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Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Wednesday, March 14, 2018

Unusual Attachment Behaviors and Their Implications

The concept of attachment—a toddler’s wish to stay near a familiar caregiver, especially when frightened, tired, sick, or injured, or when in an unfamiliar place—has given rise to thousands of research studies and much speculation sine it was formulated by John Bowlby in the 1950s. Some of Bowlby’s work focused on the attachment experiences of children who later turned out to be delinquents, so from an early point ideas about attachment have been connected with explanations of undesirable behavior and predictions of emotional problems.

The most established measure of attachment, the Strange Situation Paradigm, uses an artificially slightly scary situation to look at how toddlers respond to their mothers’ leaving them briefly in a strange place, and the way they respond to reunion with her when she returns. The great majority of young children behave in the Strange Situation in ways that let researchers categorize them in one of three categories. The largest number are classified as securely attached, and smaller proportions as either insecure-avoidant or insecure-ambivalent in their attachment relationship to the specific familiar adult who is with them in the test situation. All of these categories are within a normal range of social and emotional development , and although “secure attachment” sounds better than the other categories, it is not necessarily strongly associated with any great developmental advantage. These attachment classifications may change over time and may well be different from other attachment classifications a child would receive if tested with a different familiar person--- that is, the attachment classification is neither permanent or “in the child”, but is changeable and “in the relationship”. 

Because similar language is used, people may jump to the conclusion that insecure attachments lead to so-called “insecure” adult behavior like lack of self-confidence or jealousy or poor social skills, but this is not the case. Insecure attachments are not considered the ideal for toddlers, but neither do they require treatment to prevent current or later difficulties. In addition, it is very clear that the Strange Situation Paradigm was developed for research work comparing groups of children and not for clinical purposes—insecure attachment classifications in individuals are not diagnoses.

Years after Bowlby’s work, the psychologist Mary Main and her colleagues described a form of toddler behavior in the Strange Situation that was different from the three primary classifications of attachment. They referred to this behavior as “disorganized attachment”. Young children who were classed as having disorganized attachment behaved in quite unusual ways when reunited with their mothers after a very brief separation. Some froze in place after starting to approach the mothers; some backed toward the mothers; some simply collapsed to the floor. For their parts, the mothers, many of whom had endured earlier traumatic experiences, often appeared frightened as they looked at the children.  It seemed that the children needed and wanted contact with their mothers, but they had no effective way to get this because of their own state of fearfulness, perhaps associated with the mothers’ apparent fear. Not only was the relationship between child and mother disorganized and inadequate to give the child needed support and comfort, but children in this kind of relationship would not be able to use their mothers as “secure bases” to give them confidence for exploring and learning—one of the most important benefits of toddlers’ attachment.

Disorganized attachment has been thought of for years as an important indication of the need for treatment of mother and child. But recent work suggests that it is not completely clear how disorganized attachment develops, so it is in turn not completely clear what to do about it. In one recent article (Duschensky, R. [2018]. Disorganization, fear, and attachment: Working towards clarification. Infant Mental Health Journal, 39, 17-29) , the author suggests three different pathways by which toddlers may have arrived at disorganized attachment behavior: serious rejection by the mother, traumatic experiences leading to emotional dysregulation, and temperamental characteristics present at birth. These different possibilities would suggest different treatment approaches, so simply screening young children for disorganized attachment does not necessarily give useful guidance about what help to offer. And, once again, the Strange Situation Paradigm was never intended to make clinical decisions about individuals, but was created as a way to compare groups for research purposes.

Research on disorganized attachment has looked at whether this form of toddler behavior toward a mother is associated with abusive treatment. It’s easy to see why this question would be asked, because two of the pathways to disorganized attachment mentioned above – rejection by the mother and traumatic experiences—could be connected with abuse. Indeed, there are weak statistical relationships between child abuse and disorganized attachment. But these correlations unfortunately have led some practitioners to the idea that disorganized attachment behavior can be used to screen families for child abuse. This conclusion is wrong for various reasons. One is the oft-repeated but equally oft-forgotten fact that correlation of two events does not show that one causes the other. It’s possible that abusive treatment of a child could cause that child to show disorganized attachment behavior, but it’s also possible that children who for other reasons show unusual attachment behavior could trigger both fear and abusive treatment in their caregivers. Even more likely, additional factors like poverty and family trauma could cause both disorganized attachment behavior and abusive treatment, or could cause one or the other separately. In any case, disorganized attachment behavior cannot be used as a proxy measure or screen for child abuse; however much time and resources this approach might save, it would not find all cases of child abuse, and it would find many false positives as children who had never been treated abusively could still show disorganized attachment behavior.

A recent article on disorganized attachment, written by a large number of well-known attachment experts, has clearly stated the limits of usefulness of the disorganized attachment classification ( Granqvist, P., et al. [2017]. Disorganized attachment in infancy: A review of the phenomenon and its implications for clinicians and policy-makers. Attachment & Human Development, 19, 534-558 ). The paper commented on four assumptions about disorganized attachment that they characterized as false and misleading. These were first, that attachment measures can be used to evaluate individual children in judicial or child protective contexts; second, that the presence of disorganized attachment behavior reliably shows that a child has been maltreated; third, that disorganized attachment behavior reliably predicts emotional or behavioral problems in the future; and fourth, that disorganized behavior indicates a lasting characteristic of the child rather than one that can be influenced by changed circumstances. The last assumption, particularly, is contradicted by the fact that it is not unusual to see some mild level of disorganized attachment behavior occur in toddlers in the Strange Situation, especially if they come from challenging environments.

If children show organized insecure responses in the Strange Situation, and if their families need treatment or services, a goal may be to increase attachment security, but this does not mean that insecurity is or predicts serious problems. If toddlers show severely disorganized attachment behavior, they and their families may well need help for one or more reasons, and various kinds of help (as well as maturation) may encourage better organization of relationship-related behavior. However, it should never be assumed either that clinical work with individuals can usefully be based solely  on the observation of disorganized attachment, or that disorganized attachment shows that a child has been maltreated and signals the need for authorities to intervene in the family. Removal of the child should not be contemplated simply because of disorganized attachment behavior.

Tuesday, March 13, 2018

Distracted Parenting, Cell Phones, and Technoference

Everyone who has been a parent—or a teacher, nanny, babysitter, or other caregiver—knows what it is to multitask. Taking something out of a hot oven while using your knee to block a crawling baby from approaching this interesting event, remembering that you need to call for a doctor’s appointment while getting a shoe on a small foot, replying to “right, Mom, right?” while writing a grocery list, watching what one child is doing while comforting another with a skinned knee. Let’s face it, a great deal of parenting (or teaching or other caregiving) is distracted parenting, and children are able to deal with that fact as long as there is some minimum level of undistracted, sensitive, responsive, attentiveness. This has been the case since our Paleolithic ancestors had to keep the kids from falling in the campfire while judging the distance from them of the tiger whose cough they can barely hear.

But: enter the cellphone and assorted screens, all of which may be more attention-getting for adults than all but the most loudly shrieking child. Has distracted parenting now reached epic proportions? Is this a problem? What could we, or should we, do about it?

It’s easy to see that distracted parenting can be a safety problem for preschoolers and even for younger or more risk-taking school-age children. Look at that distracting phone for a minute and while you do so, a child who is not yet street-wise runs after a ball and is hit by a car, or one who thinks she can help herself to lunch touches a hot burner on the stove. For children of all ages who need supervision in the bath, slips and falls are more likely (although there should be fewer bathtub drownings because parents with cellphones don’t need to leave the room to take a call).

For infants who are not yet mobile themselves, there may not be so many physical safety concerns connected with parent distraction by screens, but “technoference” (the interference of electronic devices with interactions between parent and infant or toddler) presents some very real potential risks for early development. Babies’ emotional and cognitive development (including language) follows a transactional pattern, involving a series of interactions between parent and child in which each partner is influenced by the other and the way each influences the other changes over time. The baby is an active partner and seeks parent responses as well as responding to parent communications like talking, pointing and facial expressions.

 Babies of 4 months or so respond with distress to a parent face that looks at them but also looks blank and fails to respond to smiles or other communications. The baby looks away, may begin to whimper, and acts more and more distressed. In addition, when the parent looks responsive again, it takes a little while for the baby to warm up and start to interact normally.   This “still-face” situation is one that can happen with any parent and baby from time to time as a parent is temporarily distracted by the demands of life. It is more likely to happen if a parent is depressed or disturbed by something that demands attention more effectively than the baby can manage, and when this is the case the interaction between the two gets less effective or enjoyable over time. When a parent responds to a screen often, even in the midst of an interaction with a baby who is trying to get a response, we can expect “still-face” effects to be multiplied. (And how puzzling it must be for a baby who is working on developing language to see that someone talks when no one else is there, appears to look in the baby’s direction, and yet talks and looks completely differently than at other times! This would seem to signal that those noises people make with their mouths have no real meaning after all.)

A recent article in the journal Child Development (McDaniel, B., & Radesky, J. [2018]. Technoference: Parent distraction with technology and associations with childhood behavior problems. Vol. 89, pp. 100-109) reported a study that looked at parent distraction by screens and the associated behavior problems displayed by children. (Because of the study design, this work was not able to show whether “technoference” caused behavior problems or whether one or more other factors [like parent anxiety] caused both parent distraction and child behavior problems.) The authors reported other publications that have presented evidence that parents who use technology when with their children have fewer parent-child interactions, that they are less responsive to children’s bids for communication (and I should point out that sensitive and responsive parenting is well-known to be connected with good child development), and that parents even respond with hostility to child communications when they are attending to devices.  Looking at 183 families with young children, these authors concluded that parents who reported a high level of “technoference”  also reported more of both externalizing (angry acting-out, for example) and internalizing (depression or social withdrawal, for instance) problems in their children. Why this should be is not completely clear, and the authors speculated that  children of distracted parents may need to “act up” in order to get their parents’ attention—or alternatively that parents who are bored or depressed may turn to their screens to escape those uncomfortable feelings.

Most human beings find babies very attractive most of the time and respond with pleasure to young children’s efforts to interact. (We have probably evolved to have this kind of pleasurable responsiveness to the very young of our species.) These facts are what encourage most parents to do a good job caring for their children during the first few demanding and highly emotional years of the children’s lives.  Unfortunately, cellphones and other screen devices seem to be potentially even more attractive and attention-getting than our babies are. Although it isn’t clear what the eventual outcomes of “technoference” will be—and they are probably different for different families—the safest assumption seems to be that young children and parents' screens do not mix well for a wide range of reasons.

Thursday, March 1, 2018

Trust Based Relational Intervention (TM) (TBRI): Another Case of Claims Without Evidence

The alternative psychotherapy for adopted and/or traumatized children, Trust Based Relational Intervention or TBRI, promulgated by the late Karyn Purvis, is receiving much attention from adoptive and other parents’ groups. The major adoption agency Holt International shows much enthusiasm for TBRI methods on its Internet sites. A presentation by Purvis, “Introduction to TBRI”, is available at https://www.youtube.com/watch?v=TvjVpRffgHQ.

Purvis was a warm and charming presenter, and she conveyed genuine affection and concern for children who have come, as she says, from “hard places”.  But it’s clear that much of what she says in this youtube piece is without empirical support and to a considerable extent without plausibility.
What is TBRI in practice? Here is a description I gave in a recent article in Child and Adolescent Social Work Journal, including a long quotation from Purvis and her colleagues: 

"A treatment called Trust-Based Relational Intervention (TRBI®; Purvis, McKenzie, Razuri, Cross, & Buckwalter, 2014) ) bears some resemblance to AT/HT principles and practices. In a case study of this treatment as it was used with an aggressive and self-harming teenaged girl, Purvis et al. described a three-phase intervention in which Phase I was meant to mimic the early social relationship between child and caregiver which results in secure attachment.  Rachel was assigned one specific staff member to be with her at all waking hours during the day, with approximately 36 inches or less to separate them. When Rachel’s mother was present, she assumed the 36-inch role, with a staff member remaining in close proximity. Proximity between the child and caregiver is important. The rationale for maintaining this close proximity is twofold. First, proximity is important from an attachment perspective. In line with attachment literature that suggests that the proximity between a caregiver and infant in a secure attachment relationship is important for maternal responsiveness …, bringing Rachel’s caregiver closer allowed the caregiver to be aware of Rachel’s needs and meet them quickly so that Rachel could learn to trust the adult and build connection. Second, proximity is necessary for a temporally loaded response and is important to support learning” (Purvis et al., 2014, p. 362). In addition, “in mirroring the development of the infant-caregiver attachment relationship, Rachel was not given choices that pertained to her daily routine (e.g., what to eat or wear), but rather those choices were made for her. During the program, choices were presented in a compassionate and kind tone, often utilizing a playful voice to neutralize any negative affect on her part. Again, this transference of choices from Rachel to staff was intended to simulate early life experiences where a child is cared for, rather than needing to care for herself. There was the potential for compromises if Rachel’s reaction to a caregiver’s choice was too disagreeable” (Purvis et al., 2014, p. 363). A second phase of treatment involved role-playing."

In her youtube presentation (one of several, incidentally) Purvis specifically stated that TBRI is evidence-based. She referred to the treatment as having “proven efficacy with children of all ages:. She stated that TBRI “can bring any child back on line” and spoke of “many documented cases” where TBRI had been useful.

The term evidence-based treatment (EBT) has a fairly clear definition among professional psychologists and clinical social workers. Before a treatment can be said to be evidence-based, its efficacy must have been supported by two independently-done randomized clinical trials. Under some circumstances, well-implemented nonrandomized trials may also  help to establish an evidence basis for a treatment. None of these exist for TBRI,  Purvis published several before-and-after studies concluding that TBRI improved aspects of children’s moods and behavior, but those study designs are not acceptable, particularly for research on children whose development may change rapidly and be mistaken for the effect of a treatment. It is incorrect for these reasons to say that TBRI is an EBT. (It is also incorrect to claim, as some alternative psychotherapists do, that EBTs are simply treatments about which articles have been published in peer-reviewed journals.)

Purvis also claimed in the youtube piece that treatment of children who had experienced abuse and neglect should take the form of recapitulation of events in their earlier lives. I was astonished at the use of this  particular term, which I have often used in critiques of attachment therapy, primal scream therapy, “breathwork”, and so on, but I have never before seen this assumption stated so plainly. Yes, Purvis believed and said clearly that in order to treat emotional problems, it is necessary to replicate the experiences of care that a child should have had but did not receive. This theme is apparent in the quotation from the Purvis publication I gave earlier. In the youtube piece, Purvis referred to this assumption as a “scientific parable” – that if a capacity is lost, its causes must be recapitulated by going “back to the beginning”. In addition to the proximity and absence of choices used in the treatment of “Rachel”, Purvis proposed needs for hydration every two hours, food every two hours, and motor activity every two hours, a schedule based on care of a newborn infant, and implausibly applied to every age group right up into the teens. This would appear to be sympathetic magic at work, not psychotherapy.

Further implausibility behind TBRI was shown in Purvis’ belief that mental illness is caused solely by experiences from conception onward rather than by genetic and other biological factors as they interact with experiences (although she mentions substance exposure as a possible factor). She agrees with the Association for Pre- and Perinatal Psychology and Health (APPPAH) that   maternal psychological stress (e.g., from family difficulties) can cause childhood emotional disturbances. In order to counteract these difficulties, which she saw as based on sensory processing disorders, she recommended following  a range of treatment methods as recommended at one time by the occupational therapist A. Jean Ayres. These include a “sensory diet” involving the Wilbarger protocol of light and deep pressure stimulation, the use of weighted blankets, and toys buried in dry rice so that children receive skin stimulation as they try to find the toy.

Purvis referred to herself in her presentation as “a woman of science”. It would be a great deal more accurate to use the term “pseudoscience”.  A recent article by David Grimes and Dorothy Bishop (“Distinguishing polemic from commentary in science…”, Child Development, 2018, 89, 141-147) offered a list of questions that are useful ways to examine claims about TBRI as Purvis made them.

1.     1.  Is there a plausible mechanism for the effect claimed? No, there is no evident way in which recapitulation of early events could cause a repetition of development from scratch, especially not the claimed reshaping of the brain.

2.      2. Does evidence come from peer-reviewed sources? There are publications in peer-reviewed journals , but they do not meet standards for claims of an acceptable evidence basis.

3.      3. Are all relevant studies considered? The published studies are not at a level that makes them relevant to the claims made.

4.      4. Are results of specific studies misrepresented? Because of the design problems of the existing studies, it is a misrepresentation to conclude that they provide acceptable evidence about the effects of TBRI.

5.     5.  Are there claims of impacts on multiple diseases and disorders? This is difficult to answer because of omissions of diagnoses and proportions of specific problems in published material, but certainly there are claims of efficacy for children in such a broad age range that multiple problems must be under consideration, the problems of preschoolers and teenagers being different.

6.     6.  Are causal claims based on experiment, correlation, or analogy? The published studies are nonrandomized, before-and-after comparisons. Analogy to animal studies is a major argument  brought in favor of TBRI.

7.      7. Is technical, scientific information used to obfuscate rather than clarify? Yes, obfuscatory references to brain and hormonal functions are a major part of the youtube presentation. For example, Purvis followed the popular belief by recommending half a turkey sandwich for  a sleepless child (but see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2077351/ for a discussion of this idea.)  She stated that it takes “400 repetitions of an act to get one synapse”, or 12 such acts done with joy and laughter to create one synapse. (There are plenty more examples if anyone would like to follow up on this point.)

Claims made about TBRI are not evidence-based or plausible, and organizations like Holt International would do well to examine them carefully before making a commitment. Adoption has been described as the most effective treatment for children who have had bad beginnings to their lives, and experiencing sensitive, responsive care will facilitate good development for any child. Where TBRI has been helpful to families, those general factors are likely to be responsible for any benefits. Whether or not TBRI carries a risk of harm may depend on the age and other characteristics of a child. How ”Rachel” felt about the 36-inch rule, and what effect this practice had on her, is an important question yet unanswered.

Wednesday, February 28, 2018

Parental Alienation Advocates Defend Children Against Dangers of Autonomy (They Say)

A Canadian colleague recently sent me an immense document with PowerPoints and summaries of presentations that took place at the conference Children’s Participation in Justice Processes: Finding the Best Ways Forward, sponsored by the Canadian Research Institute for Law and the Family, in Calgary, Alberta, Sept. 15-16, 2017. You can see the PowerPoints of this conference through links at  www.findingthebestwaysforward.com/Materials/index.html.

There were some really excellent presentations  given at the conference, best of all in my opinion one by the well-known lawyer Nicholas Bala, who gave a brilliant discussion of children’s cognitive development and the ways that a stage of cognitive development could affect participation in judicial proceedings. This is really worth reading for anyone who is concerned with laws and judicial decisions as they work for children’s best interests.

However, the conference included some much less admirable presentations as well, notably one that focused on the idea of parental alienation (PA). As many readers will know, PA is the hypothesized situation in which one of two separated or divorced parents “brainwashes” a child and persuades the child to believe that the other parent is bad, abusive, dangerous, etc. The child who is persuaded in this way then rejects and avoids the parent who has been targeted (to use PA) language and strongly prefers to be with the other, alienating (in PA language) parent. PA advocates like Craig Childress and Dorcy Pruter claim that the child who has been alienated (in PA language) has been made mentally ill in ways that will have long-term effects, and needs to be rescued and treated. PA advocates suggest that this can be accomplished by various treatment programs, most of which have infrastructural names involving paths, roads, and bridges, and all of which focus on removing the child by court order from the preferred parent and placing him or her in the custody of the non-preferred parent.
It would be silly to claim that no preferred parent has ever manipulated the child’s attitudes—this can happen even in an intact marriage, and can be encouraged by grandparents, friends, new romantic partners of the preferred parent. However, as is usual in human affairs, multiple factors work together to produce a child’s rejection of a parent, and how often they include “brainwashing” has never been empirically demonstrated. Neither has it been shown that the child’s attitudes, however negative, are indicative of mental illness.

Let’s look more closely at the idea of mental illness as a facet of the child’s rejection of a parent. PA thinking suggests that the child’s thought processes are distorted and that, no matter what the child’s age, some attachment problem has been created. These ideas have not been validated, but in many ways they are the least of the issues here.

The great difficulty with this view is the claim that the hypothesized mental problems will be exacerbated by giving the child any choices—that the child’s stated wishes are narcissistic wishes that must be dropped in order for mental health to be regained. This idea, that adults must exert complete authority, and that children are damaged by autonomous decision-making right up to the age of 18, is common among alternative therapies. Attachment therapists too claim that children they have diagnosed as having attachment disorders must yield all authority to adults, must obey instantly and cheerfully, and should be given no information about what is going to happen to them. To treat a child as an autonomous individual and to allow the child to express beliefs and feelings is seen as a sure way to worsen any existing problems; this is why attachment therapists insist that conventional child psychotherapies will make children “worse”.

At the conference in Calgary,  presentation stood out as representing the PA belief system. They argued against the idea that a child in custody proceedings should be allowed to speak, claiming that this would be detrimental to the child.

The presentation, “The voice of the alienated child”, was the work of Rob Croezen, Melissa Ander, and Alyson Jones. These presenters listed a series of dangers of allowing the child’s voice to be heard:

·         Boundary issues
·         Being caught in the parental conflict
·         Improper empowerment
·         Loss of leadership by adults
·         Loss of hierarchy
·         Loss of stability
·         Loss of security
·         Doing the job of an adult
·         Increased anxiety
·         Feeling of responsibility
·         Parentification
·         Adultified children
·         Role confusion
·         Heightened anxiety (yes, as well as increased)
·         Attachment disruptions
·         Lack of resolution
·         Black and white thinking

Let’s have a closer look at this list. What do we see here that indicates long-term issues of mental health? Keep in mind that this list is not even about the effects of experiencing PA—it’s about being allowed to contribute to the discussion leading to custody decisions.  But are the items on the list unusual? Are they problematic? Are they supported by evidence about what happens either in high-conflict divorces or when children’s voices are heard?

1.    1.  Boundary issues certainly occur in some families and may be associated with certain kinds of parent-child relationships, but surely the argument here, if any, would be that if children have boundary issues their preferences may reflect those issues—not that being allowed to speak will cause boundary issues.

2.    2.  Being caught in the parental conflict is unpleasant for children and can take up energies and resources they need for their own developmental tasks, but children in high-conflict divorce are already caught in this way. Playing a role in decisions about their own lives would appear to allow them to use the situation for their own developmental purposes, of which a move toward autonomy is one.
“    3. "Improper empowerment” suggests that children who are heard in court will use the experience to take over decisions they are not capable of making. In fact, working to re-establish family rules and decision-making processes is one of the tasks of divorced families, and some children do “take up the slack” from distracted parents and feel empowered in ways that later need to be corrected. This is a general issue of post-divorce adjustment and not a matter either of PA or of child participation.

4.      4. Loss of leadership by adults often occurs during a post-divorce period of several years, as parents struggle to reorganize their own lives and deal with financial and emotional issues; this is true even for the parent who initiated the divorce. Parents do not lose their leadership because a child is heard, but for other reasons.

5.      5, Loss of hierarchy: how I would love to know what is behind this one! It’s so reminiscent of the German “family constellation” therapist Bert Hellinger, who believes that the breaking of age and gender hierarchy causes emotional disturbance in a family. Hellinger wants children who have been molested by an older family member to apologize to the molester because they have been instruments of breaking the hierarchy. I don’t want to exaggerate the possible connection here, but you don’t get a lot of conventional psychologists troubling themselves about hierarchies in this way.

6.     6.  Loss of stability: divorce does this, especially if the child has to move to a new house (cf. custody change with PA claims, by the way) or change schools.

7.    7.  Loss of security: divorce also brings about financial loss, disagreements about child support, and the loss of the sense of a back-up adult if one has a problem. We don’t need to look for the child’s voice in court as causing these things.

8.     8.  Doing the job of an adult: this is only a concern if we assume along PA lines that only adults can speak about their thoughts and feelings. Conventional therapists generally try to teach children to do those things.

9.     9.  Increased anxiety is the lot of any child in a high-conflict divorce and would presumably be reduced by a sense of some autonomous participation.

1   10.  Parentification: This will be a problem if the child feels that he or she must “take care of” a parent who is incompetent, no matter whether the child can speak in court. The solution is more likely to be to give the adult guidance toward competence, not to silence the child.

1 11 .  Adultified children: same as #s 8 and 10.

1 12..  Role confusion: I think the presenters really mean the same thing as they meant in 8, 10, and 11, rather than the term role confusion as used by Erik Erikson in his discussion of adolescent personality development.

1 13.  Heightened anxiety: see #9.

1 14.  Attachment disruption: oh, dear. Our presenters do seem to have forgotten the principle of developmentally appropriate practice. Children over age 3 or 4 do not experience overwhelming distress over separation from a familiar caregiver as younger children do. By age 6 or 7, children all over the world are sent to school, even to boarding school, or are sent out to do farm work or other tasks away from their parents. By the time they are at that age, the powerful emotional attachment of infants and toddlers has changed to an internal working model of social relationships in which caregivers play an important but not exclusive role. Even toddlers adjust in a few months to loss of attachment figures and are able to make new attachments—although if they have been through more than a few separations they may need help in this. These sinister references to attachment, with implications of attachment disorders and severe mental health problems, are characteristic of alternative therapies and unconventional beliefs about child development.

1 15.  Lack of resolution: this is caused by having a voice in custody decisions, is that the claim? Is it not instead a feature of loss by divorce rather than by death?

1 16.  Black-and-white thinking: again we have a problem with developmentally appropriate practice. Young children normally have trouble understanding overlapping categories or multiple factors working together. What is the evidence that continuing to have these characteristics of early thought is more common among children who are allowed to contribute to custody decisions, even if only by having their voices heard? There seems to me to be a problem here in parsing the overlapping categories of children of divorce and children of divorce who either do or do not have their voices heard—a class inclusion problem, in terms of cognitive development.

I think I’ve said enough (or perhaps too much, I don’t know who’s still with me) to show the difficulties inherent in the claims made by those who argue that children’s voices should not be heard in custody proceedings. There is no danger to the children in being heard, and a good deal of danger in being subjected to ill-considered PA thinking and practices.    

Monday, February 19, 2018

Is Attachment Therapy "Controversial"?

A newspaper in Greeley, Colorado has once again incorrectly referred to Attachment Therapy as a “controversial” treatment. AT is not controversial, not are its associated beliefs and adjuvant treatments like Nancy Thomas parenting. They are not controversial because there is no controversy here. No one who has any understanding of child development would enter into any controversy on these ideas and practices, which are clearly wrong, unfounded, and potentially harmful. There is no need to argue the point, as would be done if something were genuinely controversial.

Attachment Therapy is an alternative psychotherapy, the parallel in the psychology world of complementary and alternative medicine (CAM). It can be identified as an alternative treatment because it is implausible, incongruent with what is known about child development, and lacking both an evidence basis and a possible mechanism by which it might work. The same points can be made about the alternative developmental theories and adjuvant treatments associated with AT. Arguments in favor of the AT principles and practices are based on a completely mistaken definition and theory of emotional attachment and use terms related to attachment in obfuscatory ways rather than for clarification.  

There are many other alternative belief systems that are completely wrong, but not controversial, because no knowledgeable person would enter into serious controversy about them. For example, the belief that the earth is flat rather than spherical, as promulgated by the Flat Earth Society (https://www.tfes.org), is wrong, but there is no controversy about it in serious circles. We do not see geographers applying for grants to demonstrate that the earth is a sphere, or writing learned books arguing on philosophical principles that the flat earth view is wrong. Like AT beliefs, the Flat Earth view is a mistaken alternative belief, but not the subject of controversy.

So, why did the Greeley newspaper say AT is controversial? One reason is that lots of other people have said this and it seems like an exciting idea. (And it would be extremely exciting if any evidence were advanced to support AT beliefs, because if they are right, that would mean that almost all established facts and principles about child development have to be abandoned!) Using the word “controversial” also lets the reporter off the hook with both AT proponents and conventional psychologists, by implying that no stand is being taken—although mentioning these ideas at all, when they are so little known in the world of professional psychology, actually is taking a stand. Describing AT as controversial and giving space to differing ideas about attachment and attachment disorders provides the pseudosymmetry, or equal weight for well- and poorly-supported ideas, that passes as “fair treatment” in present-day journalism. Using the “controversial” word  about AT also gives lots of chances to talk about horrible children and the need for adult domination, topics that are bound to attract interest.

Are there controversial ideas and treatments in psychology, as opposed to alternative psychotherapies? Yes, of course. A good example is Eye Movement Desensitization and Reprocessing (EMDR), a treatment claimed to treat anxiety and other emotional discomfort by having the patient imagine the frightening situation while moving the eyes in a pattern. There are lots of controversies here, and lots of people attempting to investigate EMDR empirically. Is EMDR effective in reducing emotional discomfort? If it is effective, what is the mechanism—do the eye movements really make any difference, or is the effective component simply exposure and desensitization as they are used by other treatments without planned eye movements? Because there is genuine controversy here, you will see many articles on these in peer-reviewed professional journals. People who know a lot about the topic disagree on EMDR and seek to test their beliefs by finding new evidence. None of this is true about AT, which is an alternative (CAM) treatment, not a subject of controversy.

If there was ever real controversy among professional psychologists over AT, it died down in 2006 when the joint task force of the American Professional Society on Abuse of Children (APSAC) and the American Psychological Association’s Division 37 rejected out of hand the use of attachment therapy, of adjuvant treatments, of the related views of attachment disorders, and of the alternative theory of child development on which all of these are based. So what keeps reporters and the public talking about these ideas? I would say that it is in part the wholehearted commitment of the public to the idea of attachment as the central theme of human life, coupled with a considerable misunderstanding of what attachment is. “Everybody knows” about attachment so it’s very comfortable for readers and viewers to encounter. Really, however, we need to keep in mind that although attachment (the actual process) is important, it’s not the only thing that’s important in development.

And, there's a difference between controversy and unsupported claims about alternative treatments.

Friday, February 16, 2018

Alternative Therapists Pounce on Florida School Tragedy

Alternative therapists must have been waiting impatiently for an adopted person to commit a tragic school shooting. Now that this has occurred in Florida, various proponents of alternative belief systems have jumped onto the fact , which they claim supports their unsupported equation: adoption=feelings of loss and rage=attachment disorder=violent actions. And, they hope, this horrible situation will give them an entry into the national discussion, fame and fortune.

As I often do, I received an email message from Heather Forbes, former colleague of Bryan Post (a  smooth “plausible fellow”, well-known for his store-bought doctorate), and present ruler of the Beyond Consequences mini-empire. There is a link to the message at https://www.facebook.com/BeyondConsequences/posts/10155982520430256, but let’s look at what she had to say:
“As I watched the news on last night and this morning, all I saw was discussions about gun control, active shooter school policies, mental health, and proper law enforcement protocol. While these are all valid issues to discuss, I believe the most important issue continues to be overlooked. We aren't looking at our students from a social/emotional, heart-centered perspective. This shooter's history was rampant with experiences of rejection. He was adopted and then lost BOTH his adoptive parents. Then he was expelled from school. That is three experiences of severe rejection and loss: 1) the loss of his birth family, 2) the loss of his adoptive family, and 3) the loss of his school family. As humans, we are a social species....we are designed to live in families, especially as children… 
 I can only see that there is no coincidence that this horrifying event took place on Valentine's Day--the day we celebrate love and relationships. “ (Heather then proposed that she be a spokesperson to the nation on these issues and asked her followers to suggest her to various news outlets.)

So, let’s examine Forbes’ thinking under a strong light. What we see is the usual “proof by assertion”.
First, she equates rejection with loss, implying that the sadness and grief of loss are accompanied by equal amounts of the resentment and anger that stem from rejection. While no one can deny that we human beings often feel some anger toward those who have left us, even when they did this unintentionally, the feelings and effects of rejection and loss are not the same, and conflating them confuses the issue. As is the case for most pseudoscientific explanation, the misused terms obfuscate rather than clarifying the discussion.

Second, Heather Forbes states that the loss of the birth family is an experience of severe rejection and loss. There is no evidence that this is the case for children who are adopted early in life, especially those who are adopted before the age of 8 or 9 months when emotional attachment to familiar caregivers may have begun. The idea that adopted children are enraged and full of grief because they have been separated from a birth mother is not based on any observations of children; instead, it is implausibly based on beliefs that mother and child are genetically attached or that attachment occurs prenatally—all these ideas being fostered by alternative groups like the Association for Pre- and Perinatal Psychology and Health (APPPAH). These beliefs are worth their weight in gold to those who offer their guidance to adoptive families and adult adoptees, and who do so by creating unnecessary anxiety about the future for people who are doing very well.

Third, Heather Forbes points to losses in the adoptive family, and I will not try to argue that these may not have contributed to emotional disturbance, although the adoptive status is irrelevant here. Losses in any family act as adverse childhood experiences (ACEs) and may contribute to disturbed emotions and behavior—although they are even more likely to create later physical disorders than mental illness, and are not thought to be a major factor in serious mental illness.

Fourth, Forbes points to the loss of the “school family”, apparently reversing cause and effect. The shooter was expelled from school because of disciplinary problems, so this loss followed rather than caused his disturbed behavior.

Finally, let me note the twisted argument Forbes presents about Valentine’s Day, just as  a further example of the cherry-picking of evidence and illogical conclusions drawn in her statement. According to Forbes, it is “no coincidence” that the shooting happened on Valentine’s Day, so it should be attributed to loss of love as the triggering factor for the shooter. But it was also Ash Wednesday, the beginning of Lent—can Forbes not parlay this fact into a further non-coincidental connection? Was the shooter disturbed by seeing people with ashes on their foreheads, reminding him of life’s ultimate end and therefore his losses? Was the anticipation of giving things up for Lent too much for one who felt he had been robbed of his rights? Sorry, Heather Forbes, but if you use one fact to support your argument, you can’t ignore the other facts, whether they are about attachment or about holidays.

Not surprisingly, our old friend Nancy Thomas has chimed in, recognizing this tragedy as a way to advance her brand. She says, at https://www.facebook.com/ntparenting/posts/1579834535464320 Yes, it is possible this young man may have demonstrated many of the characteristics of RAD when he was younger. The more likely outcome at this point is he may receive a diagnosis of Conduct Disorder. That is usually the go-to dx for adults who have been or should have been diagnosed with RAD when they were children. For those who worry this is where their child is headed we have this. There is always hope as long as they are breathing. Those who have a diagnosis of RAD are not automatically killers.

Well, what a relief Thomas has given us here! Children diagnosed with Reactive Attachment Disorder will not necessarily grow up to be killers. However, she suggests, killing allows us to detect that the killer did as a child have Reactive Attachment Disorder. Presumably this means not Reactive Attachment Disorder as indicated by sadness, lethargy, and disengagement from social interaction, but instead the alternative version in which children are liars and thieves and manipulate or harm others—and, saliently, in which it is predicted that children who show no symptoms are simply too cunning to be caught, but still need an alternative treatment so they will not become either serial killers or prostitutes, depending on gender. (And I’ve always been fascinated by the equation of these two forms of misbehavior.)

One more of these, though I am sure they are multitudinous: http://www.teapartytribune.com/2018/02/15/guns-dont-kill-people/ by a person somewhat disturbingly called Bill the Butcher, who states that guns don’t kill people—psychiatrists kill people. Bill the Butcher states that his granddaughter has Reactive Attachment Disorder and as a result “ripped the ears off a small dog to get its bows for her hair”. This kind of claim is often made by people who are devoted to the alternative view of attachment and of causes of mental illness, but anyone who has jointed and skinned a chicken (a dead one, I mean!) knows that tearing flesh apart with your bare hands is not readily accomplished. I would suggest that this story is a myth related to various alternative therapists’ stories of children who have torn the heads off puppies.  By use of this myth, the child is identified as a powerful, hostile, evil being, and, as Bill the Butcher suggests, incarceration is the only legitimate response. According to B the B, mental health professionals and teachers cause school shootings by attempting to help disturbed children, and responsible people must simply lock the children up.

As most killings are not committed by adopted people (who are only about 2% of the population), it has taken awhile for  alternative therapists to get their chance to claim that mass shootings are related to adoption and to attachment disorders. But their opportunity has finally come and they are taking advantage of it as best as they can. Let’s hope that media outlets do not act in haste to accept, Forbes, Thomas, or B the B as spokespersons for the role of mental health in these tragedies.   

Tuesday, February 13, 2018

T. Berry Brazelton's 100th, and "Touchpoints"

The great pediatrician T. Berry Brazelton’s hundredth birthday will be celebrated April 23, 2018, at a symposium at the Boston Marriott hotel in Newton, MA. A stellar group of speakers will be there and people in the Boston area may want to attend. It is expensive though—so for my part I am going to offer here some reminders about Brazelton’s concept of “touchpoints” as a way for parents to organize their childrearing work.

Brazelton’s various “touchpoints” books, and his work together with Joshua Sparrow and others, focused on times of developmental changes in the lives of babies and young children, and the way those changes can disrupt family life and create parental anxiety (see www.brazeltontouchpoints.org). Guidance about these times of change and disruption can help parents keep calm and work through expectable disruptions.

It’s a big flaw in human thinking that we tend to expect things to stay the same as they are at any moment. If something doesn’t go well, we imagine that there will never be any improvement and are deeply discouraged about the future and life in general. If everything is fine, we dismiss the possibility that anything less desirable could happen, and expect smooth sailing ever after. Learning that life—and parenting—has ups and downs is quite difficult, but this lesson, if learned, helps everyone to weather difficult times. Brazelton’s “touchpoints” approach suggested that if parents can anticipate times of disruption, they will deal with those times more comfortably when they do come.

People other than Brazelton have considered this issue in terms of events in early development. Anna Freud, for example, suggested that there were natural times of what she called “regression”—periods when an infant or child who had been easy to care for became temporarily more difficult, cried a lot, had tantrums, slept or ate poorly, for no apparent reason. It’s interesting that she used the term “regression” for this behavior, because that implies that the child has gone back to acting as he or she did earlier. Actually, though, periods of “difficult” behavior may mean that a child has progressed, not regressed. A 4-month-old is not afraid of strangers and does not fuss when approached by new people, but a 10-month-old, with more advanced cognitive and emotional development, is likely to cry and try to hide, and may be much distressed when introduced into a new environment with new caregivers. Increased maturity of a child can go with greater care difficulties from the parent’s viewpoint, but it can be hard for a parent to see things that way, and when other people express annoyance or concern about developmental steps they do not recognize as progress, parents’ lives are made even harder.

Arnold Gesell and Frances Ilg, who in the 1940s and ‘50s published books for parents and teachers about developmental changes, talked about “interweaving” of negative and positive changes during infancy and the preschool period. The idea again was to anticipate and prepare for events rather than being startled and badly disrupted by them.

Brazelton’s real contribution to the idea of “touchpoints” is that children’s developmental steps—the same ones that may make parents anxious or angry—can be reframed and reinterpreted as evidence of good development. Just as parents look forward to developmental milestones like sitting alone, walking independently, the first word, they can be guided to recognize what Anna Freud called “regressions” as developmental progressions. Because some of these developmental steps are fairly predictable, parents can be encouraged to anticipate them and find them delightful as well as possibly problematic. (I’ve always thought that if I could design a greeting card, I would do one that says, “Congratulations! Your child was afraid of a stranger for the first time today! Her development is going very well!”)

Brazelton’s work looked at a range of changes in areas of development that can provide “touchpoints” for parents. For example, he noted that at about 4 months, babies’ increasing interest in the environment may make them more difficult to feed, as they stop nursing to look at other people in the room or to explore the mother’s face. By about 9 months, their desire to use their newly-developed pincer grip makes them want bits of food to pick up and decreases interest in being spoon-fed. By 12 months, new skills and an increased need for independence indicate developmental progress. Parents can take pleasure in these changes and work to accommodate them by providing changes in diet and encouragement to move forward—or they can fight the changes, making themselves and the babies unhappy. (If the parents accept the belief of some alternative therapists that emotional attachment occurs when an adult feeds the baby, they will definitely run into anxiety and difficulty on this point.)

The Touchpoints books are very much worth a look for parents of infants and toddlers.