Concerned About Unconventional Mental Health Interventions?

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

Sunday, December 17, 2017

What Do Evidence-Based Psychotherapies for Children Look LIke?

Adults who have been in psychotherapy as children may have had a lot of different experiences, but most of them had to do with talking—often a rather general “free association” kind of talking, or play with toys or drawings. A few others may recall more hands-on work, sometimes painful or frightening for the child. But evidence-based treatments for children, the ones supported by empirical research into outcomes of treatment, are more directed, and do not involve intentional pain or fear.

Here are links to some youtube clips of evidence-based treatments, made by developmental psychopathology graduate students under the supervision of their professor, Dr. Cynthia Hartung of the University of Wyoming.



Modular Cognitive-Behavioral Therapy for Childhood Anxiety
by Lauren Zimmerman & Angeline Bottera

Multifamily Psychoeducational Psychotherapy for Childhood Bipolar Spectrum Disorders
by Kandice Perry & Katy Richardson

Trauma-Focused Cognitive-Behavioral Therapy for Children & Adolescents
by Kati Lear & Sarah Steinmetz

Cognitive-Behavioral Therapy for Adolescent Depression
by Brooke Merrow & Kendal Binion

Cognitive-Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder
by Christopher Shelton & Ryan Kozina

Coping Cat to Treat Anxiety in Children and Adolescents
by Andrea Slosser & Shira Kern

Parent Management Training for Childhood Behavior Problems
by Adam Ripley & Alejandra Reyna



Most of these include actors’ performances of child and parent behaviors that are related to the original problem and to the therapeutic methods. You will see that most of the problems under treatment involve seriously concerning behaviors like undue aggressiveness, profound sadness, and unusual levels of disobedience and opposition to adult wishes—problems that  some unconventional therapists often problematically attribute to difficulties of attachment. Rather than trying to create or manipulate emotional attachments, evidence-based treatments usually concentrate on helping parents manage children’s behavior effectively, and on offering children tools and skills they can use to help themselves cope with anxiety or anger. They are certainly not about encouraging child disobedience or talking about parents' sex lives!

Wednesday, December 13, 2017

APA Continuing Education Courses: When Approved Providers Make Mistakes

In most states of the U.S., clinical psychologists have to be licensed to practice on their own, and often hospitals or other agencies prefer to hire licensees, even though sometimes a practitioner could be covered by supervision from a licensed psychologist. In order to maintain this valuable licensure, clinical psychologists must do a certain amount of continuing professional education. Although a state psychology board can approve continuing education (CE) courses for their state’s licensees, the CE courses are most often identified by approval of the American Psychological Association (APA). If the CE courses are approved by APA, all states will accept them as evidence of licensees’ compliance with continuing education requirements—and other professional organizations, like those for licensed professional counselors, usually accept APA-approved courses for their own licensing requirements. The standards for APA-approved courses are on paper more stringent than those of organizations like, say, the National Association of Social Workers.

Of course, there are thousands of licensed psychologists, and more thousands of clinical social workers, counselors, licensed mental health professionals, etc., etc. Providing and approving CE courses for all those people is a monumental task, and a big business, as fees are charged for CE credits. Although APA provides some CE courses at major conferences, most of the APA-approved CE courses are provided by organizations known as APA “approved providers”. These groups, which may be hospitals, universities, or free-standing businesses, acquire information about proposed presenters and presentations, vet it for compliance with APA standards, permit conference organizers to state CE awards in their brochures, and provide certification of attendance at CE courses to be used by licensees. Some approved providers also supply on-line courses with brief examinations on the presented material, but conference presentations do not include examinations. Conference brochures generally state that the conference organizers do not guarantee content accuracy; to the extent that this guarantee is possible, it’s the task of the approved provider.

Well, so far, so bureaucratic. Why am I getting into this at all? Here’s the problem: not all approved providers are doing their jobs properly. As a result, APA CE credits have been given for material that in no way meets APA’s stated standards, which include the existence of publications on the topic in peer-reviewed professional journals. This results in a potentially harmful situation, in which licensed psychologists may believe that content is accurate when it is not, and may base their continuing professional education on inaccurate content and miss out on other, more accurate material.

Fortunately, APA provides recourse to such problems through its Office of CE Sponsor Approval, and it’s my experience that complaints to that office are thoroughly dealt with. The complainant is fully informed, and additional information is requested if needed.

My first experience with complaining about a CE course took place several years ago when I received a brochure in the mail from the Lorman organization, an APA approved provider, advertising CE-carrying presentations by Nancy Thomas, the self-designated foster parenting and attachment expert. Thomas and her presentations fail on a number of points to meet the requirements for APA CE credits. Thomas is not a psychologist, nor does she have any other professional training, and no material supporting her methods has ever been published in a peer-reviewed professional journal. On the contrary, a joint task force of APA Division 37 and the American Professional Society on the Abuse of Children specifically condemned Thomas’s methods (Chaffin et al, 2006).  Following my complaint, the Office of CE Sponsor Approval directed Lorman to remove CE credits from courses given by Thomas. (Lorman continues, however, to sponsor and advertise Thomas’s courses, without CE credit; in my opinion, this practice raises questions about Lorman’s approved provider status as a whole.)

In Spring 2017 I brought a complaint about CE credits advertised by ATTACh, the Association for Training on Trauma and Attachment in Children, for a number of presentations to be given at their annual conference in October. The R. Cassidy organization was the approved provider in this case.The conference brochure offered APA CE credits across the board, for all presentations, although many of the presentations did not meet APA guidelines. I received a message from the Office of CE Sponsor Approval the day before the conference was to begin, stating that after investigation CEs had been refused for some of the presentations but allowed for others. A colleague who visited the conference reported that this did not seem to have been announced to attendees.

In September 2017 I filed a complaint about a presentation by Craig Childress and Dorcy Pruter at the conference of the Association of Family and Conciliation Courts (AFCC) earlier in 2017. AFCC had given APA CE credits across the board for presentations at this conference, and had included this presentation although one presenter, Pruter, has no professional training, and the material presented has never been supported by peer-reviewed publications. This complaint remains under investigation.

Within the last few weeks, I have filed two other complaints with the Office of CE Sponsor Approval. One of these concerned CE awards for presentations arranged by the Association for Comprehensive Energy Psychology (ACEP), which is for reasons that are not clear to me an APA approved provider. The CE material included claims for the effectiveness of “tapping” therapies, which are unsupported by any well-designed empirical study, as well as being contrary to any established view of the universe. In addition, I filed an objection to CE credits offered by the organization PESI, Inc., for presentations by the psychologist Terry Levy. The brochure for the Levy presentations claimed that Levy’s methods were effective, despite the absence of any peer-reviewed publications of empirical work or even of theoretical considerations. The PESI brochure’s biographical material on Levy referenced two of his books that include material making unsupported claims about the nature of attachment disorders and material written by Nancy Thomas that advocates limiting children’s diets as a therapeutic tactic. These complaints are also under investigation.

If you come across material offering APA CE credits for inappropriate material, I hope you will join me in complaining to the APA Office of CE Sponsor Approval. If you are not sure what the standards are, you can find them at www.apa.org.

Or, if you are not sure how to go about this, send your concerns to me and I will file a complaint if I agree with you.

  

Tuesday, December 12, 2017

Statutes of Limitations, Sexual Abuse, and Non-Sexual Abuse

The term “statute of limitations” is one that may be familiar to people who have tried to get recourse against those who have cheated or mistreated them. Such a statute is a law that time-limits lawsuits of some kinds. A person who seeks justice after a certain period has passed may find that he or she can no longer bring a suit for compensation for harms experienced.

It’s not unreasonable to have statutes of limitations for some problems. If too much time has passed, there may be no living witnesses to an event, and other evidence may have been corrupted or lost. Even the victim’s memories may have faded or become distorted. Few people would want to claim that someone who is 75 should be able to bring a lawsuit about something that happened when he or she was five years old, however terrible that event might have been.

However, many states have very short time limits on a range of harmful events that happened during childhood; not only are children unable to bring their own lawsuits and are helpless if their abusers are their own parents or guardians, but there are severe limits on the time that can  have passed after an abused person has reached adulthood before he or she can no longer sue.

In the current climate of concern and justified moral panic about sexual assaults, some organizations are working to alter states’ statutes of limitations on lawsuits concerning sexual abuse of children. These issues were discussed in detail by the New York Times reporter Elizabeth Harris at https://www.nytimes.com/2017/12/04/nyregion/prep-school-sex-abuse-statute-of-limitations.html and

For readers outside the United States, I should point out that statutes of limitations in the U.S. are matters of state and not Federal law. Every state has its own laws on this matter, although many states’ laws resemble each other in various ways. Elizabeth Harris’s articles focus on the laws of New York State, which are rather stringent in their time limitations, although not more so than some other states. According to Harris, residents of New York State have only until they are 21 years old to sue schools or institutions where they suffered sexual abuse, and until age 23 to sue an attacker or bring criminal charges (except for rape). For some years, activists in New York have been attempting to pass legislation to change this situation. Currently, a bill before the legislature, the Child Victims Act, proposes allowing survivors to sue until they are 50 years old and to bring criminal charges until they are 28. It would also provide a one-year window during which complaints from any previous time could be brought.

Although the Child Victims Act has been brought to the legislature repeatedly over the last 11 years, without being passed or even brought up for a vote in some cases, it is possible that the current climate of opinion, with its strong concerns about sexual misconduct, will support its passage. It is difficult to imagine resistance to such an act except among organizations that have reason to protect predators.

I would be most happy to see the Child Victims Act passed in New York and to see its passage tip off real changes in other states as well. But I want more.

Yes, sexual abuse of children is a heinous crime and one deserving of special attention. However, it is not the only form of child abuse for which recourse is subject to statutes of limitations. Legislation like the Child Victims Act should include cases of non-sexual abuse, especially if they occurred in institutions or were protected through bureaucratic or institutional means. Currently, statutes of limitations can easily prevent survivors of abusive treatment from bringing suits against their abusers.

Why do I say this? It’s apparent that many victims of sexual abuse were reluctant to come forward because they felt they would be attacked for complicity or for malicious intent. Both men and women felt correctly that publicizing their sexual histories would “punish” them and their reputations as much or more than it would hurt their molesters. It may seem less obvious why victims of non-sexual abuse would not quickly seek justice—but there are real reasons why they might not.

1.      1. They don’t have any money for legal representation. Individuals who have been in abusive institutional environments as children usually “age out” at 18 and have all they can do to take care of themselves. They do not have the background or the contacts that would enable other 18-yer-olds to get some kind of job, and they often rapidly move into homelessness, a condition that makes employment even less likely. It can take years to find their feet financially, if indeed they ever do so.

2.     2. They don’t have much education. Institutions in which abusive treatment takes place do not usually provide more than a minimum of education. As a result, individuals leaving such institutions may have no idea about lawsuits, about compensation for abusive treatment, about courts, even about what a lawyer is. Certainly they don’t know about pro bono legal work or about resources in law schools. Eventually they may learn some of these things, but it takes a while.

3.      3.They don’t know that what happened to them was abusive. How people define abuse changes over time, and most of us are really aware only of abuse that is different from what we are used to seeing (e.g., the example of debates over spanking). When children have spent years in an abusive family or foster care, and then have gone to an abusive institution, they may regard mistreatment as “par for the course”, and only with years of later experience look back and realize what happened to them.

4.     4. They think the abuse they experienced was their own fault, as they were often told. It is easy to make children feel as if adult attacks on them occur because they were “bad” in some way. Even adolescents who are coerced into false confessions of crimes may actually believe for some years that they are guilty of things they said they did—but did not actually do. Only as the years pass and more mature thinking develops do they realize that they were innocent of the charges they admitted to.

All of these are reasons why non-sexual abuse, especially in institutional settings, should not be subject to the present severe time limitations for recourse.

It is clear that institutions where abuse has taken place are quick to defend themselves by claiming time limitations for suits against them. Here is an example that I have blogged about previously. A 17-year-old girl in a Southern state, whom I will call Sophie, was placed in residential treatment center by her mother, who was concerned about the girl’s state of mind following a parental divorce that involved some sexual allegations about the father. During her time in the RTC, Sophie was subjected to withholding of food, water, and toilet facilities. When she had her period, she was not allowed sanitary materials, and was mocked as stinking. This treatment was continued until she conceded, falsely, that she had been molested by her father. The treatment then continued until she stated, again falsely, that she had herself molested a younger brother. The facility staff then reported her as a sexual predator, a label that meant she could not return to her mother’s house where there were younger children.  At 18, Sophie left the RTC, got a job, and saved up $200 for an hour of an attorney’s time (a feat that was probably possible for her only because she had not been in the RTC for as many years as she might have been). The attorney, fortunately, agreed to represent Sophie without further charge and brought a complaint against the RTC.

As you might guess, the RTC’s lawyers responded by pointing to the statute of limitations. It had taken Sophie more than a year to get her life together enough to seek legal representation, and under case law and legislation in that state she had no recourse for the harm done her. However, happily, a judge considered all the aspects of Sophie’s life and why she might not immediately have brought her complaint—and her case is going forward. (I notice that the RTC is no longer shown on the Internet under its old name.)


Including non-sexual abuse under Child Victims Acts would be a great help for the Sophies of this world.

Monday, December 11, 2017

Parental Alienation Advocate Invites Fox to Watch Henhouse


Well, I really thought I had made a couple of things plain on this blog: 1) that although I am sure that intentional “parental alienation” and manipulation of a child’s emotions toward a parent’s former partner could be the cause of a child’s avoidance of contact with one parent, this is far from the only explanation of the child’s attitude (even when the child gives no “rational” explanation for avoidance) and without a clear evidence basis no one has any business attributing the child’s feelings and behavior to a parent’s influence; and 2) that persons who attribute the child’s reluctance to problems of attachment, and who purport to treat attachment difficulties when they propose removing a child from contact with the preferred parent, do not understand the last 50 years of attachment theory and research, but instead want to hitch a ride on the attachment-fad bandwagon. (I have named Craig Childress specifically as making this latter mistake, though there are quite a few others.)

But perhaps I was not as clear as I thought… or perhaps PA advocates do not read as closely as they think they do. Some days ago I received an email from one Sarah Beeler, who said the following:

Dear Mrs. Mercer

I have read this discussion online between you and Dr. William Bernet: http://childmyths.blogspot.ch/2015/12/parental-alienation-advocates-cite-who.html?m=1
 
So I wanted to reach out to you to ask for your support. We have a new model to solve PA, a model that wil help millions of children and families around the world, it's called the attachment based model of "parental alienation". This model is only using established constructs and principles of professional psychology (no new syndrome).

The APA unfortunately does not realise that this is nothing new, they want to form a working group to research what is already established psychology (see email below).



Ms. Beeler then continues with many references to Craig Childress and his various claims to have shown that “parental alienation” is associated with a blocking of the attachment system [pretty much sic ] which is to be corrected by forbidding the child to have contact with the preferred parent (and thus his or her home and the rest of the family) and by psychoeducation in the form of videos, etc. It appears that although she read the discussion I had with William Bernet, but not everything else I said, nor the lengthy comments from Childress fans that I posted, nor my responses to those lengthy comments.

Ms. Beeler’s assumption about my position seems to have been based on the highly polarized views of Childress—that he has the right answer to the postulated problem, and that anyone who disagrees is against him—even those who also postulate PA and have their own proposed treatments. In line with the idea that the enemy of my enemy is my friend, she figures that if I disagreed with William Bernet (which I did), I must therefore be willing to agree with Childress! I am sure Childress and his various minions will be cross with Ms. Beeler, even though the sort of  careless or intentional cherry-picking of information she did is exactly like their own habit of making claims without evidence.

Childress’ blog post, quoted and linked by Ms. Beeler, states that APA should not appoint a task force to consider evidence about PA and treatments, on the grounds that the matter is urgent and that his methods and beliefs are “established psychology”. Personally, I would suggest that the task force is not really necessary (although it should be interesting), because the lack of evidence (i.e., “established psychology”) on the topic is so striking.  On the other hand, perhaps this is the time for a task force of the type APSAC and APA Division 37 appointed some years ago to look into the harm done by unconventional beliefs about and potentially harmful treatments for attachment disorders (Chaffin et al, 2006). Those beliefs and treatments were also without an adequate evidence basis, but they were being used freely by various mental health practitioners, just as various PA ideas are being put to work freely by a few practitioners and apparently quite a few lawyers.

Urgent needs, even if they exist, do not justify jumping to conclusions. Conclusions drawn on inadequate grounds have every bit as much chance of exacerbating a problem and harming families as they have of helping anyone. If Childress wants to influence APA or most other psychologists, his job should be to stop the theatricals and start doing the kind of serious research that could convince others of his position if the results were what he predicts.



Friday, December 8, 2017

Eye Contact Question

There is no more space for comments on the post mentioned here, so although I don't know whether the writer will look at this answer, I will reply here.


zhee yee has left a new comment on your post "Eye Contact With Babies: What, When, Why, and How": 

Hi dr,
My baby born at week 40 and she is now 3 months old. But she has poor eye contact with everyone, no cooing, and no respond to human voice. She is very good in tracking object, and respond to sound by her toy. She also awake from sleep if any loud noise. All these symptoms have freak my out as she is already 3 months old. I would need your advice on this. 

Thanks for your time. 

I am not completely sure what Zhee Yee is worried about or whether she is concerned that she is seeing signs of autism in her baby. I would have to say that the baby is too young for autism to be diagnosed, and that although most babies this age make some eye contact, it is usually "poor" by adult standards. Again, although most babies this age have begun to coo, there are some who vocalize very little but develop normally. I would be more concerned about the lack of response to voices, especially when there are some sounds she responds to. 

I would suggest that it might be good to have the baby's hearing tested, if this service is available. She may have some hearing loss for some frequencies of sound which would make her less able to hear voices. If this is the case, her language development will be affected unless she receives help.

For other people with queries like this, please don't try to post on the Eye Contact with Babies: What, When, Why, and How page! I have set up other pages for you to use--  just search "infant eye contact childmyths" and you will find them.

Thursday, November 30, 2017

"A Generally Accepted Record of Efficacy": States' Religious Exemptions for Caregivers Who Neglect or Harm Children

Some readers will be aware that in many states of the U.S., parents who refuse to immunize their children against contagious diseases may suffer no penalty if they can argue that their decisions were made on the basis of religious beliefs or philosophical principles. One of the reasons that the parents can do this is that state laws are affected by the requirements of the Federal law CAPTA (Child Abuse Prevention and Treatment Act, which from 1996 onward demanded this policy on First Amendment grounds, and because of lobbying by groups like Christian Scientists).

It’s likely that fewer people know that some states allow religious exemptions for crimes against children as serious as murder, as is shown at childrensheathcare.org. While outrageous indeed, this fact is not quite as outrageous as it appears at first glance—the issue has to do in many cases with legal definitions of murder and other crimes. (No one is saying that a parent could get away with arguing that his religion requires him to chop up his child with an axe.)

For example, the Arkansas code protects a person from being charged with capital murder if his or her child dies because of the withholding of medical or surgical treatment due to the parent’s beliefs in the tenets of a recognized religious group. In Delaware, unless a child dies or is seriously injured physically, a religious exemption protects the parent from a charge of child endangerment. In Idaho, parents withholding medical care for religious reasons cannot be charged with manslaughter, as this charge requires the performance of an illegal act, and using spiritual healing techniques alone is legal under the Idaho code.

A number of other states’ laws are discussed at childrenshealthcare.org, but the one that intrigues me most belongs to Texas. This law protects a parent who has withheld medical care and used spiritual techniques from charges of criminal injury to a child, provided that  “the act or omission was based on treatment in accordance with the tenets of a recognized religious method of healing with a generally accepted record of efficacy.” I am not at all sure what the Texas legislators thought they were talking about when they wrote this language, but the word “efficacy” certainly has a “generally accepted” meaning.

The term “efficacy” refers to the extent to which an intervention causes statistically significant improvement in the problems for which it is used. The use of interventions of high demonstrated efficacy is called “evidence-based practice” and is strongly encouraged by both private and public funding sources that cover either physical or mental health treatment.  Conclusions about efficacy are not based on studies of whether parents of treated children approved of the treatment, but on measurable changes in a child’s condition. Efficacy is considered to be demonstrated only by demanding research designs, and this generally requires either randomized trials, or well-managed nonrandomized trials, because when designs are weak, other factors may be “confounded” or confused with the effect of the intervention, and it may be wrongly concluded that the intervention caused any changes that occurred. In addition, conclusions about efficacy are not based on any single study, but require more than one independent investigation showing that a treatment has had a significant positive effect. By these standards, there are no “recognized religious method[s] of healing with a generally accepted record of efficacy”, although there are claims of efficacy (e.g., for prayer of different kinds).

The Texas example suggests that states’ legislation, often created hastily to be in line with CAPTA, has not been thought through very well. Whether one agrees with the thrust of these religious exemptions or not (and I don’t), they should more clearly balance the needs of children, the religious freedom of parents, and the states’ interests in supporting public health. The reports of childrenshealthcare,org on events in Idaho, where children of a religious group who died in unusual circumstances are not autopsied, is an example of public health risks, as well as children’s needs, being ignored, as the greatest weight is given to issues of religious freedom.

For obvious reasons, concerns about religious exemptions to liability for actions with ill effects on children are usually focused on medical and surgical treatments, which may if withheld contribute to serious illness or death. But religious exemptions have come to apply in other areas as well. For instance, although state laws uniformly require education of children after some minimum age, and although education other than through the public schools has long been an option for families who wanted it, “home-schooling” with few constraints or requirements has in the present generation become a choice for religious reasons--  parents essentially demand a form of religious exemption from laws that consider the failure to educate as a type of child abuse and neglect. Whereas parents in the past sought exemption from school attendance because of travel issues or because they felt the available public schools did not provide a good enough education, the current generation of parents often chooses home-schooling so their children will not learn about a number of topics, ranging from human sexuality to evolution. Permitting these choices, for these reasons, is a form of religious exemption.

Can the idea of religious exemptions also be applied to the use of some forms of psychological treatment that are popular with the religious right? Consideration of this issue requires the awareness that not all forms of psychotherapy are effective, and that some of them are potentially harmful to children. In rare cases, children have been injured or died as a result of holding therapy or because of parental actions related to associated beliefs. One assumption associated with holding therapy is the idea that children who do not comply with parental demands do so because of intentional, willful resistance, not because they are unable to comply. This assumption has even been applied to vomiting and defecation, opening the door to withholding of medical care when symptoms of illness are perceived as defiant acts.

The question of psychological rather than medical harm resulting from some forms of psychological treatment is largely unanswered, but some anecdotal information suggests that anxiety disorders, including PTSD, may result from some kinds of treatment offered for children. Some such treatments, for example “conversion therapy” to attempt to alter sexual orientation, are strongly related to religious beliefs. As several states have passed legislation forbidding psychologists to use “conversion therapy”, members of the clergy have continued to be allowed to use the treatment methods.

If parents whose children have been injured physically or mentally by psychological treatments are charged with abuse or neglect because of their treatment choices, can they claim religious or philosophical exemptions from the charges? So far, this issue does not seem to have been addressed in any U.S. court, but then, even the idea that psychological treatments can be potentially harmful is a very recent one.


Wednesday, November 29, 2017

Referencing John Bowlby: Not Your Grandpa's Attachment Theory Any More

Thousands and thousands of articles on attachment theory and research have been published over the last 40 years or so. This topic, with its emphasis on early experiences and social-emotional outcomes, has fascinated many readers and received faddish attention and emphasis both within the field of psychology and outside it. Unfortunately, not everyone who writes about attachment theory is on the same page; there is a mainstream view of attachment, developed through decades of discussion and research analysis, and there is an alternative attachment theory that has given rise to the use of holding therapy and similar non-evidence-based treatments.

How do you tell the difference between these when reading Internet articles? One way is to notice that the alternative attachment theorists quote John Bowlby, the “father of attachment theory”, to the exclusion of any more modern work. This practice is problematic, because some strongly-held tenets of Bowlby’s theory are much at odds with modern empirically-based work.

I am going to comment on some of Bowlby’s ideas that no longer appear credible. Please understand that this critique is not an attack on Bowlby himself or on attachment theory in general. John Bowlby was a man of his time, and his formulation of attachment theory was influenced by other ideas current during his professional lifetime. In addition, his thinking changed and developed over a long professional life, with relevant experiences in both wartime and peace. These statements about changing ideas are true of any influential theorist, in psychology or any other discipline—for example, asking what Freud thought about something really makes sense only if we say whether we are asking about his thoughts in 1900 or in 1935.  

References of alternative attachment theorists to John Bowlby’s work often take their information from Bowlby’s report to the World Health Organization in 1951 on maternal care and mental health (later published by Schocken in 1966 in a volume including responses of both supporters and critics to the original report). Here are some ideas rom that volume that no longer seem credible to mainstream attachment theorists and researchers:

1.    1.   Genetic factors play little or no role in the development of mental illness; early experiences, especially separation from the mother or deprivation of maternal care, are the primary causes of later mental illness and/or criminality. [This stress on experiential rather than biological factors was characteristic of Bowlby’s time and can be seen in the work of researchers working on juvenile delinquency like Glueck and Glueck. It is an optimistic view of mental and behavioral problems, because it implies that new, appropriate experiences may be able to correct the effects of early, bad experiences.]

2.     2.  Infants form attachments to a single person rather than to several caregivers and have a great deal of difficulty in forming new attachments if separated. Because of this tendency, called monotropy, the great preponderance of infant attachments are to the mother. [ During the Victorian period and later, emphasis on the powerful importance of mothers was generally assumed to be correct. By the 1940s, mothers were both praised for their benign influences and blamed  for their potential harmfulness—for example, the attribution of autism to “refrigerator mothers”.]


3.     3.  Attachment and attachment behavior are characteristic of the human species and are parallel to the rapid learning to follow other ducks shown by ducklings (called imprinting). When imprinting “goes wrong” (for instance, when a duckling imprints on a human being rather than another duck, and in adulthood tries to court the human rather than mating with another duck), it is very difficult to correct the problem, so attachment difficulties are also likely to cause serious adult problems that are hard to treat. [This ethological approach to human behavior was an outgrowth of comparative studies of  animal behavior that were a feature of psychological work from the 1930s to about 1980. We see little of this time-consuming observational research today and most people do not think of it as part of psychology, but it was of serious interest in the past, when undergraduate psychology curricula normally included a “comparative psych” course.]

4.      4. When children have been separated from their mothers or have otherwise been deprived of maternal care, encouraging regression by bottle-feeding and other “babying” can be an effective way to treat older children who have behavior problems. [ Bowlby included this idea in his 1951 report because such treatment was being used in Sweden, for example, in the care of children who had suffered severe deprivation and separation during World War II. The effect of the war, the number of orphans to be cared for, the evacuation of British children from cities that were being bombed, and so on, cannot be underestimated as a factor in Bowlby’s thinking.]

5.      5. Separation from their mothers causes psychological trauma in young children. [Bowlby based this view on observations of separated, evacuated British children, European Jewish children sent to England by their parents as Hitler came to power, and children being treated in hospitals where their parents might not be allowed to visit them for weeks.]

Much further thinking about attachment, and empirical research on the topic, have allowed us to reject these early assumptions of Bowlby’s while keeping some important tenets of attachment theory. (A paper by Michael Rutter in 1995 stated this very clearly and can be considered a beginning for a more advanced form of attachment theory, in which I do not include Schore’s so-called “modern attachment theory”.) Here are some reasons for rejecting the tenets listed above:

1.    1.  Genetic factors have been clearly shown to play important roles in the development of both mental illness (such as autism) and criminal behavior. Experiences are also important, but individuals with different genetic make-ups may respond to experience differently.

2.     2.  The research evidence indicates that infants commonly have attachments to several different caregivers, none of whom need be the mother.

3.     3.  Although human beings show many characteristic behaviors related to attachment, both in terms of seeking and of giving social interaction with others, it is deceptive to think of these as parallel with imprinting. From an evolutionary point of view, it would seem maladaptive for human beings, with their long childhoods and the relatively high chance of death of a parent (especially a mother) during that time, to have an unbreakable emotional connection with any individual and to have development badly distorted by separation from a single person.

4.    4.   Treatment of childhood mental illness by regression methods has never been shown to be effective. Parenting methods that demand a reasonable level of maturity are advantageous, so it would be surprising if the opposite treatment for mental illness worked.

5.     5.  Older infants (more than about 6 months old) and young children show great immediate distress in response to separation and continuing distress over weeks or months in cases where they receive little comforting attention and care. However, as John Bowlby’s colleague John Robertson showed in an observational study, plenty of responsive care from a small number of concerned adults reduces this distress a great deal. It would appear that it is the withdrawal of sufficient concerned care from adults that is potentially traumatic, not the separation itself. (It should be noted that the youngest infants, before about 6 months, do not appear to show distress about separation, and this is certainly true of newborns, despite some alternative theorists' claims to the contrary.)


Once again, this post is not an attack on John Bowlby or on the essentials of attachment theory. It is simply a statement that some of Bowlby’s ideas have not stood up to continuing thought and research. When advocates of alternative attachment theories and treatments for children cite  some of Bowlby’s original ideas as received knowledge or “scripture”, readers should see this practice as evidence that these people do not understand evidence-based concepts of attachment, and their other pronouncements should be approached warily.


Incidentally, material that invokes the name of Sir Richard Bowlby should be regarded with suspicion. Richard Bowlby, John Bowlby’s oldest son, has been a medical photographer. He inherited his title from his baronet uncle (John Bowlby was a younger son and not in line for the title.) There was a period of time when Sir Richard was invited to speak at conferences of alternative attachment theory proponents, presumably because of the magic Bowlby name and the magic baronetcy.  However, he did not know very much about attachment. He still has a website, though. 

Tuesday, November 28, 2017

Jumping to Conclusions About Child Custody (Lawyers, Please Read)

The Monitor on Psychology, a publication for members of the American Psychological Association, has an “in brief” section where summaries of interesting research are presented. I have often had a beef or beeves with “in brief” summaries involving child care and parenting, which too frequently suggest a cause and effect relationship where none has been shown to exist. I am really disturbed by this in cases where people who assume that one thing causes a particular outcome for children may want to argue in court for particular orders about child custody or treatment, and may cite research as a support for their arguments even when the research does not actually provide the evidence they imply.

A recent case in point: in the “in brief” section, and under the headline “Shared Custody Matters” , the Monitor (December, 2017, p. 13) reports a Swedish study that compared psychological problems of preschool children in the joint custody of divorced parents with the problems of those who spent all or most of their time with one parent, and with those of preschoolers in intact families. (This study is summarized at DOI:10.1111/apa.140014. The article is by Bergstrom, Fransson, Fabian, Hjern, Sarkadi, & Salari – “Preschool children living in joint physical custody show less psychological symptoms than those living mostly or only with one parent”, Acta Paediatrica , 2017).  The researchers reported that children in intact families had the smallest number of psychological problems, followed by those in joint custody, and those in the care of only one parent had the most problems.

There are a number of Internet references to this study that suggest that shared custody has thus been shown to help children psychologically, and some of them use language like “children of divorce” that encourages readers to ignore the ages of the preschool children in the study and to generalize from this study’s results to conclusions about children of all ages.

So what’s my problem with this? Does the article not show that shared custody is better for children? No, actually it does not, and it can only be interpreted as doing so if the reader ignores the multiple factors that affect child psychological outcomes, as well as the bidirectional influences of parents on children and vice versa. Such an interpretation also avoids the fact that the groups of families studied may have had many important differences that directly affected their custody arrangements.

Given that many divorcing families choose joint custody (in the U.S. this is the default position of most judges, as well), why do some not follow this pattern? How are families with joint custody potentially different from those without it? The list of differences is substantial.
High-conflict parents may avoid shared custody, and exposure to conflict may cause psychological problems for children. Parents who have serious physical or mental illnesses may be less likely to be able to share custody, and children may be affected by the parents’ disorders. Children with existing physical or mental problems that make them challenging to care for may be avoided by one parent, who will be unwilling to share custody, whereas the same parents might be quite ready to care for healthier or “easier” children. Parents who have the assistance of their own parents or other family members may spend more time caring for their children than those who do not have such assistance, and depending on the family circumstances, this may or may not affect the children’s psychological health. Parents who have committed domestic violence may be regarded warily by co-parents, who may try to reduce the time the abusive person spends with the children – either the domestic violence of the past or the present fears of  one parent can affect the children psychologically.

Being able to name alternative causes is not the same thing as showing evidence that one or all of them are at work, but this exercise does underline the fact that a nonrandomized study of naturally-occurring events cannot be used to conclude that a single factor caused an outcome. I don’t say the original authors did this, but other interpreters of the research seem to have done so.

I’d like to touch on another point about the Bergstrom et al study. The children were preschoolers, ages 3-5 years, but some Internet references speak of them as “children of divorce” in a general way. There are real problems about generalizing from preschoolers to older children, or vice versa, as their developmental strengths and vulnerabilities may influence the ways they react to experiences. In addition, if all the children in a study are preschoolers, this means that the divorce took place no more than 5 years ago, and in many cases is likely to have been much more recent. These families are still working out new roles and functions in the wake of the divorce and may take two years or more to manage these tasks and arrive at a calmer period of their lives. “Children of divorce”, taken across the developmental range, are in many cases past the early chaos of post-divorce adjustment and have established relatively successful ways to function. For children in those later years, who are also more mature cognitively and emotionally than preschoolers are, psychological responses to care arrangements will not necessarily be the same as those of younger children.


I would hate to see the Bergstrom et al study dragged into the courtroom as an argument in child custody cases where there is a real concern about the children’s contact with one of the parents. Having plenty of contact with each of two “good” parents is beneficial for children, but plenty of contact with a “bad” parent is not necessarily desirable and may even be harmful. The Bergstrom study does not adequately support the claim that joint custody is superior across the board to single-parent custody, with respect to children’s psychological development. Let’s hope that lawyers and judges understand this and don’t jump to conclusions.

Friday, November 17, 2017

Martha Welch Meets Bruno Bettelheim, Edgar Cayce, and the Rules of Research Design

I’ve devoted several posts and parts of some publications to the claims of Martha Welch, a New York psychiatrist, who used to claim that she could cure autism and now says she can prevent it. Welch has, inexplicably, the support of Columbia University, which has appointed her a sort of peripheral non-teaching faculty member with certain faculty privileges, and which not long ago gave her an award as a distinguished alumna.

In the 1980s, Welch visited Evergreen, Colorado, home of Holding Therapy as practiced on adopted children who were said to have attachment disorders. I have no idea exactly what happened there, but after her visit Welch decided that autism must be a form of attachment disorder, curable by facilitating emotional attachment to the child’s mother. She developed a new form of treatment that she named Holding Time. Rather than the Holding Therapy methods, which usually restrained the child in the therapist’s lap and used intrusive and painful shouting and poking to intimidate the child, Welch proposed that smaller children be held face-to-face with the seated mother and embraced so they were pressed belly to belly with her. This hold was to be maintained for an hour or more at a time, every day, as the child screamed and fought for release and eventually gave in and relaxed in the  mother’s arms. Older children were to lie on their backs while the mothers lay prone above them, partly supported on their arms. In both cases the mothers were to speak to the children, communicating all of their negative and positive feelings; the children too communicated a good deal of negative emotion.

Welch’s approach would probably have remained among the various obscure “complemetarty and alternative” approaches to autism, except that in the 1980s she made a connection with Elisabeth Tinbergen, a special education advocate and the wife of the Nobel laureate in medicine Nikolaas Tinbergen. Niko Tinbergen was a specialist in ethology, the study of innate, species-specific behavior patterns; although ethology had focused largely on insects, fish, and birds, the 1960s and ‘70s were a time when studies were attempting to find such species-specific behaviors occurring independently of culture and learning in human beings. The Tinbergens saw parallels between what Welch was doing and the occurrence of “imprinting” connections to other animals in ducks. They enthusiastically wrote a book declaring “hope” for autistic children in Holding Time methods, and included a long appendix written and illustrated by Welch. The Tinbergen book led to the publication of Welch’s 1989 Holding Time and an extensive book tour in Europe during which Welch presided over roomsfull of mothers holding tightly to screaming autistic children. (The Tinbergens also encouraged the promulgation of similar methods by Jirina Prekopova, a Czech psychologist working in Germany.) However, little was made of a point clearly stated in the Tinbergens’ book: that there was no empirical evidence to support the effectiveness of Holding Time.

I’ll leave this brief summary now because there is much more to say about Welch’s current activity. She is now running a program called Family Nurture Intervention and claims that physical contacts between premature babies and their mothers can reduce the frequency of autism, which occurs more frequently in premature than in full-term babies. You can see a demonstration and discussion of this method at https://www.youtube.com/watch?v=DIXAMaIOK64
 (my thanks to Yulia Massino for calling my attention to this video; for some reason I cannot create a link here). Welch is carrying out a research project on the effectiveness of Family Nurture Intervention as a prevention of autism and has described the research plan, a randomized controlled trial, at https://bmcpediatr.biomedcentral.com/articles/10.1186/1471-2431-12-14. Among other things, Welch proposes that autism is related to the presence of abnormal levels of peptides released from the gut, for example secretin and oxytocin (both popular suggestions for treatment of autism in CAM circles).

I want to comment on three aspects of Welch’s theory and research. First, her assumption that babies become autistic because they miss experiences of physical contact, exchange of odors, and so on with their mothers is a direct reflection of the very much outmoded “refrigerator mother” theory put forward by people like Bruno Bettelheim (an art historian who became focused on child mental health). Bettelheim claimed, without evidence, that cold, unemotional mothers caused autism by their failure to engage physically and emotionally with their children. He did not mention premature babies, but those babies can certainly be included in this hypothesis because their medical care makes it difficult for parents to touch or engage with them in pleasurable ways, and even the most loving parents of premature babies will not be able to care for them as they would normally want to do. In the video mentioned above, a scientist who works for Autism Speaks points out this problem of Welch’s approach—that she is accepting something like the “refrigerator mother” theory in spite of decades of evidence that genetic factors rather than experiences cause autism.

Second, Welch’s emphasis on literal “gut responses”, the production of peptides and their effect on the brain, is an example of an old theme in American CAM. Edgar Cayce, an early- 20th-century “prophet and seer”, emphasized the work of the “enteric brain” as a source of emotion. The Meridian Institute of Virginia Beach, VA has continued to promulgate Cayce’s ideas, which are still part of many CAM approaches. For example, Andrew Wakefield, the disgraced physician who started the claims that immunization caused autism, looked to gut contents as evidence that materials of immunization remained in the body, and, presently working in America, he continues to focus on digestive tract issues as causes of autism and ways to treat it, in contradiction to all that is known about autism.

Now, the fact that Welch’s Family Nurture Intervention smacks loudly of outmoded and CAM beliefs is not enough to condemn it. It would be very reasonable to say, “who cares if it’s based on wrong ideas? If it works, that’s what’s important.” And Welch has reported some preliminary positive results—but this leads us to the third problem about Family Nurture Intervention studies.

Welch and her colleagues state proudly that they are carrying out a randomized controlled trial, and most certainly it is randomized, with families assigned randomly to one of two treatment groups. The problem is that it is not controlled, despite the presence of a putative comparison (control) group. Here is the trouble: according to the BMCpediatrics article mentioned earlier, the two groups are receiving treatments that are different in a number of ways other than the Family Nurture Intervention itself. In the FNI treatment group, mothers have 4 1-hour intervention sessions per week, or more, plus standard care. The comparison group has no specified treatment, standard care, and 1 meeting a week with research staff in the hospital. In other words, the FNI treatment groups is experiencing 4 or more times the socially-supported time with their babies as the comparison group receives. Such social support is well-known to improve mother’s moods and therefore to help them interact more patiently and warmly with their babies.

The point of randomization is to help isolate a variable, which is the crux of all experimental work. Randomizing families to conditions means that no special characteristic of the people (like knowing about and wanting a treatment) can interfere with finding the effects of the treatment itself, which should be isolated from any other possible effects on the outcome. But randomization alone cannot isolate the effects of the treatment unless the rest of the design and implementation of the study are correct. The time spent in treatments is clearly a factor that needs to be controlled, as it is common for more of a treatment to have a greater effect on outcomes than less does. When a treatment involves social support for people in a stressful situation, the time spent and the attitudes of staff are important factors. This study should have provided 4 or more sessions per week for the comparison group, devoting them perhaps to supportive interviews and motivational discussions with the mothers. Otherwise, we can only conclude that having more sessions has a better outcome--  we can’t conclude that the Family Nurture Intervention itself is supported.

A 2015 publication by Amie Hane et al (with Welch as a co-author), https://psychology.williams.edu/files/Hane-et-al-15-JDBP.pdf, concluded that mothers’ care for babies in the NICU was improved by experience of the Family Nurture Intervention. However, this article very properly stated some limitations of the study.  “The control group received standard care (SC) (i.e., usual care) as part of our randomized controlled trial that included holding and skin-to-skin care if the mothers chose to engage in these activities. But, there were not corresponding control conditions for each of the specific activities of FNI. For instance, SC mothers did not exchange sham odor cloths with their infants (cloths that were not exposed to mothers and/or infants). The effectiveness of FNI should thus be interpreted as a function of a comprehensive and integrative intervention, since during this preliminary trial of the intervention control manipulations of FNI activities were not entirely possible.” (p. 194). In other words, mothers in the comparison group may or may not have carried out some of the activities used for the FNI treatment group, but they did not share any version of some parts of the treatment, including the length of time per week (this last not mentioned as a limitation by Hane et al.). The standard care comparison group did not receive a family support session before discharge as the FNI group did.

Martha Welch has spent many years arguing in favor of alternatives to evidence-based conclusions about causes of autism and effective treatments for the disorder. Her connection with Tinbergen was apparently sufficient years ago to earn publication of a popular book and the support of Columbia University. The Columbia IRB approved her research design, weak as it is, although even non-harmful treatments can be considered as a harmful waste of time and resources if improper design and implementation of research can lead to incorrect conclusions. What is this all about? I would like very much to know.


N.B. Nothing in this post should be taken as rejection of the extensive legitimate research on neural factors in gastric and endocrine functioning; my point is that the existence of such physiological factors is not in itself evidence that supports any statement about autism.




Monday, October 23, 2017

What Do Registries and Clearinghouses Tell Us About Child Mental Health Interventions?


I wrote the following paper for a conference about a year ago, and recently a colleague asked whether it was on line anywhere-- so here it is, for those interested. (Since writing this, I have come across cases of confusion about the meaning of the CEBC evaluations and the conflation of "relevance" scores with research scores.)





Internet Registries and Clearinghouses: Evaluation of Mental Health Interventions for Children
                                                         Jean Mercer
                                                    Stockton University
                                                           Jean.mercer@stockton.edu

                                                            Abstract
Evidence-based practice (EBP) requires a knowledge of the best current research as well as of practice wisdom and client preference. Internet registries and clearinghouses for outcome research on treatments are sources of evaluations of recent research and help identify high-quality research conclusions. This paper examines methods used by four registries and notes some problems of reporting. Ways to improve Internet registries are suggested. 


There is increasing pressure for practitioners to use evidence-based practice (EBP), an approach that combines family preferences, practice wisdom and experience, and the current “best research” to guide treatment choices.  Practitioners and clients together can work out the first two of these factors, but the third involves knowledge of outcome research that may require considerable time and access to professional journals. As a result, psychologists may turn to Internet sources of research information or to publications that summarize research work.
Internet sources range in quality from the highly variable Wikipedia, on which some articles are impeccably written and sourced but others are weak, to websites like www.wikia.psychology.com, which appear to encourage questionable statements in support of specific treatments. Treatments may also be described on proprietary websites that may provide excellent links to research support or may give no more than anecdotal evidence to support their claims. Systematic research syntheses (SRSs) also vary in quality, and journal articles assessing specific treatments do not readily allow readers to compare therapies with each other.  Although the Cochrane Collaboration ( www.cochrane.org) has evaluated some psychological treatments, their reviews are much more often concerned with physical health.
As a result of these difficulties, it is common for practitioners to go to Internet “registries” or “clearinghouses” for which volunteers evaluate outcome research and assign scores indicating the amount and quality of research supporting specific treatments. The “registry” approach is depended upon to such an extent that a 2016 publication of the National Academies of Science, Engineering, and Medicine, Parenting matters, drew its recommendations about child psychotherapies from three registries. The publication made recommendations about Triple P, PCIT, and the Incredible Years, among others.
The present paper examines a series of “registries” or “clearinghouses”, including those used in the NAS Parenting matters report, considers the evaluative methods used by each, summarizes the levels of support reported for treatments, and notes where useful information about treatments has been omitted.
                                                            Method    
Two of the “registries” used in the NAS 2016 report were examined: the National Registry of Evidence Based Programs and Practices (NREPP; www.samhsa.gov.nrepp)and the California Evidence Based Clearinghouse for Child Welfare (CEBC: www.cebc4cw.org). The new Effective Child Therapy website (www.effectivechildtherapy.org ) was also considered, as was the British registry of the National Institute for Care and Health Excellence (NICE; https://nice.org.uk ).
 .
For each registry, information on the website was used to explore a series of factors:
1.       How mental health treatments for children were chosen to be listed on the website
2.      Criteria used to evaluate information about outcome research
3.      Methods of summarizing or ranking research quality
4.      Numbers of treatments evaluated
5.      Proportions of quality ranks assigned to the evaluated treatments
In addition, experiences of the present author in correspondence with two of the “registries” were noted.

Results
NREPP
NREPP, a service of the Substance Abuse and Mental Health Services Administration (SAMHSA), evaluates treatments whose proponents apply for assessment as well as those nominated by staff members. The following requirements must be met before a treatment will be evaluated.
1.       Research or evaluation of the intervention has assessed mental health or substance use outcomes among individuals, communities, or populations OR other behavioral health-related outcomes on individuals, communities, or populations with or at risk of mental health issues or substance use problems.
  1. Evidence of these outcomes has been demonstrated in at least one study using an experimental or quasi-experimental design. Experimental designs require random assignment, a control or comparison group, and pre- and post-intervention outcome assessments. Quasi-experimental designs do not require random assignment, but do require a comparison or control group and pre- and post-intervention outcome assessments. Comparison/ control groups must be a no-treatment control group, a wait-list control group, a treatment-as-usual comparison group, or an intervention that is presumed to be ineffective or substantially less effective than the intervention (e.g., a “placebo” control or, in cases in which providing no treatment might be considered unethical, less effective treatments, even if not treatment-as-usual, such as “supportive therapy”). Studies with single-group, pretest-posttest designs or single-group, longitudinal/multiple time series do not meet this requirement, but will be considered to identify emerging programs and practices for consideration in the Learning Center.

    Comparative effectiveness trials, in which two interventions, both presumed to be equally effective, are compared, and studies in which the effects of the same intervention on various subpopulations are compared or in which various doses or components of the same intervention are compared will not be reviewed, but may be submitted as supporting documentation.
  2. The results of these studies have been published in a peer-reviewed journal or other professional publication, or documented in a comprehensive evaluation report, published within the previous 25 years. Comprehensive evaluation reports must include a review of the literature, theoretical framework, purpose, methodology, findings/results with statistical analysis and p values for significant outcomes, discussion, and conclusions (The NREPP Open Submission Process, 2016).
Changes in NREPP evaluative methods have been in the process of introduction since 2015. The website presently lists  a large number of programs that were evaluated according to the old method (“legacy” programs), and a smaller number evaluated recently. The plan is to re-evaluate all listed programs by 2019.
The original NREPP evaluation looked at outcome research reports for the following factors:




1.        Reliability of measures
2.         Validity of measures    
3.        Intervention fidelity
4.        Missing data and attrition
5.        Confounding variables
6.        Appropriateness of analysis
7.        Adverse events
8.        Plausibility of treatment, identification of therapeutic mechanism
Each treatment was given a numerical evaluation score based on these points.


Since 2015, the NREPP evaluation has examined these factors:
1.      Rigor: design, intent-to-treat assignment, statistical precision, confounding of variables etc.
2.      Effect size
3.      Program fidelity
4.   Conceptual framework
Treatments are then categorized as follows:
1.      Effective: strong evidence of a favorable effect
2.      Promising: sufficient evidence of a favorable effect
3.      Ineffective: sufficient evidence of a negligible effect OR sufficient evidence of a possibly harmful effect
4.      Inconclusive
Note that the third category classes together treatments with little effect and those with some evidence of potential harm to children.
 Of 387 NREPP-listed programs, 205 are primarily for children and adolescents. Ten of the 205 program reports mention possible adverse events as reported by the program developers. The mean rating for handling of confounded variables in programs listed on NREPP  is 2.6 out of 4.0, with a range from 4.0 to 0.0, but this was reported in this form only for the “legacy” programs.
In spite of the apparently strict criteria for admission into the registry, the NREPP list includes Thought Field Therapy, a treatment long rejected as implausible and without evidentiary support (Pignotti, 2005).


CEBC
The California Evidence-Based Clearinghouse for Child Welfare (CEBC; www.cebc4cw.org) is a searchable registry funded by the California Department of Social Services and the National Association of Public Child Welfare Administrators. CEBC evaluates programs that have strong empirical support, that are used often in California, or that are being heavily marketed in California. Evaluation is based on materials submitted by program developers.
 Programs are evaluated and rated according to the following scale (for further details, see www.cebc4cw.org/files/OverviewOfTheCEBCScientificRatingScale.pdf).
1. Well-Supported by Research Evidence
2. Supported by Research Evidence
3. Promising Research Evidence
4. Evidence Fails to Demonstrate Effect
5. Concerning Practice
NR. Not able to be Rated on the CEBC Scientific Rating Scale

 CEBC lists descriptions and findings about 286 programs, primarily for children and adolescents. Of listed programs, 26 were “non-responders” to inquiries about empirical support. Programs are rated according to stated criteria from 1 (excellent supportive evidence; 21 programs) to 5 (concerning; 0 programs, despite connections of some listed programs with adverse events), or Not Rated when supportive material is insufficient (77 programs). Seventy programs were rated “promising”.
CEBC was responsive to the present author’s query about a program, Circle of Security,  that was listed as “well-supported” although published research reports did not agree with this evaluation. CEBC took down the existing statements about Circle of Security and a representative said that further material would be requested from the program developers.

NICE
The United Kingdom National Health Service’s National Institute for Health and Care Excellence (NICE; https://nice.org.uk) provides guidance relevant to a number of UK policies and practices. For the purposes of the present paper, its important feature is an evidence search service (https://www.evidence.nhs.uk). The NICE evidence search enables users to search for information on child psychotherapies, of which 2024 are listed (although a number of these focus on pharmaceutical treatment of childhood mental illness).
NICE warns users of the uncertainties inherent in the material provided: “In relation to the NICE Evidence Search only: It is in the nature of scientific debate that not all authors will agree on all matters. Further, published papers may be in error, or superseded by later research. Users should be aware that papers accessed through the website on the same subject-matter may report different results or conclusions. It is the user's sole responsibility to assess all evidence and to reach a decision informed by it. The website is designed only to assist access to some of the material relevant to decision-making. NICE Evidence Search only facilitates access to evidence published by third parties and no representation is made as to completeness, accuracy or fitness for purpose” (“Evidence Search”, 2016). In addition, the website notes that some sources of information have been accredited by NICE, but that this accreditation or guarantee does not extend to specific information provided. Although some items on the evidence search refer to the need for randomized controlled trials, no criteria for listing information about treatments are provided.
Sources of information on the NICE evidence search include the Social Care Institute for Excellence (SCIE; www.scie-socialcareonline.org.uk), a database of social work information that is said to be updated frequently by a team of information specialists. As well as journal article summaries, sources for the evidence search include the Database of Abstracts of Reviews of Effects (DARE).
Searching NICE for the treatment Dyadic Developmental Psychotherapy (DDP; Becker-Weidman & Hughes, 2008), a therapy that has been the subject of some argument about claims to be evidence-based, yields a 2006 summary by SCIE that repeats the claim that DDP is an evidence-based treatment. Correspondence with NICE by the present author did not produce any changes in this item. However, a search on SCIE itself shows the inclusion of a series of critiques of DDP as well as the 2006 summary. This suggests that NICE is not able to keep up-to-date on information about treatments, as indeed its warning message states.
A search of adverse effects of child psychotherapies yielded no references to risks of psychotherapy but gave examples of risks of medication.

Effective Child Therapy
 Effective Child Therapy (www.effectivechildtherapy.org) is a recent registry project of the Society of Clinical Child and Adolescent Psychology (Div. 53 of the American Psychological Association). It is also supported by the Association for Behavioral and Cognitive Therapies. Effective Child Therapy lists programs as evidence-based according to rating methods used in evidence base update articles in the Journal of Clinical Child and Adolescent Psychology ( see Southam-Gerow & Prinstein, 2014.). These methods include criteria for well-established, probably effective, possibly effective, experimental, and ineffective treatments; none of these designations include consideration of adverse events. To understand the selection of programs to be evaluated and specific information used in evaluation, a reader would have to have access to the evidence base update articles that are the sources of the assessments. The site provides a listing of treatments for 19 disorders, with 82 uses of treatments evaluated (this number counts some treatments more than once, as the presentation shows the effectiveness of a treatment for a specific disorder). In 24 cases, a treatment is reported as having well-established effectiveness for a disorder; in 34 cases, a treatment is deemed probably effective; in 34 cases, a treatment is called possibly effective; in 40 cases, treatments are evaluated as experimental or with unknown support; and in 9 cases, treatments are said to be ineffective. Because the evaluative methods do not include assessments of adverse events, no treatment is described as harmful.
                                                    Discussion
Internet registries or clearinghouses are useful but not perfect in their provision of the current “best research” that should be a factor in EBP. Because there are many people who want to use these sources for a variety of purposes,  some improvements are needed. 
NREPP set an example that could well be followed by other registries when it asked for examination of the plausibility or possible mechanism assumed by developers of a treatment. This factor, now described by NREPP as a conceptual framework, is not specifically addressed by other registries.
It is notable that registries tend to omit references to adverse events or to potential harm resulting from evaluated treatments, in some cases using the same category for weakly-supported positive effects and for potential for harm. This seems to be a failure to keep up with increasing concerns about the potential harmfulness of some child mental health treatments, which have grown along with a more general awareness of the possible iatrogenic effects of both physical treatments and psychotherapies. Lilienfeld (2007) considered both adult and child interventions as they might fit into the category of potentially harmful treatments (PHTs) .Lilienfeld (2007) suggested this term, PHT,  for psychological interventions that were known to have caused or been associated with adverse events, or for treatments that might logically be expected to cause adverse events in some cases. Lilienfeld (2007) operationalized treatments as PHTs when they met three criteria: 1) demonstrated psychological or physical harm to clients or others, 2) enduring harmful effects, and 3) replicated evidence of harmful effects by independent research groups. Dimidjian and Hollon (2010) pursued these issues in a paper that discussed the concept of harm in psychotherapy and offered a distinction between treatments that are harmful and those that are simply unhelpful.  Dimidjian and Hollon noted that a treatment may worsen outcomes both for the target problem and for other domains (including the creation of new problems) , that a treatment can have both helpful and harmful effects (again, with the possible creation of new problems), that an outcome can be considered helpful or harmful in different ways when seen from different perspectives, that outcomes may be initially harmful and later beneficial or the other way around, that outcomes of a treatment may be harmful for some patients but not all, that misuse of a beneficial treatment may cause harm, and that errors about benefits and risks may cause harm by preventing the use of a beneficial treatment. Although Dimidjian and Hollon did not comment on this, it may be added that in the case of mental health interventions for children, even an “unhelpful” treatment may also cause indirect harm by wasting family resources to the detriment of other family members as well as of the treated child.  In spite of these developing concerns, however, Internet sites seem to be lessening attention to risks associated with treatments; the changing evaluative methods of NREPP are an example of this problem.
In addition to omitting attention to risks of treatments as well as to their benefits, Internet registries and clearinghouses generally fail to provide information about the cost-benefit analyses that may be important factors for choice of treatments in the present economy. Some of this information is available (Washington State Institute for Public Policy, 2016), together with assessments of the probability of benefit of a given treatment. For example, PCIT for disruptive children has been estimated to result in a benefits-minus-costs sum of $1808 and to have a probably of causing benefits of 79%; cognitive behavioral therapy models for child trauma have been estimated to have a benefit-minus-cost sum of $6550 and to have a probability of benefit of 100%; some other treatments are estimated to have costs that exceed their benefits and to have a probability of benefits as low as 4%.  For registries to include this information where possible would be helpful to users, especially those working on projects like the Parenting matters book.
Internet registries tend to depend on volunteer evaluators and/or to base evaluations on material provided by program developers. They may or may not be responsive to critiques and queries from outsiders. In some cases, such as NICE, they draw material and conclusions from other organizations which take responsibility for assessing evidence and for updating recommendations when new evidence becomes available.  Although no registry can be expected to do a perfect job or to keep up with new evidence in real time, it could be useful for registries to use volunteers primarily to search for emerging evidence and to employ trained staff to do the job of evaluating outcome research on child mental health interventions.






References
Becker-Weidman, A., & Hughes, D. (2008). Dyadic Developmental Psychotherapy: An    evidence-based treatment for children with complex trauma and disorders of attachment. Child and Family Social Work, 13(3), 329-337.
Dimidjian, S., & Hollon, S. (2010). How would we know if psychotherapy were harmful?American Psychologist, 65, 21-33.
“Evidence Search” (2016). Retrieved Sept. 3, 2016 from https://www.evidence.nhs.uk
Lilienfeld, S.O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2(1), 53-70.
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