Concerned About Unconventional Mental Health Interventions?

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

Monday, May 2, 2016

Evidence-Based Treatment: What Is It?

I’ve had a number of annoyed reader comments lately, claiming that certain mental health interventions were evidence-based, and I should stop saying that they weren’t. I’ve been in various brouhahas in professional journals, too, when authors claimed that they were writing about evidence-based treatments (EBTs), and I (and other people too) pointed out that they were not.

Why is everyone so eager to say that they are using an EBT? First, there is considerable cachet nowadays to be gained by saying you have an EBT. Many professional organizations recommend EBTs as the first choice among psychological treatments, and in the interest of accountability, many funding sources require that EBTs be used if available for the needed work.  Second, most people don’t know what the technical term “evidence-based” means, so it’s not too hard to convince them that a treatment is an EBT when it is not.

Everybody knows what “evidence” is in the everyday and the legal senses. It’s information that comes from people’s direct observations or from expert interpretations of indirect factors--  like DNA on underwear or contacts on cellphones. If I tell you what I experienced during a mental health intervention, and whether it made me feel better or not, that’s evidence. But it’s not the “evidence” in “evidence-based treatment”.

“Evidence-based treatment” is a technical term, a “term of art”, or “jargon” if you like that better. It first came into use in the 1990s, when the evidence-based medicine movement began to discuss definitions of the kind of evidence needed to give acceptable support of the effectiveness and safety of a treatment. Soon afterward, psychologists and others began to discuss the idea of levels of evidence--  that the significance of supportive information depended on how the information was gathered. An anecdote or testimonial, for instance, provides a very low level of evidence, and  treatments should not be chosen on the basis of that kind of evidence. To be called EBTs, treatments must have been supported by two independently-done randomized controlled trials; the studies must also meet other requirements such as presenting measures of intervention fidelity (showing that the treatment was done the same way each time). In cases where a treatment cannot be randomized, clinical controlled trials with many restrictions can be used. If a study just looks at people’s conditions before and after treatment, that treatment can’t be said to be an EBT. There has to be a comparison (control) that takes into account the fact that people’s conditions may change spontaneously or with maturation, and it has to be possible to tell how much change occurred that way and how much was caused by a treatment. In addition to these requirements, nowadays there is increasing pressure to include in research reports any evidence that a treatment can be associated with harm, and EBTs need to be reported in ways that allow both potential benefits and risks to be calculated.

Unfortunately, as EBTs have been seen as more and more desirable, the term “evidence-based” has been thrown around ever more loosely. Sometimes this has been done by unethical practitioners who want to increase their business success and know that interesting anecdotes or testimonials will get people’s attention and interest. But sometimes it has been done, I think almost inadvertently, by organizations that aim to provide lists of EBTs for the information of both practitioners and the public.

Such organizations present lists of treatments, but the material must in many cases be read quite carefully before it becomes clear whether a listed treatment is or is not actually to be considered an EBT. Let’s look at two of these--  the National Registry of Evidence-based Programs and Practices; NREPP, www.samhsa.gov/data/evidence-based-programs-nrepp) and the California Evidence-based Clearinghouse for Child Welfare (CEBC; www.cebc4cw.org). Each of these uses a name suggesting that programs listed there should be expected to be evidence-based.

However, NREPP includes the New Age “tapping treatment” Thought Field Therapy on its list, in spite of clear evidence that this method is ineffective. NREPP lists 205 treatments that are primarily for children and adolescents, and mentions possible adverse events for only ten of them. Until 2015, NREPP used a rating and report method that made it easy for readers to assess adverse events and design problems, and it could be calculated that when design problems were assessed, the average rating for handling confounded variables was only 2.6 out of a possible 4.0. A new rating method (which is supposed to be applied gradually to all old reports) makes these and other aspects of studies much more difficult to see.

CEBC lists very few programs that are not aimed at children and adolescents. The website rates treatments from 1 (evidence-based by the definition given earlier) to 5 (concerning methods). But it also classifies some listed treatments as “non-responders” (when proponents did not provide requested material) or as Not Rated (when the material available was not sufficient for a numerical rating). Of 286 programs for children and adolescents, 26 were non-responders and 77 of the “evidence-based” treatments listed were in fact Not Rated. Only 21 of the listed programs were rated as 1, and none whatever were rated 5 (concerning), even though the list included Corrective Attachment Therapy and a “camp” managed by Nancy Thomas--  both associated with adverse outcomes for children.

“Evidence-based treatment” mustn’t be confused with the kind of evidence that we use for decisions in everyday life. The term has a very specific and important meaning--  even more important now that funding sources and third-party payers may reject anything that does not meet the definition of EBT. Unfortunately, even websites that were intended to help the public deal with understanding EBTs are not doing their jobs well, because treatments appear on their lists when they should not. Teachers of introductory psychology classes, listen up—you can help by making this issue a point for your students to understand!  


  



Flying Monkeys, "Parental Alienation", and... No Vivid Writing Please

Craig Childress, the proponent of non-evidence-based and intrusive treatments for children who reject contact with one of their divorcing parents, has a rather remarkable newsletter going (https://drcraigchildressblog.com/2016/03/01/the-flying-monkey-newsletter/). He uses the term “flying monkeys” to designate the various people who argue against his approach and who thus stand in the way of parents who want to pre-empt child custody and prevent children from communicating with their preferred parent. This vivid term is no doubt gratifying to Childress’ clients, but the American Professional Society on the Abuse of Analogies, an august body that I just made up, is taking exception and umbrage in response to Childress’ effort to demonize psychologists and lawyers who regard high-conflict custody battles as individualized, complex, and nuanced situations.

Childress’ persuasive and inflammatory language technique  is of course hallowed among PR and advertising groups, but is not acceptable in professional circles, where avoiding fallacious reasoning is everyone’s responsibility. Although psychological events are often best communicated through some use of metaphor, it’s necessary that two entities that are compared in this way  share many characteristics, and especially characteristics that are relevant to the predicted outcome under consideration. By using the term “flying monkeys”  Childress is not appealing to a useful analogy for better understanding of high-conflict divorce, but instead suggesting to his fans that those who oppose them are doing so only from vicious inclination, without foundations in fact or logic—and indeed that they do so at the behest of a Wicked Witch, not even for their own purposes. This is regrettably an excellent way to build a base of admirers and supporters whose emotional needs are met by this kind of thinking, but it is not a way to persuade professional psychologists that Childress’ claims are correct. The only way to do that would be by offering information from research that meets current standards for evidence-based treatment.

Let’s hold our noses and examine some other statements from the newsletter linked above. How about “these allies of the narcissistic/(borderline) parent provide support for maintaining the pathology involving the psychological abuse of the child…”? The “allies”, presumably, are people like me who are aware that Childress has not made his case, and ask for acceptable evidence to be provided. The “narcissistic/(borderline) parent” is the person less excitingly referred to as the child’s preferred parent, who is now classified by fiat as emotionally disturbed or even psychotic. The “pathology” would be more accurately described as the family dynamics. The “psychological abuse of the child” is at the very worst discouragement of a relationship with one parent by the other; not admirable in some cases, but not found in Garbarino’s discussion of emotional abuse--  and in addition, it’s the exact action that Childress proposes to “cure” the child’s rejection! So, in translation to a less inflammatory tongue, what we have is this: “ people who think Childress is wrong are helpful to preferred parents who do not want to change present family  arrangements and dynamics and support the child in his or her wish not to have contact with one parent.” So, it would appear that when the statement is stripped of its connotative language, it’s actually quite true--  but the implicit scariness written into Childress’ statement is not true.

Why do we monkey-allies say what we do? Well, it’s very simple, and anyone who has become familiar with pseudoscientific claims will know what I’m about to say, because there are only two reasons anyone ever argues with psychological pseudoscience. Here are the two reasons in Childress’ terms: “They likely do so because of their own ignorance or because of trauma histories in their own background that resonate with the false trauma reenactment narrative being presented in attachment-based “parental alienation” (a process called “countertransference” in professional psychology)” So, passing lightly over the actual use of countertransference, we see that we dissenters are perhaps More to Be Pitied Than Censured. We either just haven’t studied the right stuff, or we are Sick because of our own histories that blind us to reality. This familiar form of faux counterargument is one I’ve been hearing for years from Attachment Therapy and “Nancy Thomas parenting” advocates, who are sure that if I hadn’t had a severe attachment trauma I would certainly see the force of their arguments. Whereas science has ways of responding constructively to criticism, pseudoscience is confined to the arguments Childress uses.

Just one more thing and then I quit. Smack in the middle of the page linked above, Childress places this as a link:

“New APA Position Statement: Some children are manipulated into rejecting a parent.”

This is NOT, however, a new APA position statement, however it may appear to the casual reader. It is a petition that APA make a new statement, and one agreeable to Childress & Co. APA has refused since 1996 to become involved with “parental alienation” and its various treatments. The organization does not reply to letters from persons on either sides of the PA debate. Whether that is wise or not is arguable—but it is clear that Childress’ implication that there has been a new APA statement is not only wrong but profoundly self-serving.


Sunday, May 1, 2016

Baby Looks at Toys More Than At You? Probably Not a Problem

If you’re a parent of a young child and feel scared about autism, you probably are aware of “red flags” that might warn you of an infant’s future autism diagnosis. The most popular of these has to do with gaze at faces and especially mutual gaze or “eye contact”. Young parents watch to see whether their baby looks toward their faces and gives prolonged examination to their eyes. Not only the many “red flag” lists, but advertisements (usually showing mothers and babies) suggest that long periods of shared gaze are normally frequent events in the lives of parents and infants. Some parents get the idea that these periods of gazing are not only frequent but should be present practically from birth. Others become more concerned about the role of mutual gaze in joint attention after about 9 months and expect those shared gazes to last a long time. 

‘Tain’t so, however, as I’ve commented before on this blog. What is “so”, then? To know this, we have to turn to some very careful, detailed work of microanalysis on video records of infant-adult activity.

In a recent article (De Barbaro, Johnson, Forster,and Deak, [2016]. Sensorimotor decoupling contributes to triadic attention: A longitudinal investigation of mother-infant-object interactions. Child Development, 87, 494-512), the researchers looked at babies as they developed from four months of age to 12 months. They made videos of each baby playing with his or her mother when objects were available to handle or look at. Both partners’ hand movements and gazes were recorded as they sat with interesting toys between them. Both mothers and babies could and did pick up toys and look at them, or look at them without picking them up, or pick them up and not look at them. Each could also watch what the other was doing. The very large number of recorded events were assessed by trained observers with respect to what the individual was touching and where he or she was looking. (The frame-by-frame analysis contained 610,000 behavioral events, which should show readers what it actually takes to understand developmental changes.)

As the babies got older, they spent more time touching the toys, and less time looking at them, but about the same (relatively low) amount of time both looking and touching. The mothers changed what they did as the babies got older, too--  as the babies touched more, the mothers touched less. With increasing age, the babies also increasingly “decoupled” their actions--  that is, they became more likely to look at something without touching it, or to touch it without looking at it. In addition, they became less locked into having their two hands do the same thing, and increased their tendency to do one thing with the right hand and another with the left (an important ability that lets them hold an object in one hand and poke it with the other, or, later on, tie their shoelaces).

For parents who are concerned that their four-month-olds do not make enough eye contact, I want to point to the findings of De Barbaro and her colleagues that four-month-olds actually showed more “joint attention” by looking at objects the mothers were attending to than they did when they were older. The four-month-olds spent more than 40% of their session time touching objects, and 75% looking at them, even though they  were face-to-face with their mothers and could easily have spent more time looking at faces. These authors cited an earlier study as showing that “3-to-5-mont-old infants were approximately 5 times more likely to look at objects manipulated by their parents than at their parents’ faces”.  In addition, when the babies began to spend less time looking at the toys, they did not look more at the mothers’ faces; “rather, infants increasingly looked at other features of their environment (e.g., tray, floor, and furniture)”. 

DeBarbaro and her colleagues also noted that “decoupling”—changing the tendency to link looking and touching, or to link left hand and right hand movements—“allows infants to watch their mothers’ object activity while maintaining contact with their own objects. This sets the stage for activities like taking turns using toys or attempting to imitate the mother’s actions.”

I don’t at all mean to ridicule young parents’ concerns about autism or about problems of attachment. I just want to point out that babies in their first year have a lot of developmental tasks to do in addition to social interactions and the foundations of attitudes toward the self and others. Sighted human beings use gaze in communication in very significant ways, but they use gaze for a great many other things they learn and do. As a highly visual species, we take in most of our information with our eyes. Looking at just one thing we do with our eyes as infants is a mistake, because we need to be considering all the many ways a child interacts with the world.



I also want to point out that the article by De Barbaro and her colleagues is an excellent example of what it takes to understand development at a detailed level. Rather than just doing things more and more or better and better over the first year, babies do some things more and some things less over time. As is the case for crawling and walking, they may abandon an action they do very well and take up one that is quite challenging at the time. The whole picture of development can’t be reduced to “red flags.”  

Tuesday, April 19, 2016

Time-Outs, Time-Ins: Good, Bad, and Badly Misunderstood

A brief article published a couple of years ago in Time magazine is still getting a lot of attention. This piece, written by Daniel Siegel and Tina Payne Bryson, was entitled “ ‘Time-Outs’ Are Hurting Your Child” (www.time.org/3404701/discipline-time-out-is-not-good/ ). Siegel and Bryson began with the statement that painful experiences can “change the structure of the brain”  (though they did not follow up by saying what behavioral or mood changes might result, if any). They noted that emotional pain activates the same brain areas as physical pain, commented that isolation can be emotionally painful, and concluded that children who were temporarily isolated in “time-out” may be damaged by the experience. They advised that “time-out” should give way to “time-in” to give increased experience of warm affection.

Members of the Society of Clinical Child and Adolescent Psychology, Division 53 of the American Psychological Association, have been quite concerned about the inaccuracies in these statements. In a press release headed “Outrageous claims regarding the appropriateness of Time Out have no basis in science”, members of the division pointed out the highly selective cherry-picking of neurological evidence that Siegel and Bryson made use of, and noted that there were decades of research supporting the safety and efficacy of “time out”, and little or none supporting “time in”.

The efforts of Siegel and Bryson to argue that “time outs” or harmful were characterized by a common theme among pitchers of woo--  that when the brain is “changed” by events, that the outcome is of necessity a bad one. This ignores the fact that the brain is constantly changing in structure and function because of maturational factors, and is simultaneously being changed as memories of experiences of all kinds are formed. The outcomes of these changes are generally positive, so it is absurd to present “changes in the brain” as evidence of harm. The first problem is to show that an experience (“time out”, for instance) is regularly followed by undesirable behavioral or attitudinal changes; if this had been accomplished, which it has not, the next step would be to trace the brain events that cause the connection between the experience and the bad outcome.

Like all other organisms, children change their behavior in response to reinforcing events that follow behaviors. If something nice happens after you do something, you become more likely to repeat that action. Unfortunately, sometimes behaviors that other people do not want or like get reinforced by accident. For example, most children will cut back on a behavior that gets them scolded and yelled at, but a child who gets very little attention may find that being focused on by an angry adult has reinforcing power. It’s not the yelling itself, but the attention, that reinforces the behavior. Similarly, a preschool child who acts up may find that although the teacher does not reinforce the behavior, all the other kids are excited and interested and attentive--  that reinforces the behavior and makes it more likely to be repeated.  

If children are “being bad” because an undesirable behavior has been reinforced in the past, the unwanted behavior can be reduced by making sure that it does not get reinforced.  The purpose of “time out” is to prevent reinforcement by removing the child temporarily from a potentially reinforcing situation. If done consistently, this is an effective approach--- but ONLY if the unwanted behavior has reached its present frequency because it was reinforced in some way by the social environment.

If a behavior is self-reinforcing, like eating when hungry, scratching an itch, or masturbating, unless it has also been socially reinforced, “time-out” will not affect its frequency. Neither will “time-out” reduce seizures or periods of inattentiveness due to neurological disorders, or fearful behavior stemming from previous traumatic experiences, or attention-getting behavior resulting from the absence of normal adult attention. The reason to choose a method other than “time-out” is that a specific behavior may not have developed as a result of reinforcement, and it will not diminish as a result of non-reinforcement. Under those circumstances, “time-in” and increased interaction with an adult may be helpful to a child who needs social support in order to do his or her best.

“Time-out” is not always the best choice--  but this is not because it “changes the brain” in some mysterious but threatening way.

P.S. Then there’s my two-year-old granddaughter, who when sent to “time-out” trots off looking very pleased with herself as she does just what her older brother is sent to do! Is this experiencing actually reinforcing for her? Maybe, but after all she wasn’t so very naughty to begin with…


Saturday, April 9, 2016

How Kids Enlist in the Culture Wars

Anyone who has been watching American political events this year will be aware of the reasons for the term “culture wars”. We’re not just watching groups of people who happen to agree with each other and not with their opposite numbers; we’re watching groups each bound together by beliefs and practices, and each disapproving strongly of the other’s positions. The beliefs and practices of each group are defined as cultures because they are taught and learned by members whose group shares them. The “war” part is unfortunately pretty obvious these days.

Although the United States is fortunately multicultural, there are two broad groups (each a coalition of smaller groups) that form the cultures now struggling in the political arena. The first of these is a modernist, progressive, liberal group,  consisting of the mainstream religious bodies combined with the secular humanists, whose beliefs and practices are not very different from those of the liberal churches. The second group is traditionalist, fundamentalist, and conservative. As adults, the two groups display strong differences in attitudes and preferred behaviors associated with a variety of issues. For examples of differences in the beliefs of these two groups, we can look at attitudes toward contraception and abortion, toward same-sex marriage, and toward reports of global warming.

Not surprisingly, the modernist and traditionalist groups each do their best to inculcate their beliefs and practices into children growing up in their groups. But how do they do this? When do the children begin to share the adult attitudes? Are modernist 5-year-olds and fundamentalist 5-year-olds already very different in their thinking? Or does it take years of teaching and cognitive development before differences are evident? Gilbert and Sullivan claimed that “Every boy and every gal that’s born into this world alive/ Is either a little liberAL or else a little conservaTIVE”. Were they right?

These are not easy questions to answer, but some help has been provided in a recent article (Jensen, L.E., & McKenzie, J. [2016]. The moral reasoning of U.S. evangelical and mainline Protestant children, adolescents, and adults: A cultural-developmental study. Child Development, 87[2], 446-464; N.B., if you look at this paper—I think the captions to figures 2 and 3 are reversed). Jensen and McKenzie compared moral reasoning in members of two Presbyterian groups, the modernist Presbyterian Church (USA) and the fundamentalist Presbyterian Church in America (PCA). The first is a member of the National Council of Churches, the second a member of the National Association of Evangelicals. (Although I mentioned earlier that secular humanists might share a good deal with the modernist churches, I want to point out that no secular humanists were included here, and the results of this study may not apply to them as well.) Interviews about moral judgments and reasoning were carried out with 60 members of each church, the groups divided evenly into 7-12-year-olds, 13-18-year-olds, and adults ages 36-57. For example, at one point, interviewees were asked whether they could tell about a time when they had an important experience involving a moral issue—this might be a situation where they now think their actions were morally right, or they may now seem morally wrong. 

Of course most people find it difficult to explain all the details of their moral reasoning and judgment, whether they think an action is right or whether they think it’s wrong. Jensen and McKenzie worked out some details of the interviewees’ thinking by analyzing issues and answers on three dimensions. One was the age of the participant, a piece of information that would help establish developmental change in moral reasoning. A second was whether the moral issue being discussed was a private experience (like drug use, behavior toward friends, theft, or volunteering) or had to do with public sphere (like giving money to panhandlers, divorce, or capital punishment). The third dimension had to do with the ethical perspective taken. The authors referred to the three possibilities as follows: The Ethic of Autonomy focuses on harm to the self and the interests of the self and the needs of other individuals (as unique persons, not simply as group members). These moral decisions attempt to protect the self and other individuals, and this type of moral reasoning begins in early childhood and persists into adulthood. The Ethic of Community makes moral decisions on the basis of duties toward group needs, initially the family and later schools and even broader social organizations, whose harmony is seen as important. This type of moral reasoning is minimal in early childhood and may gradually increase through adolescence and into adulthood. Finally, the Ethic of Divinity stresses the role of spiritual or religious entities, with moral decisions involving obedience to a god’s authority, natural law, or spiritual purity. The last ethic has received much less research attention than the others.

Jensen and McKenzie’s interviewees used the Ethic of Autonomy most as children and decreased this perspective somewhat through adolescence and into adulthood. The Community perspective increased for everyone from childhood into adulthood.

The great difference between the groups was in the use of the Ethic of Divinity—rare even among evangelical children, almost nonexistent among modernist children, and increasing with age through adolescence, but by far most common among fundamentalist adults thinking about public moral issues (e.g., same-sex marriage).  Mainline adults, though less likely to use the Ethic of Divinity at all, applied it more often in the private than in the public sphere. A major difference between modernist and fundamentalist adults was in the appeal to scriptural authority, with Bibles being used and on display in fundamentalist households but rarely referenced by modernists.

 Jensen and McKenzie pointed out that the two “armies” in the current culture wars are not committed to the same “moral lingua franca” and therefore find themselves unable to carry out any real discussion of their differences. This is not so much a problem in childhood, when evangelical and mainline children tend to share the Ethic of Autonomy, but looms large after adolescence, when evangelicals emphasize the Ethic of Divinity, a perspective rarely taken by modernists.


That such different moral languages are spoken by the two major  groups may be one of the reasons for the current intense emphasis on angry emotion in politics. Neither understands what the other is saying, and the discussion is regrettably reduced to mime. Can we generalize this view to an explanation of world-wide conflicts? I think that’s possible—but such thinking is only a baby step toward  resolution on any stage.  

Saturday, March 19, 2016

Adopted Children, Lying, Aggression, and Antisocial Behavior

This blog has intermittently been the scene of disagreements between me and certain adoptive parents. Our discussion usually goes something like this:

Parents: Our adopted children are terrible! They lie and steal and are even dangerous to other people. They have Reactive Attachment Disorder, that’s the problem.

Me: That’s not Reactive Attachment Disorder. Reactive Attachment Disorder is [defines RAD as in DSM-5, even in ICD-10 if feeling energetic].

Parents: Yes, they do have RAD!  How dare you say it’s not RAD! You’ve never lived with these kids, how would you know?

Me: I just said, those things you described are not the symptoms of Reactive Attachment Disorder. I didn’t say the kids didn’t do the things.

Parents: You ignorant no-good know-it-all, can’t you see that they need their attachment fixed, etc., etc.

Outside of the Attachment Therapy model, I have not seen anyone writing about RAD including antisocial behavior, or even about antisocial behavior as a problem of adopted children. However, while doing a search of the trauma literature for another purpose, I came across an article that focused on antisocial behavior as a particular problem of later-adopted children. The article proposed certain reasons for such behavior and also outlined a possible treatment, which I will describe. I must point out, though, that the article seems to have been published twice in the same journal in slightly different forms, is poorly proofread, and occasionally cites authors who have approved of holding therapy, so I don’t know exactly how seriously to take it. Nevertheless, some interesting points are made.

The article I’m referring to is: Prather, W., & Golden, J.A. (2009). A behavioral perspective of childhood trauma and attachment issues: Toward alternative treatment approaches for children with a history of abuse. International Journal of Behavioral Consultation & Therapy, 5(1), 56-74.

As you can see from the title of the journal, this paper takes a behaviorist position relative to both the causes and the treatments of undesirable behaviors of adopted children. They do not mention Reactive Attachment Disorder. Instead, they list various disturbing and undesirable antisocial behaviors like lying, sneakiness, and manipulation. Rather than proposing that these were caused by a poor attachment history, Prather and Golden discuss how these behaviors could have been rewarded, first by the child’s experiences with abusive or neglectful caregivers, and second by unintentional behaviors of foster or adoptive parents and of other children. Please note that these authors are not blaming the foster or adoptive parents, but pointing out that their natural actions toward the child may reinforce the very behaviors that they want to eliminate.

Prather and Golden point out that adopted children who behave antisocially may appear to lack “conscience”  or “attachment”, but in fact they have learned very well from their early experiences with abusive or neglectful caregivers. They have never been punished for lying or using unacceptable language—such actions may have been met with indifference or even amused approval. They may have been taught antisocial rules about hitting as a generally acceptable response, and may have been regularly teased into aggressive reactions by adults. They are likely to have learned to avoid adults in some or even most circumstances, as avoidance has led to the negative reinforcement of evading adult mistreatment. Whether or not they were attached emotionally to their caregivers may be seen as a minor problem compared to their history of learning to behave in “unattached” ways.

It is not surprising that abused or neglected children bring their learned behavior patterns with them to adoptive or foster homes. Once there, it may be a while before the new caregivers realize what undesirable behaviors are going on (and I wonder whether the time this takes is what is perceived as the “honeymoon” period of adoption). During that period, adults in the household may inadvertently reinforce the unwanted behaviors, for example, by failing to notice a lie or a theft. People outside the household are even more likely to provide accidental reinforcement, and this is related to an important issue.

The study of learned behavior has yielded some important principles about how reinforcement affects learning and behavior. The frequency of behavior is raised when the behavior is followed by reinforcement, but there is more to it than that. When the reinforcement stops, the length of time it takes for the behavior to stop depends on how and when the reinforcement used to occur. Paradoxically, when the behavior has been reinforced every time, stopping the reinforcement altogether causes the behavior to drop quickly to a low frequency—but if the behavior was reinforced only intermittently, it will persist for a long time after the reinforcement stops.

Most socially-reinforced behavior is reinforced only intermittently. The abusive and neglectful parents of the now-adopted or fostered children are very unlikely to have reinforced a behavior every time; in fact, they may have been just as likely to punish or to appear indifferent as to be amused or admiring of any action. This means that whatever behaviors were learned by the children, it will take a long time for them to be “unlearned”, especially if they are very occasionally reinforced by well-meaning adoptive or foster parents, by strangers, or by other children who are fascinated by the “bad kid”. Also, of course, some of the unwanted behaviors are self-reinforcing—the child is rewarded by getting the thing he stole or by avoiding punishment by lying.

So, what do Prather and Golden suggest as treatment for the concerning antisocial behaviors? I must emphasize that I have not found any published empirical work that they have done, but they made some suggestions that may be fruitful. Much of the focus is on “catching them being good”: encouraging the family to put less stress on “unattached” behavior and more on times when the problems are not apparent, and especially on ways that problems have been solved and parents have managed not to reinforce unwanted actions . Identifying antecedents, or triggering situations followed by unwanted behavior, can help anticipate and control how the child acts. (For example, does the child act up when the mother goes out without telling him she is going?) Acknowledging and paying attention to negative feelings is another important item, especially as the children may have become numb to their own feelings and therefore fail to experience or to anticipate a sense of guilt or fear of punishment. As Prather and Golden point out,” Unlike traditional attachment based family therapies, which often interpret verbal information in terms of underlying emotional dynamics, the rational cognitive emotive view of human behavior focuses solely on the causal sequences of a child’s experiences and perceptions, and the impact that the child’s negative thoughts concerning trauma have on the role of emotion in behavioral causation.”

Again, there does not seem to be any new evidence about how well this approach can be made to work. And those who are committed to an all-attachment, all-the-time perspective may say, “that’s just treating the symptoms!” But, to quote Nicole Hollander’s “Sylvia”, I might respond: Words to live by!

  

Tuesday, March 8, 2016

Flint and Elsewhere: What Aspects of Lead Poisoning Are Irreversible?

Far, far be it from me to imply that lead poisoning in infants and children is a minor problem, but I feel uneasy about the repeated declarations that children exposed to lead in the environment suffer “irreversible” effects. This I find especially worrisome when there is stress on mental retardation as a possible outcome of lead exposure—to say that mental abilities have been irreversibly affected when infants and toddlers are lead-exposed may in some cases be correct, but ignores the many factors that work together to determine an individual’s mental development. How awful it must be for parents of lead-exposed children to encounter these statements and know that people have essentially disposed of their children as beyond help!

 The dramatic statements about lead exposure remind me irresistibly of the “crack baby” concept of the 1990s, when headlines regularly stated that children who had been exposed to crack cocaine prenatally were hopelessly ruined. That did not turn out to be correct, and with proper care given to lead-affected children, the present claims will probably not be true either. Naturally it would have been far better if the children had not been exposed to lead to begin with, but they can be helped to develop at normal levels or close to them. This statement applies not only to the children of Flint, whose water supply was contaminated, but also to the many children in the United States who are exposed to lead in paint, dust, and so on in their own homes.
To support this statement, I am going to refer to a document produced by the Centers for Disease Control, “Managing Elevated Blood Lead Levels Among Young Children” (www.cdc.gov/nceh/lead/casemanagement/managingEBLLs.pdf).

Where children’s blood lead levels are very high, the CDC document recommends chelation therapy, a technique that chemically removes lead from the child’s body. (Please note that while this method is necessary and effective for management of heavy metals poisoning, it is most inappropriate and should never be used for treatment of autism or related problems!) The document points out that chelation should be used with caution and that primary care providers need to seek the help of experts. “A child with a [elevated blood lead level] and signs or symptoms consistent with encephalopathy should be chelated in a center capable of providing appropriate intensive care services!” (! in original; this treatment is nothing to take casually—JM). If the treatment is done with oral chelation agents with the child as an outpatient, the dosage needs to be carefully monitored, and the treatment needs to be done in a lead-free environment.

Children with elevated blood lead levels often have inadequate nutritional intakes of iron, calcium, and vitamins, and nutritional changes have been recommended as ways to prevent absorption of lead or to combat its effects. However, it is not at all clear that nutritional factors affect blood lead levels; it may simply be that children whose families live where lead exposure is likely also have families who do not have access to healthy food or information about child nutrition. Nevertheless, improving children’s early nutrition can be an important step toward good child health and development, both physical and intellectual. Low levels of protein intake and lack of iron are associated with problems of brain and mental growth, especially when they occur in the infant, toddler, and preschool years. Giving children adequate diets is a way to fight mental retardation, even if it does not actually lower blood lead levels. The CDC recommends giving pureed meat to infants as soon as they are developmentally ready, and giving red meat to children once a day. Dairy products and fruits or fruit juices several times a day are also recommended. (Minimizing fatty snack foods is also a good idea, in that it will increase children’s appetites for nutritious foods that may be of less interest when calorie-rich snacks  are available.) In order for many parents to assure good nutrition to their children, they need to have not only enrollment in WIC, but access to grocery stores that offer a variety of foods at reasonable prices.

To ensure that each child reaches the highest intellectual level he or she is capable of, high quality preschool programs are of great importance whether or not children have elevated blood lead levels, and it’s possible that such programs can make the difference between moderate retardation and fairly normal achievement for some children, if they are combined with other ways of treating lead exposure. The CDC document also suggests that developmental monitoring is needed for older children who have had elevated blood lead levels in early life. These need to continue into school age, with times of transition like first grade, fourth grade, and seventh grade getting most attention. Children who are inattentive and distractible will need help in order to have the maximum benefit from school.

To summarize, we have a number of ways to encourage good development in children who have been exposed to lead. The lead exposure may be “irreversible”, but a poor developmental outcome is not inevitable, and the worrisome trajectory present when no interventions take place can be reversed to a greater or lesser extent by help we know how to provide. What is needed, of course, is the political will and the funding to put these interventions in place. In the case of Flint, if the right decisions are made, the interventions could begin almost at once, while replacement of water pipes will take years. Similarly, when lead exposure comes from old paint, interventions can be of help now, while actually removing lead from houses can take many years—the process, indeed, can create even more dust and lead exposure than already exist. 
  
Do I hear any candidates for president talking about this? Not really…



Saturday, February 27, 2016

Apparent "Parental Alienation" and the "Chameleon Child"

 It would be silly to claim that no parent ever caused a child to be alienated from and to reject contact with the other parent. This can be done inadvertently, as when one parent is afraid of the other and an infant sees this through social referencing, or it can be done intentionally with the goal of hurting the other adult. However, it is not silly to consider that the apparent alienation of a child, with refusal to be with one parent, can have a wide variety of causes. That range of causes is not so easy to explore, and a parent who feels rejected may readily assume that any problem is of the other parent’s making.

Benjamin Garber has discussed one possible situation, in which each parent believes that the child fears and wants to avoid the other parent. He calls this pattern the “chameleon child” (Garber, B.D. [2014]. The chameleon child: Children as actors in the high conflict divorce drama. Journal of Child Custody, 11,25-40). The point of Garber’s discussion is not to blame children, but to consider that they are not simply passive recipients of parental pressure. Rather, they actively involve themselves in an uncomfortable situation and attempt to adapt themselves to the situation, and the situation to themselves. In pointing this out, Garber follows (without mentioning it) some important principles of modern developmental psychology. One of these principles is that the effects of family experiences are not just bidirectional but transactional: parents and children affect each other, and the ways in which they do this change over time. The second is that children’s own characteristics can influence the ways in which experiences affect them. This is most often discussed in terms of the ways a child’s genetic make-up and her experiences interact to change developmental outcomes, but it can also be considered with respect to the ways a child’s needs may evoke responses from caregivers, or the ways a child may actively seek to get from caregivers what he or she wants; in either of these cases, the child can also be influenced by the caregivers’ responses.  

The “chameleon child”, according to Garber, is one who tells the father how much the child likes to visit him, and what bad things the mother does. The same child does the reverse with the mother, praising her and criticizing the father. For both parents, the child cries and resists going to the one she is not presently with. Each parent is convinced that the other parent is mistreating the child and that the child hates and rejects the other one.

What is going on here? Is the child simply a wicked little creature who lies and likes to cause trouble? No--  a much simpler and more accurate statement would be that the child wants both parents and wants to have them together. The child wants both parents to love him, so he tells each one what that parent seems to be fascinated by hearing: 1. How much the child likes to be with the present parent, and 2. What bad things the other parent does. This line of conversation gets the deep interest and attention of whichever parent is hearing it at a given time. The child does not imagine that parental conflict is heightened by the stories told to each parent. On the contrary, he may imagine that the conflict is just about him, that one or both parents don’t like him so much and that’s why each is with him for only part of the time, and that if he can get them to like him more, they will reunite and both be with him all the time.

What about the parents? Are they trying to cook up some attack against each other? They may be, but chances are that they, and their attorneys, and their therapists, are all just suffering from the same confirmation bias that all of us have to fight. This means that they (and we) are ready to hear and remember information that supports a way of thinking that we already have, and ready to ignore or forget anything that confuses us by contradicting or only partially supporting our existing assumptions. For each one, the co-parent is a person who is unreliable, or unsympathetic, or sneaky, or cruel in some way--  if it were not so, they would not have separated, and that is the opinion of both the “one who left” and the “one who was left”. That such a person might mistreat a child in some way seems fairly credible, and anything that supports the idea that mistreatment has actually happened fits beautifully into confirmation of this  assumption. In addition, of course, each of the parents sees himself or herself as a protector of children, and to find that someone else treats the child badly and should be stopped is an event that confirms the bias about the self as well as about the other adult. These biases are so powerful that most parents do not investigate further or seek other information to help them decide whether a conclusion is correct—and this may be true of the attorneys and the therapists as well.

Garber recounts an anecdote that shows how confirmation bias can not only lead to the wrong conclusion, but can interfere with seeking stronger evidence about an issue. A four-year-old girl returned from a visit to her father and announced cheerfully to her mother, “Daddy showed me all about sex!”. The mother was flabbergasted, but not altogether surprised--  after all, we all know about pedophiles, don’t we? After a restraining order and much consulting and investigation, it turned out that the father had taken the girl to a museum with an entomology exhibit. He showed her all about, not sex, but insects. The child was obviously safe and happy, but the mother’s confirmation bias prevented her from asking a few questions about this “sex” business, which might have revealed that butterflies and moths were the real topic.


That child’s “chameleon” position came to be when the mother misunderstood or misinterpreted a statement that everyone would agree to be ambiguous at the very least. But a number of children provide fodder for their separated parents’ confirmation biases by adapting their behavior to what a parent seems to want to hear, praising the present parent and criticizing the absent one. Like real chameleons, the children make themselves safe and comfortable by doing what the social environment signals them to do, in ways that are no more antisocial than telling Aunt Lily you like your birthday present when you actually don’t. We want children to have these skills of social adaptation. We also want to know if anything bad does happen to them. For the best outcome, then, we need for co-parents, attorneys, and therapists to examine their own confirmation biases and seek all the factors that may determine a child’s attitudes and statements, rather than leaping to either the parental alienation or  the child abuse conclusions.