The Investigation of the Death of Maxim Kuzmin (Shatto)

Yulia Massino has called my attention to a report on the autopsy of Maxim Kuzmin (Shatto), the Russian-adopted three-year-old who died in Texas last January (http://www.oaoa.com/news/crime_justice/law_enforcement/article_53ef4076-9663-11e2-9e1b-0019bb30f31a.html). The autopsy report was released following a request under the Freedom of Information Act.

The report does not answer a great many significant questions, but it does clarify some points that have been made, denied, and then made again. It includes the fact that although Maxim showed a few bruises and scratches when first seen by a pediatrician in the U.S., at the time of his death from internal bleeding he had many bruises at different stages of healing. It also explains that the pediatrician had indeed prescribed an antipsychotic drug after concluding that Maxim was schizophrenic, and that Mr. and Mrs. Shatto, the adoptive parents, had stopped administering the drug three days before the child’s death, because it appeared to them that the medication made it difficult for Maxim to swallow.

The report also notes that Maxim had “breath-holding” incidents and had fallen off a chair after choking on a bite of cooked carrot. When Mrs. Shatto came out of the house and saw Maxim lying on the ground, she believed that he had “held his breath” and lost consciousness. According to the report, she grabbed and shook him while calling out his name. When this had no result, she grabbed him by the neck with both hands and shook hard until bubbles of blood came out of his mouth.

On the day of Maxim’s death, according to the report, he woke at a normal time in the morning but resisted Mrs. Shatto’s efforts to take him to the bathroom. According to her, he “had a fit” and went back to bed, where he remained until she woke him and his napping brother in mid-afternoon.

There is much to talk about here. An important unanswered question about this tragic story has to do with the diagnosis of schizophrenia and the treatment prescribed. Again, the report does not tell everything, and there may be a reasonable answer to this question--  but, are we to take it that the pediatrician made a diagnosis of schizophrenia (very rare in young children) on the basis of the parents’ comments alone? I certainly agree that parents know their children better than anyone else, but in the case of two months’ acquaintance with a child accustomed to a different language, even those who know him best may not know very much. A home visitor or other observer could have contributed much of importance to the diagnosis, for example whether any disturbing child behavior was related to adult actions or other events. Did the adoption agency (still unidentified as far as I know) not provide home visiting as part of post-adoption support? Did the physician not seek more objective evidence than the parents could provide?

Given the surprising diagnosis of schizophrenia, surely there must have been some uncertainty about both diagnosis and treatment. Were there any efforts at professional parent education and social support before medication was prescribed? When there is an unlikely diagnosis like schizophrenia, and when medication specifically approved for children does not exist, why was this treatment given without any attempts at less dangerous approaches? Or, were there other approaches taken, and these have not been included in the report because the right questions were not asked?

Side effects of antipsychotics (and of course we do not seem to know exactly which one was used here) include constipation, difficulty in urinating, and drowsiness. Maxim was reported as resisting toileting and being drowsy on the day of his death. He had been withdrawn, apparently abruptly, from the drug three days before. Did he have persisting effects from the drug? Or was the abrupt withdrawal in some way implicated in his death? Were the Shattos in touch with the prescribing doctor about side effects--  and did they discontinue the medication on their own decision, or did they have guidance in how to do this gradually?

A few weeks ago I commented on this blog that permission for adoption from abroad should be based in part on availability of a range of services that may be needed. The Shatto case exemplifies the problems I was talking about. As far as one can see from the report, their pediatrician not only prescribed in a possibly questionable way, but may have failed in his responsibility for parent education about the use of powerful drugs.

The adoption agency also appears to have failed in both post-adoption services like home visiting and in pre-adoption education. So far, it does not appear that the Shattos learned any Russian or any other means of communicating (like signing) with children who were likely to be language-delayed because of their care history. Mrs. Shatto appears to have misunderstood Maxim’s episodes of “breath-holding” which is an involuntary response to being startled or alarmed, sometimes seen in young children. (Falling off his chair when choking may have been an episode of this.) When she thought he was “holding his breath”, she shook him and shouted, responses which are neither necessary nor beneficial when a child has temporarily lost consciousness in this way. Why she subsequently seized him by the neck with both hands and shook him is incomprehensible except as the panic reaction of a person without the first-aid training that she should have received from the adoption agency.

Perhaps there was some sort of sexual abuse in Russia, as suggested, but if there was, it is hardly relevant except as a way of distracting from the central issues. Sexual abuse, repugnant though it is, does not cause schizophrenia or make young children injure themselves. My question about what happened in Russia is this: who decided that an older couple should take two young children, a year apart in age, and at developmental stages that require even more skill and attentiveness than are needed by infants? This is not the first time I’ve heard of this arrangement being encouraged, or even pressed, by Russian institutions, and permitted by U.S. adoption agencies who ought to know the difficulty being created for the naïve adoptive family.

Murder mysteries sometimes feature a situation in which each of many people contributes to a death, making it difficult to know who is to blame. Maxim’s death is similar, it would seem. A dozen people, perhaps, each made some contribution to the outcome. There is no point thinking of any of them as “a murderer”. But if Russians want to understand what happened, and if we in the U.S. want to keep adopted children safe, we need to know the whole truth and to answer all the questions I’ve posed here.

   

Attachment, Empathy, Conscience: What Are the Connections?

A reader recently commented on this blog and referred to the belief that unless a child develops a secure attachment, he or she will be unable to feel empathy for other people and also will have no conscience. This statement is often made by proponents of attachment therapy as well as by many others. Is it just one more example of the current tendency in some circles to reduce everything in personality development to some aspect of attachment? I think it may be useful to go through some of the relevant facts and logical connections between facts, and to try to see what causal associations there actually are between attachment and other developmental milestones.

Let’s begin by looking at the assumption that attachment must be secure in order for empathy to develop. This seems most unlikely simply from a statistical perspective. About 35% of normally-developing toddlers are evaluated as insecurely attached on the basis of their behavior in the Ainsworth Strange Situation. Can it be that 35% of the older population is entirely without the capacity for empathy? Recognizing the frequency of selfish, egocentric, even narcissistic behavior, nevertheless it seems impossible that empathy is totally absent in that large a group, or that a society could function if a third of the population could not recognize or respond to other people’s emotions. In addition, insecure attachments, although not seen as ideal in terms of attachment theory, are within the normal range of personality developments, and it seems implausible that an important aspect of human behavior like empathy would be non-functioning while related aspects are normal. These things raise questions about whether secure attachment could be a necessary cause of empathy.

Thinking about empathy itself is an important step in examining these issues. Empathy can be thought of as responsiveness to other people’s feelings, but there is more than one way that responsiveness can occur. There is cognitive empathy, or accurate identification of facial expressions or other emotional messages like voice tone or posture and gestures. Even newborn babies show some of this ability by imitating facial movements like mouth opening, and it’s posited that they have “primary intersubjectivity” or the awareness that the face they see belongs to another person. Emotional empathy, the next step, involves a sharing of the emotions another person displays, but this does not happen all at once. After a couple of months, babies respond to smiles with smiles, and are disturbed if a person who usually responds to them stares blankly. By 7 or 8 months (yes, the time when attachment is first evident), babies recognize expressions of fear and respond to them with anxiety. They use social referencing--  looking at the faces of familiar people--  to see what those people feel about new events and people. If the familiar caregiver looks scared, the baby avoids the new thing; if the familiar adult looks happy, the baby explores it. So, that kind of empathy is certainly well underway by the end of the first year, at about the same time that attachment is really perking for family-reared children.

What about what we might call “functional empathy”--  not only identifying and feeling with another’s feelings, but also behaving in a kind and helpful way when someone is in distress? This is a much trickier development. Unfortunately, we human beings of all ages have complex responses to others’ distress, and our responses are not all helpful by any means. Sometimes we laugh when someone gets hurt---the basis of the Three Stooges’ popularity, but also of the embarrassing impulse to laugh at a funeral. Sometimes we get angry when someone displays distress and we can’t or don’t want to be of help; we tell them the problem was their own fault and maybe they’ll know better next time, or accuse them of manipulating people by pretending to be hurt. We may even attack a person who displays distress. Physical abuse of infants is often in response to the infant’s crying. Even normally kind parents under stress may threaten or actually smack a child who is whining or complaining (classically saying, ‘I’ll give you something to cry about”).  And toddlers and preschoolers too show all these kinds of responses to others’ distress.

So, how does it come about that a lot of people, both children and adults, respond helpfully a lot of the time, when they get other people’s messages of pain or fear?  Almost all will have had mixed experiences of responses to their own distress. Very few, if any, will have survived without ever having anyone respond to their needs and related emotions. Very few, if any, will have had caregivers who were always willing and able to respond to a child’s distress. Most will occasionally have had a parent unable to respond (for example, I remember having an allergic reaction and not being able to speak to my two-year-old for perhaps 15 minutes while the medicine went to work). Many will have had a caregiver laugh at a fall or other accident that later proved to be more serious than it looked. And probably most will at least once have had a stressed-out parent respond with an angry look to one-too-many complaints. Children who become nurturing and helpful as they get older seem to be the ones who have most often had sensitive and responsive care from adults who identified the child’s emotions correctly and acted as well as they could to comfort and soothe. Their experience with good role models tells them the ideal way to act, and like adults they do this as well as they can in given circumstances. (This does not mean, of course, that as children they can understand or deal with some of the powerful emotional issues of adulthood, nor should they be expected to empathize with many adult emotions.)

Given all of this--   does attachment (secure or insecure) serve as a necessary foundation for empathy? There seems to be no reason why the first should be the basis of the second. However, it is reasonable that this might appear to be the case. Secure attachment grows through experiences of pleasant social interactions with caregivers who are interested, engaged and engaging, sensitive and responsive to child messages. Although most parents and caregivers are better at dealing with certain child ages than with others, it’s generally true that those who have been sensitive and responsive (and fostered attachment) early on will continue to behave in the same way with an older child--  and thus will foster positive, helping behavior toward others’ distress. If the child who has become attached stays with the same caregivers, their continuing modeling of empathy and nurturing will help shape the same kind of behavior in him or her. Although the responses the child gets to his or her own distress are probably most important, such caregivers will probably also model empathy by direct instruction (“we pat the kitten very gently”) and by observable nurturing behavior to other people (“let’s get Grandma a cup of tea, she’s tired”).

But as usual, it’s not as simple as one experience, one child outcome. The researcher Grazyna Kochanska has looked at conscience development as an outcome not only of parenting methods, but of the child’s basic temperament. For children who were not very fearful, secure attachment in infancy was a good predictor of later conscience. For temperamentally fearful children, a better predictor was the mother’s use of gentle discipline. Kochanska referred to attachment as an “alternate pathway” to conscience.

Rather than secure attachment causing empathy, it may well be that “good things go together”, as so often seems to be the case in child development.

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More on the Death of Maxim Kuzmin (Shatto)

An announcement at http://permianbasin360.com/fulltext?nxd_id=257022 states that the adoptive parents of the Russian-born three-year-old Maxim Kuzmin (Shatto) will not be charged in his death. The case has been closed  by the grand jury and the death ruled an accident, with the speculation that Maxim was in some way struck and injured by a playground glider while his mother briefly went indoors. The district attorney noted that Maxim was small and undernourished, and that “with the behavioral disorder he was prone to hurt himself.” The behavior disorder was not specified.

Texas child protective services is continuing an investigation into the family’s circumstances, according to the news release.

I have no wish to charge Mr. and Mrs. Shatto or anyone else who might be associated with Maxim’s death, unless much different evidence turns up justifying prosecution. I would say, though, that it is a mistake to close the door on this case as an accident, a random event whose causes cannot be ascertained. If this death were an isolated incident, that decision would make sense. However, it is one of a number of deaths that share certain characteristics--   adoption, undernutrition, physical injury, and the claim that a behavior disorder has caused the child to hurt himself.

Prosecution, and judicial findings of guilt or innocence, are desirable if the goal is to punish guilty people. If the goal is to prevent more deaths that follow the pattern described above, however, grand jury investigations and prosecutions may not be the best way to go. Those investigations focus on evidence of law-breaking and direct responsibility for children’s injuries or deaths. Even a successful prosecution of culpable persons fails to examine the possibly systemic causes for these advents.

Can we examine these cases and decide whether the pattern is coincidental, or whether there are indeed systemic reasons for these occurrences? To do so would require examination of a good deal of evidence and would need a broad perspective rather than the narrow focus on persons who may be accused of abuse or even murder. Although the evidence turned up by the district attorney would be relevant, this broader approach could only be managed by an investigative group like the one we have been told that Senator Mary Landrieu would head in the Shatto case, or, to some extent, by the investigation that Texas child protective services is still carrying out.

One important question in all these cases has to do with the claimed behavior disorder that causes self-injury. Certainly some children are impulsive and poorly self-regulated and get many bumps and bruises because of this, but it’s hard to imagine death resulting except in some very unusual situations. Other children injure themselves directly, and self-injurious behavior can be associated with autism, with Lesch-Nyhan syndrome, and with Rett syndrome, which is exceedingly rare in boys and is associated in boys from the time of birth with other problems like breathing disorders. Reactive Attachment Disorder, so often referenced in discussions of adopted children, is not in itself associated with self-injurious behavior. (However, advocates of holding therapy, who claim a version of attachment disorder that only they can detect, do argue that children can injure themselves badly in order to cause trouble and blame to be directed toward their adoptive parents. One chat group in 2001 even suggested that Candace Newmaker had died intentionally, just to cause trouble.)

In the Nathaniel Craver case, and in the ongoing Chritton case, defense attorneys have claimed that injured or dead children had been caused to bring harm to themselves by their Reactive Attachment Disorder. While this is not likely, the statement does raise some important questions. Was Maxim diagnosed as having Reactive Attachment Disorder, and if he was, who diagnosed him? If he had that diagnosis, was he being treated, and by whom? What advice about home care did the Shattos receive, if such a diagnosis was made? And, if there was such a diagnosis, was it by some circular reasoning based in part on the existence of injuries, which were later attributed to the disorder?

If Maxim was not diagnosed with Reactive Attachment Disorder , was he diagnosed with autism, Lesch-Nyhan syndrome , or Rett syndrome? The latter two very serious disorders would have been readily apparent before he left the orphanage, but because children who have been in institutions are often delayed in speech, autism might not have been diagnosed. I think the two syndromes mentioned can probably be dismissed as unlikely, but if they were present Maxim would have had to receive medical and other treatment. Was he receiving such treatment? As for autism, the related developmental delays may not have been obvious to anyone at this point, but it would be important to know whether he was receiving any treatment such as speech therapy or ABA—or whether the Shattos were trying to deal with a serious problem on their own.

Another topic that needs to be dealt with in order to understand Maxim’s death has to do with his poor nutritional status. Children who have been in institutions are often undergrown, as staff and other issues interfere with their taking as much food as they need, and the kinds of food they need. Maxim had only been with the Shattos for 2 ½ months at the time of his death, but surely they are likely to have sought a medical evaluation and should have received advice about his dietary needs and suitable growth goals. (If their pediatrician was not able to manage this, post-adoption services should have provided help such as reference to a group like the SPOON Foundation, which specializes in feeding help for parents who have adopted from abroad.) Were Maxim’s growth and nutritional status where they might be predicted to be after a couple of months in the adoptive home, or were they still at the levels seen when he was first examined? (The growth and nutritional status of the younger adopted child, Kirill, would make a useful comparison here, perhaps showing whether Maxim had some undetected medical problem that could have been implicated in his death.)

Horribly, apparently at least one person has adopted a Russian child for sexual purposes. I find it difficult to believe, however, that many adoptive parents in the U.S. have obtained children for the purpose of injuring and killing them. (My reasoning is that the number of people who want sex with children is probably a good deal larger than the number who find it pleasant to injure them.) This position leads me to explore the systemic reasons and the context in which adoptee deaths have occurred, with the hope of finding a background to the death pattern I mentioned earlier. Understanding that background could help prevent more deaths of children and disasters to surviving members of the adoptive families, including other children.

Warnings From the Attachment Industry: Examining Online Material About Attachment Therapy

Looking over the details of attachment therapy web sites is always interesting and revealing. Somehow, laborers in the attachment biz seem to make the same mistakes repeatedly. Maybe they never read anything that contradicts their viewpoints--  but of course that would mean omitting a great deal of relevant material, without which an educated perspective is impossible.

 Today, I notice that at www.instituteforattachment.org, mouthpiece of the Institute for Attachment and Child Development in Colorado, includes a message called “Beware of Attacks on Attachment Therapy”. The author, Forrest Lien, provides a mixture of truths, half-truths, and errors to support his argument that people like me are mistaken in their concerns about attachment therapy.

Lien distances his organization from the lady formerly known as Connell Watkins, but also describes Watkins as having “wrapped a child up in a blanket which affected her breathing and she died”. This description seems to me to parallel the statement that Jesus was in an upright position with his arms extended, this influenced his health, and he passed away. Both are true, but a bit incomplete. Lien’s comments about Candace Newmaker may appeal to those who have seen the related “Law & Order” episode, in which the scriptwriters avoided the issue by having the child’s death due to an allergic reaction to the blanket. But the reality is that Candace suffocated because of pressure exerted against her immobilized body by a number of large adults who believed they were imitating the experience of childbirth and that this would cause Candace to be the “real” attached child of her adoptive mother. Silly and pointless as it may be, rebirthing should not be fatal. It was fatal in this case because of the factor Michael Shermer has called “death by theory”. That is, Watkins and her fellow-therapists were convinced of the basic tenet of attachment therapy, promulgated by Foster Cline, that a display of power and authority was necessary in order for a child to become attached to a parent. Watkins persisted in her actions for 70 minutes, ten times longer than the usual rebirthing session--  70 minutes in which the child initially begged for release, vomited, defecated, and for the last 30 minutes was silent. It was not the blanket that affected Candace’s breathing; it was the deep conviction of the therapists that in order to be successful they must ignore the child’s “lies” and force her compliance.  

Lien is perfectly correct in saying that rebirthing is not holding therapy, and it is wrong to equate the two. This error on the part of a Congressional resolution and of the American Psychological Association has caused a great deal of trouble, although it pleased holding therapists, who were happy to point the finger at rebirthing and away from their own principles and practices. In fact, rebirthing is quite unlikely to do either harm or good--  unless it is intensified to a dangerous level by beliefs like those Watkins held.

Interestingly, Lien notes that his organization stopped using holding therapy in 2006 (even though, as they state, it was not the same thing as rebirthing). Six years after Candace Newmaker’s death! Several years after a number of publications pointed out other child deaths associated not only with the therapy, but with the belief system that equates obedience with attachment! Can we believe that people who took that long to drop a particular practice have also dropped all of the harmful mistaken beliefs that supported the practice? I find it difficult to believe, and my difficulties are confirmed by the rest of the www.instituteforattachment website.

As usual, some of the principles that make attachment therapy dangerous are seen in the list of symptoms of Attachment Disorder given on this site. There we are, at “What is Attachment Disorder?” --  the same old same old claimed symptoms, totally different from the characteristics of Reactive Attachment Disorder as described in DSM. Manipulativeness, lack of conscience, remorse, or empathy, inability to give or receive love, lack of cause and effect thinking (ever wonder how they can be so manipulative without this?), lying, destructiveness, cruelty, and of course superficial charm. But Reactive Attachment Disorder is officially characterized by either excessive clinging and dependency on caregivers or by a lack of normal preference for familiar people. Where did the IACD Attachment Disorder  list come from? It’s a combination of a number of old checklists, including one that’s supposed to identify psychopathy. How did this list get associated with Reactive Attachment Disorder, the term used at several places on the website? Do the website authors hold that Reactive Attachment Disorder is the same as Attachment Disorder? If not, what is the evidence that there is a distinct disorder called Attachment Disorder? If www.instituteforattachment.org is not sure what problem it’s treating, it seems a bit arrogant to declare that the treatment is a safe and effective one.

Given the apparent confusion about the problems being treated, perhaps, it’s not surprising that www.instituteforattachment.org features among “research articles” a piece on the Randolph Attachment Disorder Questionnaire, which makes many of the  assumptions noted in the last paragraph. The RADQ is an instrument that has never been published in a peer-reviewed journal and one whose efforts at validation involved having the same person administer questionnaires to parents and make diagnostic decisions, a pretty sure way to create bias in the results. It’s not clear on the rest of the site whether IACD even uses the RADQ, and indeed they should not, because not only is the instrument poorly validated, its author states perfectly clearly that it is NOT an assessment for Reactive Attachment Disorder, but for “something else”—Attachment Disorder. This does raise the question, though--  if IACD does not use the RADQ, why do they post information about it? Is the answer that they actually do use it, or is the presence of the RADQ on the site simply a code that communicates to some readers the real belief system at work here?

I didn’t come here to argue that IACD uses directly harmful methods, that they killed Candace Newmaker, etc. I do believe that some psychotherapeutic methods are indirectly harmful, in that they are ineffective but delude parents into avoiding more effective treatments. This problem points up questions about the effectiveness of the treatments used by IACD. Exactly what these are is not obvious, of course; however, some of the articles and other materials give us an idea. For example, there is a piece by Sebern Fischer touting neurofeedback, a method that has never been supported by adequate outcome research. An article by Victoria Kelly claims that physical contact and eye contact are important factors in treatment of childhood emotional disorders--  a claim that has never been supported by evidence, and that in fact has been tested only by proponents of holding therapy.

There are some other questions that the web site put into my head, but did not answer. Why does www.instituteforattachment.org state in a testimonial that a child diagnosed with PDD was successfully treated with their methods? Is this a claim that PDD is caused by the same factors that appear to create RAD? Is it that, as someone commenting on this blog remarked the other day, that all but clearly genetic early mental health problems are due to attachment difficulties? And what would be the ground for making these claims?

Another question: children treated at IACD are apparently sent to “therapeutic foster homes” for periods of months. If the goal is to create emotional attachment to their parents, what would be the rationale for this separation? Do Forrest Lien and his staff believe, like the old holding therapists, that they can create an attachment in a child and then transfer it from one attachment figure to another? How would that work, when attachment is a matter of a relationship, not some entity inside the child?

And finally: is it true that IACD uses the Attachment Disorder diagnosis? When seeking third-party reimbursement, do they use that term, or do they claim DSM code 313.89, Reactive Attachment Disorder?  It’s my understanding that  public funds are received by IACD, and surely there is a problem if in applying for such funds the organization substitutes an acceptable diagnosis for one that is not evidence-based.

Until IACD and other organizations can correct their misinformation and answer these questions, I will continue to hold the position that attacking attachment therapy is not only an appropriate action in terms of the evidence--  it is in fact a professional responsibility.

The RAD Defense: Questionable Testimony in the Chritton Trial

What is the RAD defense? It’s an argument in a court of law, claiming that harm done to a child was not the fault of an abusive adult, but was in some way related to the child’s diagnosis of Reactive Attachment Disorder. The RAD defense may argue that the child injured himself or herself—as, for example, in the case over a decade ago of the Russian adoptee toddler David Polreis, who was said to have beaten himself to death with a wooden spoon, or the more recent case of Nathaniel Craver, who was said to have hurled himself against a stove until he inflicted fatal head injuries. The RAD defense does not appear to have been successful in the sense of leading to acquittal of those accused of child abuse, but it may have acted to mitigate their sentences.

Now the RAD defense is back with us in a complicated though fortunately non-fatal case. As many readers already know, in the Chritton case a teenage girl was found walking barefoot in the Wisconsin winter. She was taken to a hospital, where she was found to weigh only 68 pounds and to be of very small stature for her age. She told a story of having been kept in a basement by her father and stepmother, given little to eat, and provided with very limited toilet facilities. This story, shocking enough in itself, was further complicated by the presence in the house of a step-brother who was a sexual predator and by the apparent failure of social services to manage any part of the situation. While in the hospital, the girl developed refeeding syndrome, a potentially fatal physical response to the restoration of a normal diet after long starvation.

The father and stepmother, Chad Chritton and Melissa Drabek-Chritton, are being prosecuted on a number of charges. Their lawyer has invoked the RAD defense, claiming that the girl starved herself as a consequence of Reactive Attachment Disorder, as recounted here: http://host.madison.com/news/local/crime_and_courts/judge-in-chad-chritton-s-child-abuse-trial-questions-one/article_dfd1c8ec-8b83-11e2-b7c2-001a4bcf887a.html?comment_form=true.

To support the RAD defense, the Chritton attorney has called an Iowa therapist, Rhonda Lettington, who testified about the “numerous symptoms” of RAD and stated that medical records show that the girl has the disorder.

In my opinion, calling Lettington was a desperate move on the part of the defense, and I am surprised that she was qualified as an expert witness by the judge (still, I suppose they have to qualify somebody). Let’s look at her credentials. According to her website, www.lettschatreactiveattachment.com, Lettington has a bachelor’s degree in psychology (and I as a long-time professor thereof can tell you that this teaches very little indeed about mental illness), a master’s in community counseling and one in professional development (?), and certification in alcohol and drug counseling. She is a licensed mental health counselor and belongs to several counseling organizations. She has trained in EMDR, a poorly-evidence-based but probably harmless technique, and in Healing Touch, an “energy therapy” that uses touch or hand positions near the body for spiritual and other benefits and that remains unsupported by evidence as a treatment for physical or mental disorders. Lettington appears to have no training in assessing or treating childhood mental illness, but she has some adopted children, so I suppose she says this has trained her.

This is exactly the kind of person I try to direct people away from when they ask for advice about childhood mood or behavioral disorders. Assessing and treating such disorders requires training at the doctoral level and specialized work on child development and family issues. A degree in counseling is simply too general to be of use in these complicated situations where mental illness can interact with normal developmental change and where parental moods and practices require expert guidance. By the way, the use of “alternative” methods like EMDR and Healing Touch should be red flags warning knowledgeable persons away from a practitioner.

Let’s also look at the claims about Reactive Attachment Disorder that Lettington makes on her website. It’s no surprise to find the good old checklist trotted out (just like the one at www.attach-china.org that I mentioned the other day).  Some of the items here--  apparently meant to be applicable for children of any age—are a high pain tolerance, a lack of cause and effect thinking, and destructive or cruel behaviors. These, and the other “symptoms” cited, are in no way connected with the description of Reactive Attachment Disorder in DSM. Lettington would appear to have recounted this list to the judge, but we can’t tell yet whether anyone else’s testimony has corrected her. Interestingly, at the bottom of the list, Lettington also says that physical health is affected by RAD; although the original description of RAD in DSM-III did consider RAD to be the appropriate diagnosis for some cases of  infant failure to thrive, it has not otherwise, or since then, ever been spoken of in the mainstream literature as having physical effects. (Of course, such a claim does provide a foundation for the RAD defense, if no one contradicts it.)

We can also have a look at the links provided by Lettington’s site. Interestingly, there is a link to Families by Design, Nancy Thomas’s outfit. Did the Chrittons get some information about Nancy Thomas parenting, with its limitations on diet? I have no idea, of course, but the existence of this link certainly raises questions. Had the Chrittons consulted Lettington? Was their treatment of the girl advised by her, or simply accepted as a possible approach?   Or is it just that Lettington, like many another alternative therapist, believes in principles that are without empirical foundation but make the RAD defense possible?  

On the basis of other cases involving the RAD defense, I have one prediction: whether  Lettington or another practitioner advised the Chrittons, that person will not be prosecuted. If convicted, the Chrittons will be punished, but their advisers--  in person, on videos, or in books—will be free to give the same dangerous advice to other families. The First Amendment is supposed to be limited in the sense that one may not falsely shout “Fire!” in a crowded theater. Is it not time that we limited the protection of people shouting “RAD!” ?

  

Attach-China: What Treatment Methods and Principles Does It Support?

In response to my open letter of a few weeks ago to Mary Landrieu, on the subject of pre- and post-adoption training and services, Lynne Lyon of Lawrenceville, NJ has provided her own open letter intended to contradict my statements, especially in reference to certain organizations ( see http://childmyths.blogspot.com/2013/01/russian-adoption-letter-to-mary.html; scroll down to comments). In this post, I will repeat Lynne’s statements and refute them by referencing material from www.attach-china.org, one of the organizations whose methods and principles I challenged.

Lynne begins her letter with a red herring alluding to outrageous statements about rape. She then quotes part of my original letter, which refers to the belief that “adoptive parents can cause children to become attached to them by displaying their power and authority. In order to display authority, parents must make children completely dependent on them and obedient to them; children may eat and drink only as parents allow them, must not use the toilet without asking, and may be kept in cold or uncomfortable sleeping arrangements, including cages.” Lynne goes on to say that this is poor scholarship and that she herself does none of these things, and that I am wrong about attach-china and other groups.

I am happy to accept Lynne’s statement that she does none of the things mentioned. But I maintain that material on attach-china and other similar websites conveys support for the practices described above.

Why do I say that attach-china and other groups support the belief that adoptive parents cause attachment by displaying power and authority? Let’s begin with the material  called “When the Bonding Cycle is Broken” on www.attach.org. This material begins with a quotation from Terry Levy and Michael Orlans, formerly of the Attachment Center at Evergreen, the original hotbed of “rage-reduction” holding therapy as invented by Robert Zaslow and perfected by Foster Cline (both of whom surrendered professional licenses following injury to clients). The book quoted here, and Levy’s 2000 edited book published by Academic Press (to their lasting shame), both advocate physical restraint and provocation of children as a way to break attachments and create new ones. Levy’s 2000 book also rejoices in a lengthy chapter by Nancy Thomas, in which she advises limitation of children’s diets, isolation in locked rooms, enforced “strong sitting”, and hours of manual work as ways to treat emotionally-disturbed children. (Sylvia Vasquez, who was convicted  of keeping her adopted children in cages with buckets as toilet facilities, claimed that a book by Thomas was the source of her practices.) The quotation of Levy and Orlans’ book by www.attach-china.org conveys to readers an approval of all these people’s publications and claims.

To go on with the same material from www.attach.org: the following section cites the “bonding cycle”, an imaginary process claimed by attachment therapists to be the source of normal attachment in infancy (see http://thestudyofnonsense.blogspot.com/2012/08/parsing-attachment-cycle-fox-terrier-of.html for a discussion of the actual sources of this idea). The “bonding cycle” belief system ignores the evidence that attachment does not develop through experiences of gratified physical needs, but instead involves an interaction of pleasant social exchanges with the naturally-developing fear system in the second half of the first year. Of course, for attachment therapists simply to misunderstand how attachment comes about would be a minor problem--  except that on the basis of this misunderstanding, a commitment to the “pathophysiologic rationale” (the belief that if you know how a problem arose, you can tell how to solve it), and a belief that re-enactment rituals can undo past developmental errors, some practitioners have come to the principle that older children can become attached only if their parents control everything about their lives until the children comply. As is the case for many other mistaken beliefs about child-rearing, this one can become dangerous when parents escalate their efforts by withholding food or intensifying other sources of physical discomfort. Again, the emphasis placed on the “attachment cycle” by www.attach-china.org conveys to readers that statements about the repetition of such a cycle in treatment are somehow legitimate.

Let’s look at another section of the www.attach-china.org site: a Reactive Attachment Disorder Checklist, as usual in no way related to the symptoms of Reactive Attachment Disorder as described in DSM. And this one is of extra interest as having been acquired from Walter Buenning, well-known in past years for power-asserting holding therapy with infants as well as with older children. Although this checklists purports to be for assessment of infants, it includes some of the old goodies from checklists back to Foster Cline and before--  preoccupation with fire, gore, and evil, for instance. None of these characteristics are in fact used in conventional evaluation of Reactive Attachment Disorder, but are  given great emphasis by holding therapists who advise power assertion.

Well, this is entertaining, and we could go on and on, but let’s just look at one more interesting thing--  the www.attach-china.org material about treatment. The site references Martha Welch, whose specialty for many years has been a version of holding therapy in which young children are restrained face-to-face with parents, older children restrained in the supine position with the parent lying on top of them. This goes on for an hour or more while the children fight and scream and the parent shouts her anger and distress about the child. Welch originally proposed this as a treatment for autism, but more recently has called it Prolonged Parent-Child Embrace and focused it on Reactive Attachment Disorder. The site also references Gregory Keck and Regina Kupecky, whose support of physical restraint as a treatment method is well-known.

The section on treatment goes on to discuss neurofeedback, a method without an evidence basis, and to reference with approval its use by Larry van Bloem, a Utah practitioner whose clinic was implicated in deaths and injuries of children, and who himself was under investigation and would have had his license revoked if he had not been killed in a car accident almost ten years ago.

And finally, about the treatment section: curiously, attach-china is willing to state that sand tray therapy and play therapy are ineffective for children with Reactive Attachment Disorder. I don’t dispute this, and would agree that there is little good evidence that they are effective with any child, but I query the implication that if those two methods are not effective, the other ones mentioned must have good evidence of effectiveness. Not only is there no such evidence, but holding therapy and related parenting methods have been associated with serious adverse events as no other child psychotherapies have ever been.

On the basis of the evidence I have just put forward, I stand by my statement that attach-china and other organizations provide potentially dangerous misinformation about attachment and attachment disorders. This misinformation may create expectations and behaviors in adoptive parents that can lead to mistreatment of children, and once again I query the involvement of these factors in the injuries and deaths of children adopted to the U.S. from abroad.

I do not, of course, accuse Lynne Lyon of any of these misunderstandings or inappropriate treatments of children. I would ask her, though: if you agree that the methods and principles I attributed to attach-china are wrong and dangerous, why do you not stand up to rid your profession of therapists who are committed to dangerous advice? Why spend your time complaining about someone who is making an effort to correct potentially harmful practices?

Unanswered Questions About the Death of Maxim Kuzmin (Max Alan Shatto)

[Russian readers can find this post translated at http://yuliamass.livejournal.com/115359.html ]

The New York Times yesterday and today noted the release of results from a preliminary investigation of the death of three-year-old Maxim Kuzmin (Max Alan Shatto), a child adopted from Russia, in Texas last January. The released information declared the death accidental, associated it with bleeding from an injury to the mesenteric artery supplying blood to the intestine, and pointed to the child’s having been diagnosed with a behavioral disorder associated with self-injury.

The investigation appears to be ongoing, and so it should be. Without at all wishing to suggest that the adoptive parents intentionally killed the child, or even that they were in some way instrumental in his death, I want to point out that the statement released last Friday was by no means a full explanation. A complete explanation of the death of any young child would be desirable, especially as it might help prevent further deaths--  but in the context of deaths by injury of a number of other children also adopted from abroad, it would appear to be essential.

No investigation can provide answers to questions that are not asked, and when I think about past investigations of adoptees’ deaths I must query whether the present investigators know all the questions they need to ask in order to provide a complete explanation.

Here are some questions I would like to have answered by the investigation:

What information was provided to the adoptive parents either before or after Maxim and his brother came to them? Were they led to expect serious emotional disturbance in the children, and were they offered unconventional advice about appropriate child-rearing methods?

Who provided the diagnosis of Maxim’s stated behavior disorder? Was this done on the basis of his behavior in the adoptive home, or were assumptions made about his early experiences and the impact they would be expected to have?

What was the diagnosis that was said to be associated with self-injury? Did the occurrence of self-injury lead to the diagnosis, or was the diagnosis that had been made on other grounds then predicted to be associated with self-injury?

If there was self-injury, what form did it take? That is, did the child sustain injuries because of clumsiness or impulsiveness, or were there attempts at other forms of injury, like tongue-chewing or lip-biting?

If there was self-injury, what treatment or support was the family receiving in efforts to prevent further injury? Had the child received either medical or psychological treatment for these injuries? Had the parents received related counseling, either from the adoption agency or from any other source?

If the child was receiving any form of psychological treatment, did this include so-called “visceral manipulation” involving deep massage of the abdominal area? (Some alternative practitioners hold that emotional memories are carried in the abdomen rather than the brain and can be influenced by massage pressing deeply into the belly. This practice has occasionally been associated with holding therapy in the past; it is exquisitely painful and has apparently caused visceral injury in adults.)

The answers to these questions would help paint a complete picture of the causes of Maxim’s death. Failure of the adoption agency to provide appropriate guidance or services might indicate negligence on the part of the agency, and failure of the adoptive parents to seek help or treatment when needed might indicate that there was neglect of the children. Inappropriate diagnosis and/or recommendations by mental health professionals may be evidence of malpractice. Any or all of these difficulties could be associated with either careless or intentional actions leading to Maxim’s death.

In closing, I would like to point out that the various references made to Reactive Attachment Disorder as a cause of the posited self-injury in Maxim’s case are at best irrelevant and at worst an intentional red herring.

Russian Adoption: Trying to Talk About Maxim Shatto

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Enough said, I hope?  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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