks. Then what can we expect to happen? Looking at the World War II study of adult volunteers, we see that characteristically, this food regimen made them more irritable, apprehensive, and moody. If this effect generalizes to children-- and we might plausibly predict that the effect would actually be greater in children than in adults-- the impact of a period of reduced food intake would be to worsen the undesirable behavior that triggered this form of discipline to begin with.
Making a normal diet depend on a child’s behavior may cause behavior to get worse over time, and is certainly potentially dangerous from the physical viewpoint. But this doesn’t mean that negotiating behavior with the help of that slice of pie is necessarily a bad idea, if it seems to work in your family. If you’re worried about using that method too much, make sure that the pie-less child can have seconds on the main course if still hungry, and you can be sure that nobody is semi-starving.
If a child misses some food on one day-- as a punishment or because of a tummy-ache-- he or she generally makes up for it the next day. There’s no real need for food, or food intake, to be “balanced” over a 24-hour period, and there’s no long-term effect if it isn’t.
But a long period of time with less food than normal, as well as fewer nutrients than normal, is a different matter. This condition has been referred to as semi-starvation by some nutritionists. The starving person does not die within a week, as would be the case if all food and liquids were withheld, but gradually experiences both physical and mental effects.
Understanding the effects of gradual starvation is a matter that requires some tricky research approaches. Although all too many people in the real world are suffering from being underfed, most of them have other health problems-- contagious and chronic diseases, parasites, untreated injuries--- all of which may affect them physically and mentally in ways that are easily confused with the effects of lack of food. There are few circumstances in which experimental work can be carried out on the impact of semi-starvation; only adult volunteers could be used in this kind of investigation. The most famous experimental investigation of semi-starvation took place toward the end of World War II and used volunteers who were conscientious objectors to the war (Keys, A., et al. [1950] The biology of human starvation. University of Minnesota Press; Kalm, L.M., & Semba, R.D. [2005]. They starved that others be better fed: Remembering Ancel Keys and the Minnesota experiment. Journal of Nutrition, Vol. 135, pp. 1347-1352). These healthy young volunteers agreed to be subjected to months of calorie restriction and continuing physical exercise. They became emaciated, irritable, apprehensive, and moody, and were preoccupied with food; some ended up eating garbage or items like raw rutabagas, even though they were strongly committed to the program in terms of what its data could do to help people who were involuntarily starving in war zones. Not only were their bodies affected in complex ways beyond simple weight loss, but personality changes appeared.
Of course no experimental work of this kind would be done on children. But there is some related information which was secretly collected in the Warsaw ghetto, again during World War II. A lecture by Myron Winick on this sad topic can be found at www.columbia.edu/cu/epic/winick_lecture_2005.pdf. Winick reports the studies of what was called “hunger disease” in Jewish children confined and semi-starved in a section of Warsaw. Obviously, weight loss and growth failure resulted from their experience, but there were other effects as well. Low blood pressure and other cardiovascular effects were a consequence of slow starvation, as were cataracts (changes in the lens of the eye that prevent light from entering). The children reported being always cold.
It’s well known that infants, toddlers, and preschoolers, if subjected to poor nutrition for a period of time, are likely to be badly affected. Kwashiorkor, a nutritional deficiency disease resulting from lack of protein, causes slowing of brain development, among other things. Malnourished young children are reduced in stature and brain size.
These physical effects are all excellent reasons for avoiding the use of serious, long-term food withholding as a technique for disciplining children. But let’s consider the mental and personality effects in addition. Parents who consider using these techniques are usually concerned with what they consider to be serious behavioral problems. They may be dealing with an emotionally disturbed child whose irritability, aggressiveness, or tantrum behavior are trying or even frightening. They may begin a regimen that makes a normal amount of food dependent on behaving well-- but if the child is really not able to improve, or if other aspects of the environment reward the behavior, semi-starvation may go on for many weeks. Then what can we expect to happen? Looking at the World War II study of adult volunteers, we see that characteristically, this food regimen made them more irritable, apprehensive, and moody. If this effect generalizes to children-- and we might plausibly predict that the effect would actually be greater in children than in adults-- the impact of a period of reduced food intake would be to worsen the undesirable behavior that triggered this form of discipline to begin with.
Making a normal diet depend on a child’s behavior may cause behavior to get worse over time, and is certainly potentially dangerous from the physical viewpoint. But this doesn’t mean that negotiating behavior with the help of that slice of pie is necessarily a bad idea, if it seems to work in your family. If you’re worried about using that method too much, make sure that the pie-less child can have seconds on the main course if still hungry, and you can be sure that nobody is semi-starving.
Tuesday, July 6, 2010
Child Death By A Thousand Cuts in California
Not long before the return of the Russian adoptee to his homeland, an event that received enormous media attention, another foreign-born child died at the hands of her foster parents—and almost nothing has been said about this. In February, Lydia Schatz, an almost-8-year-old child from Liberia, died an appalling death, whipped for hours with a thin plastic plumbing supply line until vital organs were damaged by the effects of muscle damage. Lydia’s “mother” held her down while her “father” applied this punishment for a minor mistake in English. More details about this matter can be seen at www.icrawl.org/44034264874-jane-schatz-8-yo-paradise-ca, or on the web site of the Paradise (CA) Post, although you’ll have to pay to get at the archives of the latter.
I don’t want to dwell on this child’s experience, as anyone with the slightest imagination will be able to envision her pain and terror all too clearly. What I want to do in this post is to consider the sources of these parents’ actions, which were not impulsive but instead were based on a philosophy of child discipline. It appears that Lydia’s guardians were followers of the Tennessee fundamentalist child-rearing gurus, Debi and Michael Pearl. The Pearls are authors of “To Train Up a Child”, a publication whose first part appears on line at www.gospeltruth.net/children/pearl_tuac.htm. I have discussed the Pearls’ book in detail in my article “Destructive trends in alternative infant mental health approaches”, Scientific Review of Mental Health Practice, 2007, Vol 5(2), 44-58.
While Lydia’s guardians certainly must take full responsibility for their decision to whip the child, it is also important for people concerned with child welfare to note that there are sources of bad advice that are never forced to take any esponsibility. The Pearls are among these. They share the view I mentioned in a post a few days ago, that children are basically bad and must be forced into obedience; like some other authors since the early days of this country, the Pearls put this belief into a religious context so that it becomes the parents’ responsibility to make children submit utterly to adult expectations.
The Pearls advise that submission to parental wishes should be forced in infants as young as four months of age (these babies, by the way, would be too young to be able to sit up unsupported or to recognize their names when spoken). The primary method for achieving submission is pain, and this is produced by whipping either with the old-fashioned willow switch or with quarter-inch-diameter plastic plumbing supply line. Whipping is advised as a way to make children stop crying or to persuade them to do something that is wanted, or to refrain from doing something unwanted. For example, Debi Pearl recounts a situation in which a toddler was left in her care for a few hours-- the first separation from his mother this child had ever experienced. Although other children were playing around him, the little boy did not eat or play, even though Mrs. Pearl offered him a roller skate and showed him how the wheels spun. When she told him directly to play with the wheels, he “defied” her and did not do so. She whipped him on the leg, but he still did not obey; this continued for ten whippings, until he did put his hand on the wheel, and was described as content now that he had yielded to someone higher than himself.
The Pearls advise that whipping should be done without any indication of anger and with a friendly facial expression, an extraordinarily confusing situation for young children who use social referencing-- checking of faces and voices-- to understand the intentions of adults. Although their stress is on whipping, there are other physical punishments they approve, for example, yanking the hair of a nursing baby if he or she bites the mother.
No doubt the Pearls will say that they never told anyone to whip a child to death, or even to continue whipping for hours. However, advising that pain is the major tool in child discipline opens the door to such actions, particularly when the pain is not to be withdrawn until the child obeys and/or stops crying. The Pearls’ advice, when combined with the belief that children can obey but are wickedly choosing not to, sets the stage for a frustrated or mentally ill adult to injure or kill the child who is being “disciplined”. Such an outcome may seem justified to those who are convinced of the religious value of these actions.
I challenge both mainstream and fundamentalist religious groups to come forward and make clear their rejection of the Pearls’ methods. Some fundamentalist organizations have done this in a quiet way, but a loud shout is needed. I also challenge neighbors and police to be aware of the Pearls’ advice and to try to prevent child injury and death that might otherwise result from systematic whipping.
I don’t want to dwell on this child’s experience, as anyone with the slightest imagination will be able to envision her pain and terror all too clearly. What I want to do in this post is to consider the sources of these parents’ actions, which were not impulsive but instead were based on a philosophy of child discipline. It appears that Lydia’s guardians were followers of the Tennessee fundamentalist child-rearing gurus, Debi and Michael Pearl. The Pearls are authors of “To Train Up a Child”, a publication whose first part appears on line at www.gospeltruth.net/children/pearl_tuac.htm. I have discussed the Pearls’ book in detail in my article “Destructive trends in alternative infant mental health approaches”, Scientific Review of Mental Health Practice, 2007, Vol 5(2), 44-58.
While Lydia’s guardians certainly must take full responsibility for their decision to whip the child, it is also important for people concerned with child welfare to note that there are sources of bad advice that are never forced to take any esponsibility. The Pearls are among these. They share the view I mentioned in a post a few days ago, that children are basically bad and must be forced into obedience; like some other authors since the early days of this country, the Pearls put this belief into a religious context so that it becomes the parents’ responsibility to make children submit utterly to adult expectations.
The Pearls advise that submission to parental wishes should be forced in infants as young as four months of age (these babies, by the way, would be too young to be able to sit up unsupported or to recognize their names when spoken). The primary method for achieving submission is pain, and this is produced by whipping either with the old-fashioned willow switch or with quarter-inch-diameter plastic plumbing supply line. Whipping is advised as a way to make children stop crying or to persuade them to do something that is wanted, or to refrain from doing something unwanted. For example, Debi Pearl recounts a situation in which a toddler was left in her care for a few hours-- the first separation from his mother this child had ever experienced. Although other children were playing around him, the little boy did not eat or play, even though Mrs. Pearl offered him a roller skate and showed him how the wheels spun. When she told him directly to play with the wheels, he “defied” her and did not do so. She whipped him on the leg, but he still did not obey; this continued for ten whippings, until he did put his hand on the wheel, and was described as content now that he had yielded to someone higher than himself.
The Pearls advise that whipping should be done without any indication of anger and with a friendly facial expression, an extraordinarily confusing situation for young children who use social referencing-- checking of faces and voices-- to understand the intentions of adults. Although their stress is on whipping, there are other physical punishments they approve, for example, yanking the hair of a nursing baby if he or she bites the mother.
No doubt the Pearls will say that they never told anyone to whip a child to death, or even to continue whipping for hours. However, advising that pain is the major tool in child discipline opens the door to such actions, particularly when the pain is not to be withdrawn until the child obeys and/or stops crying. The Pearls’ advice, when combined with the belief that children can obey but are wickedly choosing not to, sets the stage for a frustrated or mentally ill adult to injure or kill the child who is being “disciplined”. Such an outcome may seem justified to those who are convinced of the religious value of these actions.
I challenge both mainstream and fundamentalist religious groups to come forward and make clear their rejection of the Pearls’ methods. Some fundamentalist organizations have done this in a quiet way, but a loud shout is needed. I also challenge neighbors and police to be aware of the Pearls’ advice and to try to prevent child injury and death that might otherwise result from systematic whipping.
Any Treatment Is Better Than No Treatment At All
“Any treatment is better than no treatment at all.” I’ve drawn that quotation from the published work of an unconventional therapist who shall be nameless. It’s not just his idea-- plenty of people believe that this is a true statement about psychotherapies. It’s common to think that those who “seek help” always get help, rather than hindrance. But is it true?
Let’s just consider the logic of the whole thing. There are three logical possibilities for the outcome of psychotherapy. One is that the person being treated gets much better, and is both happier and more effective in his or her life. Another is that there’s really no change-- the patient is neither better nor worse during or following the therapy. And the third is that the treatment has an effect opposite from what was wanted: the person who was treated ends up in worse condition than before.
The clinical psychologist Scott Lilienfeld and others have referred to this third possibility as a matter of “potentially harmful treatments” (PHTs). Although a PHT may not harm everyone who experiences it, there is clear evidence that some persons treated in that way have suffered real worsening of their situations-- in some cases even dying as a result. It’s not too difficult to see that physical treatments could have harmful effects, because although medications may benefit people, they can also have adverse effects. Chelation therapy for autism and restraint therapies for “attachment disorders” are understandably potentially harmful. But people may have more trouble understanding how a non-physical psychotherapy of any kind could be a potentially harmful treatment. Cynics are far more likely to expect psychotherapies to be useless than to think they might cause emotional or other damage.
“Recovered memory’ treatments are a very good example of psychotherapies that are potentially harmful. When therapists suggest to patients that their symptoms must be the result of some long-repressed memory of abusive treatment or even of “Satanic rituals”, and when the patients then “recover” such memories with therapist encouragement--- in the absence of confirming evidence, or even the presence of disconfirming evidence----- harm to the individual, friends, and family can be very real. There are many substantiated cases of patients who “recovered memories” that accused family members of horrendously abusive behavior, followed by family alienation, divorce, criminal charges, and so on--- and in some cases eventually followed by the patient’s awareness that in fact the memory had been suggested by the therapist, not actually “recovered”. The potential for harm in this kind of treatment has become pretty clear over the years, although it was not necessarily obvious to the first therapists and patients who used it.
Programs like “boot camps” and “Scared Straight” programs, which lack evidence of effectiveness, may also be PHTs because of their deliberately traumatic components. It’s curious, isn’t it, that our society currently has so much concern with post-traumatic stress disorders, yet we accept some treatment programs based on trauma! It’s especially curious that we want young people from backgrounds of poverty and family dysfunction, who have already been exposed to emotional trauma in many cases and may be sensitized to it, to attend “boot camps” where programs will intentionally frighten and disturb them. (Surely the closest analogy would be a situation where traumatized combat veterans would be exposed to more fear and stress in the bizarre expectation that their original trauma would be defused by this.)
If adults want to choose PHTs, they have the right to do so. Under the First Amendment, advocates of PHTs have the right to state what they consider the strong points of their treatments, and those of us who oppose those treatments can only exercise our own First Amendment rights to state what we consider the problems of those treatments. When it comes to PHTs for children and adolescents, the matter is more complicated. Adults who make choices or recommendations about psychotherapy for children need to remember that they have a fiduciary responsibility-- not one that necessarily involves money, but one that involves guardianship or stewardship of a child’s developmental pathway. Choosing for another, dependent person, who may suffer from our mistakes, feels much more difficult to most of us than choices that affect ourselves alone. One of the first steps in such a choice should involve making sure that PHTs are not among the options we are considering.
In fact, some treatments for mental health problems appear to be potentially worse than no treatment at all, and not all psychotherapies are therapeutic. Let’s not fall for the idea that anything described as an intervention must either do good or do nothing.
Let’s just consider the logic of the whole thing. There are three logical possibilities for the outcome of psychotherapy. One is that the person being treated gets much better, and is both happier and more effective in his or her life. Another is that there’s really no change-- the patient is neither better nor worse during or following the therapy. And the third is that the treatment has an effect opposite from what was wanted: the person who was treated ends up in worse condition than before.
The clinical psychologist Scott Lilienfeld and others have referred to this third possibility as a matter of “potentially harmful treatments” (PHTs). Although a PHT may not harm everyone who experiences it, there is clear evidence that some persons treated in that way have suffered real worsening of their situations-- in some cases even dying as a result. It’s not too difficult to see that physical treatments could have harmful effects, because although medications may benefit people, they can also have adverse effects. Chelation therapy for autism and restraint therapies for “attachment disorders” are understandably potentially harmful. But people may have more trouble understanding how a non-physical psychotherapy of any kind could be a potentially harmful treatment. Cynics are far more likely to expect psychotherapies to be useless than to think they might cause emotional or other damage.
“Recovered memory’ treatments are a very good example of psychotherapies that are potentially harmful. When therapists suggest to patients that their symptoms must be the result of some long-repressed memory of abusive treatment or even of “Satanic rituals”, and when the patients then “recover” such memories with therapist encouragement--- in the absence of confirming evidence, or even the presence of disconfirming evidence----- harm to the individual, friends, and family can be very real. There are many substantiated cases of patients who “recovered memories” that accused family members of horrendously abusive behavior, followed by family alienation, divorce, criminal charges, and so on--- and in some cases eventually followed by the patient’s awareness that in fact the memory had been suggested by the therapist, not actually “recovered”. The potential for harm in this kind of treatment has become pretty clear over the years, although it was not necessarily obvious to the first therapists and patients who used it.
Programs like “boot camps” and “Scared Straight” programs, which lack evidence of effectiveness, may also be PHTs because of their deliberately traumatic components. It’s curious, isn’t it, that our society currently has so much concern with post-traumatic stress disorders, yet we accept some treatment programs based on trauma! It’s especially curious that we want young people from backgrounds of poverty and family dysfunction, who have already been exposed to emotional trauma in many cases and may be sensitized to it, to attend “boot camps” where programs will intentionally frighten and disturb them. (Surely the closest analogy would be a situation where traumatized combat veterans would be exposed to more fear and stress in the bizarre expectation that their original trauma would be defused by this.)
If adults want to choose PHTs, they have the right to do so. Under the First Amendment, advocates of PHTs have the right to state what they consider the strong points of their treatments, and those of us who oppose those treatments can only exercise our own First Amendment rights to state what we consider the problems of those treatments. When it comes to PHTs for children and adolescents, the matter is more complicated. Adults who make choices or recommendations about psychotherapy for children need to remember that they have a fiduciary responsibility-- not one that necessarily involves money, but one that involves guardianship or stewardship of a child’s developmental pathway. Choosing for another, dependent person, who may suffer from our mistakes, feels much more difficult to most of us than choices that affect ourselves alone. One of the first steps in such a choice should involve making sure that PHTs are not among the options we are considering.
In fact, some treatments for mental health problems appear to be potentially worse than no treatment at all, and not all psychotherapies are therapeutic. Let’s not fall for the idea that anything described as an intervention must either do good or do nothing.
Thursday, June 24, 2010
Fires in Crowded Theaters
A few days ago I appeared in court to defend myself against a suit claiming that I had defamed and interfered with the business of a clinical psychologist in another state. It was true that I had stated in pointed fashion my disapproval of the advice my opponent has given to parents-- advice that I consider potentially dangerous and without any evidence basis. I “won” the lawsuit, in the sense that the other person was unable to show evidence that any injury had been done, but did not have a chance to show that my statements had been based on fact.
This experience brought back to my mind an article I co-authored some years ago (Kennedy, S.S., Mercer, J., Mohr, W., & Huffine, C. [2002]. Snake oil, ethics, and the First Amendment. American Journal of Orthopsychiatry, Vol. 72, 5-15). In that paper, we discussed the responsibilities of psychologists, nurses, physicians, and other professionals with respect to speaking out against practices they deem dangerous or lacking in validation.
Professionals have the same First Amendment rights as other citizens, and may exercise freedom of speech within reasonable limits. A common example of boundaries on freedom of speech is that people should not shout “Fire!” in a crowded theater when there is no fire. Neither should professionals say “X treatment can kill you” when there is no evidence that this is true. Although only the situation in the crowded theater is likely to prove tragic, harm can also be done by making unsupported negative statements about other professionals’ practices. There is always a trade-off or balance to be calculated between the rights of the individual and the rights of the community. Even commercial speech is protected to a considerable extent. These matters have been debated at length in the search for some slackening of the tension between individual and group rights.
We often forget that people who have rights also have obligations to their community. The two are alternative ways of looking at the relationship between the individual and the social group. Citizens share obligations like paying taxes and obeying traffic laws. But what about professionals? Do professional groups take on additional obligations to their community, by reason of the unusual rights and privileges they enjoy? Is there something professionals should do in response to those whose cries of “fire” take the form of fraudulent statements and may lead others to avoid conventional treatments or seek potentially dangerous ones?
An initial point to be considered is that professionals have a fiduciary responsibility. This term, although it is often used to refer to financial dealings, actually has a much broader application. A fiduciary responsibility involves any position of trust or stewardship in which one makes decisions for the good of another person. Professionals, who are by definition likely to be much better-versed in their own subject than their clients are, make or contribute to decisions that are intended for the good of the client, who cannot decide so effectively for herself.
This fiduciary role involves a special group of rights and obligations, beginning with the famous “first, do no harm”. But we need to ask the following question: does doing no harm include preventing harm from being done? Does it mean acting in a way that protects the public from potentially dangerous treatments? And, if this is the case, how should that be done? Is it possible for professionals to manage this task without the negative consequences associated with unfavorable publicity or litigation (of the type I mentioned at the beginning of this post-- or worse)? Can the job be done in an effective, comprehensive manner rather than the current case-by-case, ad hoc style, carried out by a small number of concerned people?
It could be done, yes-- but only if large organizations pulled together to support public debate on the question of harmfulness. Such actions would be fiduciary indeed in their protection of the public and of individual professionals too. Yet they do not happen, except in the case of very occasional resolutions vaguely condemning isolated practices.
As a psychologist and student of child welfare issues, I believe I see one problem standing in the way of the comprehensive response that should be organized by national groups like the American Psychological Association. This is the view, almost endemic to the helping professions, that it’s “not nice” to say things that are “not nice”. On the whole, neither individual professionals nor professional organizations want to get caught being critical of colleagues who are assumed to be well-intentioned and competent. Neither does anyone want to decide how to deal with the professional who proved to be not well-intentioned, or not competent--- unless some form of sexual activity was involved, which leads to a quick decision. Like a defense attorney I came across recently, who argued that abusive treatment of a child was trivial because there was no sexual abuse, professional organizations are (justifiably) quick to condemn sexual contact with a client, but (unjustifiably) very slow to recognize other ways in which harm can be done.
Until mental health and child welfare professionals correct these problems, we are in a position where we may see that the theater is smoldering, but we have no way of evacuating the place before someone gets burned. It’s “not nice” for professionals or the public to get singed just because we have failed to develop an organized response.
This experience brought back to my mind an article I co-authored some years ago (Kennedy, S.S., Mercer, J., Mohr, W., & Huffine, C. [2002]. Snake oil, ethics, and the First Amendment. American Journal of Orthopsychiatry, Vol. 72, 5-15). In that paper, we discussed the responsibilities of psychologists, nurses, physicians, and other professionals with respect to speaking out against practices they deem dangerous or lacking in validation.
Professionals have the same First Amendment rights as other citizens, and may exercise freedom of speech within reasonable limits. A common example of boundaries on freedom of speech is that people should not shout “Fire!” in a crowded theater when there is no fire. Neither should professionals say “X treatment can kill you” when there is no evidence that this is true. Although only the situation in the crowded theater is likely to prove tragic, harm can also be done by making unsupported negative statements about other professionals’ practices. There is always a trade-off or balance to be calculated between the rights of the individual and the rights of the community. Even commercial speech is protected to a considerable extent. These matters have been debated at length in the search for some slackening of the tension between individual and group rights.
We often forget that people who have rights also have obligations to their community. The two are alternative ways of looking at the relationship between the individual and the social group. Citizens share obligations like paying taxes and obeying traffic laws. But what about professionals? Do professional groups take on additional obligations to their community, by reason of the unusual rights and privileges they enjoy? Is there something professionals should do in response to those whose cries of “fire” take the form of fraudulent statements and may lead others to avoid conventional treatments or seek potentially dangerous ones?
An initial point to be considered is that professionals have a fiduciary responsibility. This term, although it is often used to refer to financial dealings, actually has a much broader application. A fiduciary responsibility involves any position of trust or stewardship in which one makes decisions for the good of another person. Professionals, who are by definition likely to be much better-versed in their own subject than their clients are, make or contribute to decisions that are intended for the good of the client, who cannot decide so effectively for herself.
This fiduciary role involves a special group of rights and obligations, beginning with the famous “first, do no harm”. But we need to ask the following question: does doing no harm include preventing harm from being done? Does it mean acting in a way that protects the public from potentially dangerous treatments? And, if this is the case, how should that be done? Is it possible for professionals to manage this task without the negative consequences associated with unfavorable publicity or litigation (of the type I mentioned at the beginning of this post-- or worse)? Can the job be done in an effective, comprehensive manner rather than the current case-by-case, ad hoc style, carried out by a small number of concerned people?
It could be done, yes-- but only if large organizations pulled together to support public debate on the question of harmfulness. Such actions would be fiduciary indeed in their protection of the public and of individual professionals too. Yet they do not happen, except in the case of very occasional resolutions vaguely condemning isolated practices.
As a psychologist and student of child welfare issues, I believe I see one problem standing in the way of the comprehensive response that should be organized by national groups like the American Psychological Association. This is the view, almost endemic to the helping professions, that it’s “not nice” to say things that are “not nice”. On the whole, neither individual professionals nor professional organizations want to get caught being critical of colleagues who are assumed to be well-intentioned and competent. Neither does anyone want to decide how to deal with the professional who proved to be not well-intentioned, or not competent--- unless some form of sexual activity was involved, which leads to a quick decision. Like a defense attorney I came across recently, who argued that abusive treatment of a child was trivial because there was no sexual abuse, professional organizations are (justifiably) quick to condemn sexual contact with a client, but (unjustifiably) very slow to recognize other ways in which harm can be done.
Until mental health and child welfare professionals correct these problems, we are in a position where we may see that the theater is smoldering, but we have no way of evacuating the place before someone gets burned. It’s “not nice” for professionals or the public to get singed just because we have failed to develop an organized response.
Taking a Little Walk: What Factors Make a Difference to Toddlers?
The “Question” feature in the New York Times Science Times section today focused on an issue about babies’ early attempts at walking alone. A reader inquired whether what she had been told was true-- that babies could actually walk much earlier, except that their vestibular systems were not developed enough to control their balance until about a year of age. The “Question” editor, C. Claiborne Ray, reported on the inquiries he had made and noted the need for development of the nervous system and its control of the leg muscles.
There’s actually a lot more to walking than that answer implies. Perhaps the first point to examine involves the facts about development of the vestibular system. This system, embedded in the skull near the inner ear, and sending messages along the 8th cranial nerve as the auditory system does, is actually one of the first sensory systems to come “on line” in the course of development. It’s a primitive system which we share with some fairly simple living creatures, and essentially it signals information about the pull of gravity and about the movement of the head. Lean forward or tip your head sideways, and the changed direction of the pull of gravity on parts of the vestibular system signals parts of the brain about the new position. Turn your head, or undergo rotation as you do when going around a corner in a car, and that information is also detected and sent. There is little or no conscious awareness of vestibular activity, but messages from the system enable the body to stay upright by changing muscle tension to counteract accidental movement. They also enable us to know when an object is really moving in front of our eyes, and when an image is moving across the eyes because of head or body rotation. A great deal of vestibular function is already present at birth, and you can see it at work if you hold a young baby in a horizontal position and suddenly move her downward a few inches. The Moro reflex, a movement pattern governed by vestibular activity, causes the baby to fling her arms outward in a grabbing movement.
So , we see that the newborn has almost-mature vestibular function, but she can’t walk (though she can display a stepping reflex when held in the right position). What’s the problem? Why can’t the baby bear her own weight on her legs? Part of the difficulty is the factor mentioned in the Times “Question”: the immaturity of the myelin coating of nerves in the lower part of the body makes conduction of messages poor, and signals from the brain do not effectively control muscle contraction and relaxation. Like other aspects of development, this one follows a cephalocaudal pattern, with the head end maturing more rapidly than the “tail” end. It’s usually about a year before the baby has voluntary control over the legs (and by the way, that developmental pattern also means that toilet-training is not really possible in the first year of life, because voluntary control over the lower part of the body is needed for that purpose).
We haven’t finished yet. There are more factors that enter into the walking equation. One important one would be obvious to us if we were talking about adults, but we tend to forget that it works for babies too: muscle strength. Young babies don’t have strong leg muscles. For them, as for adults, muscle strength increases with exercise. Chances to push with the feet or pull to stand help to strengthen the leg muscles until they have the power to support the weight of the body. In fact, the late and much-respected developmental scientist Esther Thelen showed that a “baby treadmill” that exercised the legs could improve the age at which Down syndrome babies walked-- an event that is ordinarily delayed for these children.
Even when independent walking is achieved, we can see from watching toddlers that they do not yet have a mature gait. Their large heads and relatively short legs make it hard for them to keep their balance when walking, and they compensate by bending their knees a bit and placing their feet far apart to lower the center of gravity and stabilize their position. As their ankles are not yet very strong, toddlers often keep the foot extended and hurtle, from place to place on tip-toe, a gait that has its problems but helps compensate for ankle weakness. (Ideally, they get to use and strengthen those muscles by walking barefoot rather than in hard, unbending “baby shoes”.)
Their first walking experiences have enormous fascination for small children-- so much so that they may not even notice painful results. I have a vivid memory of seeing my older son at 11 months, prancing barefoot over painfully prickly holly leaves, then a month later, when the excitement had worn off, yelping when he stepped on one. That joy of early mastery must be included as one of the factors that helps walking emerge as a new skill.
There’s actually a lot more to walking than that answer implies. Perhaps the first point to examine involves the facts about development of the vestibular system. This system, embedded in the skull near the inner ear, and sending messages along the 8th cranial nerve as the auditory system does, is actually one of the first sensory systems to come “on line” in the course of development. It’s a primitive system which we share with some fairly simple living creatures, and essentially it signals information about the pull of gravity and about the movement of the head. Lean forward or tip your head sideways, and the changed direction of the pull of gravity on parts of the vestibular system signals parts of the brain about the new position. Turn your head, or undergo rotation as you do when going around a corner in a car, and that information is also detected and sent. There is little or no conscious awareness of vestibular activity, but messages from the system enable the body to stay upright by changing muscle tension to counteract accidental movement. They also enable us to know when an object is really moving in front of our eyes, and when an image is moving across the eyes because of head or body rotation. A great deal of vestibular function is already present at birth, and you can see it at work if you hold a young baby in a horizontal position and suddenly move her downward a few inches. The Moro reflex, a movement pattern governed by vestibular activity, causes the baby to fling her arms outward in a grabbing movement.
So , we see that the newborn has almost-mature vestibular function, but she can’t walk (though she can display a stepping reflex when held in the right position). What’s the problem? Why can’t the baby bear her own weight on her legs? Part of the difficulty is the factor mentioned in the Times “Question”: the immaturity of the myelin coating of nerves in the lower part of the body makes conduction of messages poor, and signals from the brain do not effectively control muscle contraction and relaxation. Like other aspects of development, this one follows a cephalocaudal pattern, with the head end maturing more rapidly than the “tail” end. It’s usually about a year before the baby has voluntary control over the legs (and by the way, that developmental pattern also means that toilet-training is not really possible in the first year of life, because voluntary control over the lower part of the body is needed for that purpose).
We haven’t finished yet. There are more factors that enter into the walking equation. One important one would be obvious to us if we were talking about adults, but we tend to forget that it works for babies too: muscle strength. Young babies don’t have strong leg muscles. For them, as for adults, muscle strength increases with exercise. Chances to push with the feet or pull to stand help to strengthen the leg muscles until they have the power to support the weight of the body. In fact, the late and much-respected developmental scientist Esther Thelen showed that a “baby treadmill” that exercised the legs could improve the age at which Down syndrome babies walked-- an event that is ordinarily delayed for these children.
Even when independent walking is achieved, we can see from watching toddlers that they do not yet have a mature gait. Their large heads and relatively short legs make it hard for them to keep their balance when walking, and they compensate by bending their knees a bit and placing their feet far apart to lower the center of gravity and stabilize their position. As their ankles are not yet very strong, toddlers often keep the foot extended and hurtle, from place to place on tip-toe, a gait that has its problems but helps compensate for ankle weakness. (Ideally, they get to use and strengthen those muscles by walking barefoot rather than in hard, unbending “baby shoes”.)
Their first walking experiences have enormous fascination for small children-- so much so that they may not even notice painful results. I have a vivid memory of seeing my older son at 11 months, prancing barefoot over painfully prickly holly leaves, then a month later, when the excitement had worn off, yelping when he stepped on one. That joy of early mastery must be included as one of the factors that helps walking emerge as a new skill.
Wednesday, December 2, 2009
Curriculum Vitae
CURRICULUM
VITAE
JEAN
MERCER*
134 E. Main St., Moorestown, NJ 08057
E-mail: Jean.Mercer@stockton.edu
EDUCATION:
Mt.
Holyoke College, 1959-1961
EMPLOYMENT:
Assistant
Professor, Wheaton
College Norton ,MA
Assistant
Professor, State University College Buffalo , NY
Assistant
Professor, Richard
Stockton College Pomona , NJ
Associate
Professor, Professor, Richard
Stockton College Pomona NJ
Professor
of Psychology, Richard
Stockton College Pomona , NJ
Professor Emerita of Psychology, Richard Stockton
College
PROFESSIONAL ACTIVITIES:
Consulting
reader, Infants and Young Children,1992-
Editor, The
Phoenix
Nurture
Notes (NJAIMH Newsletter), 2000-2001.
Vice President,
New Jersey
Association for Infant Mental Health, 1996-2000
President, New Jersey
Association for Infant Mental Health, 2000-2005
Past
president, ex officio Board of Directors member, NJAIMH, 2005-
Member,
Prevention and Early Intervention Committee, New Jersey Community
Mental Health Board, 2000-
Consulting
editor, Scientific Review of Mental Health Practice, 2002-
Member, New Jersey Better Baby
Care Campaign Advisory Committee, 2002-3
Fellow, Council for Scientific Medicine and Mental Health,
2003-
Faculty member,
Youth Consultation Services Institute for Infant and Preschool Mental Health,
2003-
Chair, Board of
Professional Advisors, Advocates for Children in Therapy, 2003--
Expert witness,
Utah Division of Occupational and Professional Licensing, 2005
(license revocation matter)
[*Name was legally changed from Gene Alice Lester, May,
1977]
Expert witness,
Middlesex NJ Family Court, 2005 (best interest hearing)
Member, "Critical Pathways"
teleconference on training and credentials (formed after ZTT/Mailman Foundation Infant Mental Health Systems
Development Summit Conference, September 2005)
Expert witness, Thibault
vs. Thibault, Pasco County, Florida, 2006 (child custody and discipline matter)
Expert witness, California vs. Sylvia
Jovanna Vasquez, Santa Barbara County, CA, 2007
(child abuse matter)
Reviewer, American Journal of Orthopsychiatry,
2008.
Testimony, Robertson
vs. Mannion, Montgomery County, PA, 2008 (child custody matter)
Founding member,
Institute for Science in Medicine, 2009—
Reviewer, Choice:
Current Reviews for Academic Libraries, 2009-
Board of Directors, Delaware Valley Group of WAIMH, 2010—
PUBLICATIONS:
Lester, G., & Morant, R. (1967). Sound localization
during labyrinthian stimulation.
Proceedings
of the 75th Annual Convention of the American Psychological
Association,
1,19-20.
Lester, G. (1968). The case for efferent change during
prism adaptation. Journal of
Psychology,
68, 9-13.
Lester, G. (1968). The rod-and-frame test: Some comments
on methodology. Perceptual
and
Motor Skills, 26, 1307-1314.
Lester, G. (1969). Comparison of five methods of
presenting the rod-and-frame test.
Perceptual
and Motor Skills, 29, 147-151.
Lester, G. (1969). The role of the felt position of the
head in the audiogyral illusion. Acta
Psychologica,
31, 375-384.
Lester, G. (1969). Disconfirmation of an hypothesis about
the Mueller-Lyer illusion.
Perceptual
and Motor Skills, 29, 369-370.
Lester, D., & Lester, G. (1970). The problem of the
less intelligent student in the introductory
psychology course. The Clinical Psychologist, 23(4), 11-12.
Lester, G., & Lester, D. (1970). The fear of death,
the fear of dying, and threshold differences
for death words and neutral words. Omega,1, 175-180.
Lester, G. (1970). Haidinger’s brushes and the perception
of polarization. Acta
Psychologica,
34, 107-114.
Lester, G., & Morant, R. (1970). Apparent sound
displacement during vestibular stimulation.
American Journal of Psychology, 83, 554-566.
Lester, G. (1971). Vestibular stimulation and auditory
thresholds. Journal of General
Psychology,
85, 103-105.
Lester, G. (1971). Subjects’ assumptions and scores on the
rod-and-frame test.
Perceptual
and Motor Skills, 32, 205-206.
Lester, G., & Lester, D. (1971). Suicide: The
gamble with death. Englewood
Cliffs, NJ:
Prentice-Hall.
Lester, D., & Lester, G. (1975). Crime of passion:
Murder and the murderer. Chicago :
Nelson-Hall.
Lester, G., & Rando, H. (1975). No correlation between
rod-and-frame and visual
normalization
scores. Perceptual and Motor Skills, 40, 846.
Lester, G., Bierbrauer, B., Selfridge, B., &
Gomeringer, D. (1976). Distractibility,
intensity
of reaction, and nonnutritive sucking. Psychological Reports, 39, 1212-1214.
Lester, G. (1977). Size constancy scaling and the apparent
thickness of the shaft in the
Mueller-Lyer
illusion. Journal of General Psychology, 97, 307-398.
Mercer, J. (1979). Small people: How children develop
and what you can do about it.
Mercer, J. (1979). Personality development and the
principle of reciprocal interweaving.
Perceptual
and Motor Skills, 48, 186.
Mercer, J. (1979). Guided observations in child
development. Washington , D.C. America
Mercer, J., & Russ, R. (1980). Variables affecting
time between childbirth and the establishment
of lactation. Journal of General Psychology, 102, 155-156.
Mercer, J., & McMurphy, C. (1985). A stereotyped
following behavior in young children.
Journal
of General Psychology, 112, 261-265.
Mercer, J. (1991). To everything there is a season:
Development in the context of the
lifespan.
Lanham , MD America .
Mercer, J.,& Gonsalves, S. (1992). Parental experience
during treatment of very small
preterm
infants: Implications for mourning and for parent-infant relationships.
Illness,
Crisis, and Loss, 2, 70-73.
Gonsalves, S., & Mercer, J. (1993). Physiological
correlates of painful stimulation in preterm
infants. Clinical Journal of Pain, 9, 88-93.
Mercer, J. (1998). Infant development: A
multidisciplinary introduction. Belmont ,
CA
Brooks/Cole.
Mercer, J. (1999). ‘Psychological parenting” explained
(letter). New Jersey
Mercer, J. (2000/2001). Letter.Zero to Three, 21(3),
39.
Mercer, J. (2001). Warning: Are you aware of “holding
therapy?” (letter). Pediatrics, 107, 1498.
Mercer, J. (2001). “Attachment therapy” using deliberate
restraint: An object lesson on the
identification of unvalidated treatments. Journal of Child and Adolescent
Psychiatric
Nursing, 14(3), 105-114. This paper is posted at
http://www.bpkids.org/learning/reference/articles/index.htm#journals_#
with
permission of the publisher to the Child and Adolescent Bipolar
Foundation.
Mercer, J. (2002). Surrogate motherhood. In N. Salkind (Ed.), Child Development
(pp.
399). New York :
Macmillan Reference USA .
Mercer, J. (2002). Child psychotherapy involving physical
restraint: Techniques used in four
approaches. Child and Adolescent Social Work Journal, 19(4), 303-314.
Kennedy, S.S., Mercer, J., Mohr, W., & Huffine, C.W.
(2002). Snake oil, ethics, and the First
Amendment: What’s a profession to do? American Journal of
Orthopsychiatry,
72(1), 5-15.
Mercer, J. (2002). Attachment therapy: A treatment without
empirical support. Scientific
Review of Mental Health Practice, 1(2), 9-16.
Reprinted in S.O. Lilienfeld, J. Ruscio, & S.J. Lynn (Eds.), Navigating the mindfield: A user’s guide to
distinguishing science from pseudoscience (pp. 435-453). Amherst, NY:
Prometheus Books.
Mercer, J. (2002). The difficulties of double blinding
(letter). Science,297, 2208.
Mercer, J. (2002) Attachment therapy. In M.Shermer (Ed.), The
Skeptic Encyclopedia of
Pseudoscience
(pp. 43-47) .Santa Barbara ,
CA
Mercer, J., & Rosa, L. (2002). Letter on Attachment
Therapy. New Jersey
School
Psychologist,
24 (8), 16-18.
Mercer, J., Sarner, L., & Rosa, L. (2003). Attachment
therapy on trial: The torture
and
death of Candace Newmaker. Westport ,
CT
Mercer, J. (2003). Letter to the editor. APSAC
Advisor,15(3), 19.
Mercer, J. (2003) Attachment therapy and adopted children:
A caution. Readers’
Forum. Contemporary
Pediatrics, 20(10), 41.
Mercer, J. (2003). Violent
therapies: The rationale behind a potentially harmful child
psychotherapy and its
acceptance by parents. Scientific
Review of Mental Health
Practice, 2(1), 27-37.
Mercer, J. (2003). Media Watch: Radio and television
programs approve of Coercive Restraint
Therapies. Scientific Review of Mental Health Practice, 2(2).(see also letters in subsequent issues)
Mercer, J. (2004). The dangers of Attachment Therapy:
Parent education needed.
Mercer, J. (2005). Bubbles, bottles, baby talk, and
basketty. Early Childhood Health Link
(Newsletter
of Healthy Child Care New Jersey ), 4(1),
1-2.
Mercer, J. (2005). Coercive Restraint Therapies: A
dangerous alternative mental health intervention.
Medscape General Medicine, 7(3). (see also letters in subsequent issue).
http://www.medscape.com/viewarticle/508956.
Mercer, J. (2006).
Understanding attachment: Parenthood, child care, and emotional development. Westport , CT
Mercer, J. (2006).
IEPs and Reactive Attachment Disorder: Recognizing and addressing misinformation. Scope (Newsletter of
the Washington State
Mercer, J., Misbach,
A., Pennington, R., & Rosa, L. (2006). Letter to the editor (age regression definition). Child
Maltreatment, 11, 378.
Mercer, J. (2007).
Behaving yourself: Moral development in the secular family. In D..McGowan (Ed.), Parenting beyond belief (pp.
104-112). New York :
Amacom Books.
Mercer, J., &
Pignotti, M. (2007). Letter to the editor (neurofeedback research critique). International
Journal of Behavioral and Consultation therapy, 3 (2), 324-325 (http://www.behavior-analyst-today.com/BAR2007/BAR-VOL-2.pdf
).
Pignotti, M., & Mercer, J. (2007). Holding Therapy and Dyadic
Developmental Psychotherapy are not
supported, acceptable social work interventions: A systematic research synthesis revisited. Research on
Social Work Practice, 17 (4),
513-519.
Mercer, J. (2007). Systematic child maltreatment: Connections with
unconventional parent and
professional education. Society for Child and Family Policy and Practice Advocate
(Division 37 of APA), 30 (2),
pp.5-6.
Mercer, J. ( 2007).Media
Watch: Wikipedia and "open source" mental health information. Scientific Review of Mental Health Practice. 5(1),
88-92.
Mercer, J. (2007)
Destructive trends in alternative infant mental health approaches. Scientific Review of Mental Health
Practice, 5(2), 44-58.
Mercer, J.,
& Pignotti, M. (2007). Shortcuts
cause errors in Systematic Research Syntheses: Rethinking evaluation of
mental health interventions. Scientific Review
of Mental Health Practice, 5(2), 59-77.
Mercer, J. (2008). Minding controls in curriculum study
(letter). Science, 319, 1184.
Mercer, J. (2009).Child
Development: Myths and Misunderstandings.Los Angeles,CA: Sage.
Mercer, J., Pennington,
R.S., Pignotti, M., & Rosa, L. (2009). Dyadic Developmental Psychotherapy
is not "evidence-based": Comments in response to Becker-Weidman and Hughes (2009). Child and Family Social Work, 15, 1-5. http://www.wiley.com/bw/journal.asp?ref=1356-7500
. DOI:10.1111/j.1365-2206.2009.00609.x.
Mercer, J. (2009). Child
custody evaluations, attachment theory, and an attachment measure: The science
remains limited. Scientific Review of
Mental Health Practice, 7(1), 37-54.
Mercer, J. (2010). Themes
and variations in development: Can nanny-bots act like human caregivers? Interaction Studies, 11(2), 233-237.
Mercer, J. (2011). Attachment theory and its
vicissitudes: Toward an updated theory. Theory
and Psychology, 21, 25-45.
Mercer, J. (2011). The
concept of psychological regression: Metaphors, mapping, Queen Square, and
Tavistock Square. History of Psychology,14,
174-196.
Mercer, J. (2011). Some
aspects of CAM mental health interventions: Regression, recapitulation, and “secret
sympathies”. Scientific Review of Mental
Health Practice, 8, 36-55.
Mercer, J. (2011). Book
review: Rachel Stryker’s (2010) The road
to Evergreen. Scientific Review of Mental Health Practice, 8, 69-74.
Mercer.J. (2011). Martial
arts research: Weak evidence. (Letter). Science,
334, 310-311.
Mercer, J. (2012). Reply
to Sudbery, Shardlow, and Huntington: Holding therapy. British Journal of Social Work,
42, 556-559 . DOI:
10.1093/bjsw.bcr078.
Mercer, J. (2013). Child development: Myths and misunderstandings,
2nd ed. Los Angeles, CA: Sage.
Mercer, J., (2013).
Deliverance, demonic possession, and mental illness: Some considerations for
mental health professionals. Mental
Health, Religion, and Culture 16(6), 596-611. DOI:10.1080.13674676.2012.707272.
Mercer, J. (2012).
Attachment in children and adolescents. (Childhood Studies section). H.
Montgomery (Ed.), Oxford Bibliographies Online. www.oxfordbibliographies.com.
Mercer, J. (2013, in
press). Attachment therapies. In R. Cautin & S.O. Lilienfeld (Eds.), Encyclopedia of clinical psychology. New York: Wiley-Blackwell.
Mercer, J. (2013, in
press). Controversial therapies. In R. Cautin & S.O.Lilienfeld (Eds.), Encyclopedia of Clinical Psychology. New
York:Wiley-Blackwell.
Mercer, J. (2013). Holding
Therapy in Britain: Historical background, recent events, and ethical concerns.
Adoption & Fostering, 37(2),
144-156. .
Mercer, J. (2013). Holding
therapy: A harmful alternative mental health intervention. Focus on Alternative and Complementary Therapies, 18(2), 70-76.
Mercer, J. (2013). Giving
parents information about Reactive Attachment Disorder: Some problems. Brown University Child and Adolescent
Behavior Letter, 29 (8), 1, 6-7.
UNPUBLISHED/ IN PREPARATION:
Lester, G. (1968). Some investigations of the audiogyral
illusion. Unpublished Ph.D. thesis, Brandeis University
Mercer, J. (1993) The successful single parent.
Unpublished book-length ms.
Mercer, J. The
developing child in
changing
times: Infancy through adolescence Unpublished book-length ms.
Invited comments on the New Jersey Children’s Initiative
proposal (March 10, 2000 );
with
Gerard Costa and Elaine Herzog.
Invited comments on the U.S. Bright Futures children’s
mental health proposal (July
5, 2000 ); with Gerard
Costa.
Mercer, J. (2000). Notes on Attachment Therapy: Relevant
Research and Theory. Prepared for use by
the prosecution in the trial of Connell
Watkins , Colorado
Sarner, L., & Mercer, J. (2003). Statement to Human
Resources Subcommittee of House Ways and Means
Committee. http://
waysandmeans.house.gov/hearings.asp?formmode+view&id+1342.
Mercer, J. (January, 2005). Expert witness report. State
of Utah
Division of Occupational and
Professional Licensing. Case number 2002-223.
Mercer, J. (April, 2005). Expert witness report. Child custody case, Middlesex Family Court,
New Brunswick, NJ.
Mercer, J. (October, 2006). Expert witness report. Child
custody case, Pasco County ,
Florida
BLOGS AND OTHER INTERNET MATERIALS:
“Attachment therapies and associated parenting
techniques.” www.scienceinmedicine.org/policy/papers/AttachmentTherapy.pdf.
“Critical thinking and the mastery of child development
concepts.” www.thelizlibrary.org/liz/critical-thinking.html.
RECENT PRESENTATIONS:
Various presentations on child development and parenting
issues to parent groups and
training
workshops, including CASA.
“Law, policy, and attachment issues”; presentation at the
Second Annual Conference on Attachment
of the New Jersey Psychological Association. June 9, 2000 , Newark , NJ
“Custody changes and their effect on children’s
development”; presentation at New Jersey
State Child Placement Advisory Council conference, April, 2001.
“Bad language: How the professions confuse each other with
words,” welcoming address at
conference on Attachment, New Jersey Association for Infant Mental Health,
“That cranky, crying baby”; presentation at National
Association for Education of Young Children Conference on Health in Child Care,
Princeton, NJ, May, 2002; repeated
May, 2003, May, 2004.
“Warning Signals: When parents consider unusual mental
health treatments for their children”;
presentation at Third Annual Multicultural Health Conference, Richard Stockton College, Pomona, NJ, Sept. 2002.
“Misuse and abuse of attachment theory”; keynote speech at
2002 Annual Meeting, New Jersey
Association for Infant Mental Health, Piscataway, NJ, Nov. 2002.
“Attachment Therapy: Science adversaries appeal to
scientific evidence.” Institute of Contemporary
British History conference, “Science, Its Advocates and Adversaries”, London ,
July 7-9, 2003 .
“Analyzing Attachment Therapy”, at “Right From the Start:
Supporting the Earliest Relationships
and their Impact on Later Years,” professional conference presented by Youth Consultation Services Institute for Infant and Preschool Mental
Health, Newark, Sept. 24-25, 2003
(continuing professional education credit-bearing).
“Principles of Infant Mental Health”, at “What Does Infant
Mental Health Mean to Me?”, professional
conference sponsored by New Jersey Association for Infant Mental Health, Gateway Maternal-Child Health
Consortium, Northwest Maternal-Child Health
Consortium, Piscataway, NJ, Nov. 13, 2003 (continuing professional education credit-bearing).
“Attachment and Attachment Therapy: The Good, the Bad, and
the Ugly”, at annual meeting, Gateway Maternal-Child Health Consortium. East Orange , NJ March 25, 2004 (Continuing professional education
credit).
“Attachment.” Annual conference of New Jersey Association
for Education of Young Children, East
Brunswick, NJ, Oct. 16, 2004 (continuing professional education
credit)
Discussion of Attachment Therapy. “All in the Mind”,
Australian Broadcasting Company, Dec. 18, 2004 . Transcript available at http://abc.net.au/rn/science/mind.
“Attachment: Social and Emotional Development from Birth
to Preschool.” Conference of Coalition of Infant and Toddler Educators,
East Brunswick, NJ, March 18, 2005.
“Attachment Therapy: Concerns on Unvalidated Treatments.”
Institute for Infant and Preschool
Mental Health Didactic Series, Youth Consultation Service, East Orange, NJ, May 12, 2005.
"Violent therapies
with children: History and theory.” 9th International Family Violence Research
Conference, Portsmouth , NH July 11, 2005 .
Invited state delegate and
New Jersey
presenter, Infant Mental Health Systems Development Summit conference,
sponsored by Mailman Foundation/Zero to Three. Washington DC Sept. 22-24, 2005 .
New Jersey Perinatal Mood
Disorders training program presentations, 2005-2006.
“Dangerous therapies”,
with Alan Misbach. LCSW. Independent
Educational Consultants Association conference, Philadelphia , Nov. 14, 2005 .
"Attachment
Therapy". Institute for Infant and Preschool Mental Health Didactic
Series, Youth Consultation Service, East
Orange , NJ April 27, 2006 .
"Attachment
Therapy" comments, Paula Zahn show, CNN, Nov. 14, 2006 .
"Attachment
Therapy" comments, Court TV, Nov. 27, 2006 .
"Understanding attachment." Delaware Valley
Group, WAIMH. Dec. 1, 2006 .
"Strategies for picky eaters." Jan 31, 2007 , NJ WIC
training, Ewing , NJ
"Just the facts,
ma'am: Asking and answering the right questions about evidence-based
treatment." May 17,
2007 . Florida
Association for Infant Mental Health, Ft. Lauderdale
Panel on secular
parenting, moderated by Dale McGowan. Atheist Alliance International,
annual conference, Arlington , VA Sept. 29, 2007 .
"Circumstantial
Evidence: Evaluating Design and Details of Outcome Research" (poster
presentation). Dec. 1, 2007. Zero to Three National Training Institute, Orlando , Florida
"Theory of Mind: A
New Approach to Attachment." Conference of Coalition of Infant and Toddler
Educators, New Brunswick , NJ March 14, 2008 .
"Novel Unsupported
Therapies: Pseudoscientific and Cult-like". With Monica Pignotti and James
Herbert. International Cultic Studies Association conference, Philadelphia , June 27, 2008 .
"Attachment Theory,
Evidence-based Practice, and Rogue Therapies: Using and Misusing the Concept of
Attachment." With R.S. Pennington, L. Rosa, and L. Sarner. Wisconsin
School Psychologists Association conference, LaCrosse, WI, Oct. 29, 2008 .
"Are There
Research-based Child Custody Evaluations? An Ongoing Case and an Ongoing
Discussion." Annual Conference, New Jersey Association
for Infant Mental Health, Dec.
12, 2008 , North Brunswick ,
NJ
“A Problematic Parenting
Pattern Associated With Child Deaths.” Eastern Psychological Association,
March7, 2009, Pittsburgh, PA.
“Personalities and Power
Struggles: Discipline, Temperament, and Attachment.” Coalition of Infant and
Toddler Educators Annual Conference, March 14, 2009, Somerset, NJ.
“Don’t Be So [Un]critical!
Using Critical Thinking to Foster Mastery of Child development Concepts.” Developmental Science Teaching Institute,
Society for Research in Child Development, April 1, 2009, Denver, CO.
“Psychological Concepts
and Measures in the Family Court”. Judicial Orientation, Essex Vicinage (NJ).
Princeton, NJ, Oct. 2, 2009. (With Michelle DeKlyen, Ph.D.)
“Are There Research-Based
Child Custody Evaluations?”. Conference on Infants and Children in the Courts,
sponsored by Youth Consultation Service and NJAIMH; Clara Maass Medical Center,
Belleville, NJ, March 19, 2010.
“Unconventional
Psychotherapies: Some Questions About Their History.” Eastern Psychological
Association, March 11, 2011, Cambridge, MA.
“Myths and Misunderstandings.”
Conference of the Delaware Valley Group of the World Association for Infant
Mental Health, Feb. 3, 2012, Philadelphia, PA.
Comments on Attachment
Therapy and treatment of Russian adoptees. “Life with Mikhail Zelensky”,
Rossiya-1 TV, Feb. 21, 2013.
“Fetal Psychology in
Psychohistory.” Eastern Psychological Association, March 2, 2013, New York.
“Jirina Prekopova’s
holding therapy: Scientifically founded or otherwise?” Conference of the
International Working Group on Abuse in Child Psychotherapy, April 20, 2013,
London.
“ ‘Nancy Thomas parenting’ in the U.S. and
Russia: Another part of the holding therapy problem.” With Yulia Massino. Conference of the International
Working Group on Abuse in Child Psychotherapy, April 20, 2013, London.
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