Sunday, April 12, 2015
In the Alice books, Humpty Dumpty and Alice have an argument. H.D. says that as far as he is concerned “glory” means “a nice knock-down argument”. Alice counters that you can’t make words mean just what you want, but Humpty says he can, and refers to “Saturday night when they comes around to get their wages”.
For Humpty Dumpty, it was the words that profited by getting paid for expressing a meaning other than their own. But people whose mental health interventions are not characterized by a strong sense of professional ethics can and do profit from using familiar words and giving them new meanings. This is especially likely when the familiar words reference treatments or concepts that are generally respected—the “new meanings” benefit from the respect that actually belongs to the old meanings.
As I mentioned some time ago in this blog (http://childmyths.blogspot.com/2011/05/what-is-floortime-well-folks-it-isnt.html), Ronald Federici and Heather Forbes borrowed the term “floortime” and applied it to their practice of physically restraining a child on the floor for supposed therapeutic reasons. As some parents and mental health professionals already know, Floortime™ has a specific meaning and indeed has been trademarked by its originators. Floortime™ is a method used by practitioners trained in DIR™ (Developmental, Individual-difference, Relationship-based treatment). Practitioners who use Floortime™ do play and interact with children on the floor, but their methods involve following the child’s lead and encouraging verbal and nonverbal communication through play. Really, no two things could be much farther apart in meaning than the respectful, empathic, interactive methods used by DIR™ professionals and the intrusive, authoritarian, coercive techniques used by Federici and his few followers. What was the point of calling the coercive methods “floortime” when this word had already been used for many years by DIR™ practitioners? Was it simply ignorance, or was it an attempt to get under the more popular umbrella of DIR™ by adopting what was essentially a stolen word? Profit, or just fun? I can’t explain it myself, but it worries me greatly to see meanings muddled in a way that advantages the muddlers.
More recently, I came across the theft of the term “tummy time”. Now, this is an expression that has been well-known to millions of parents over the last ten years, the period when infants in the U.S. have been supposed to be put to sleep in the supine position, and when developmentalists had figured out that supine-sleeping babies were not achieving motor milestones as the old standards said they should. Tummy time, a period of prone positioning for play or at least non-sleep activities, was advised as a daily experience that would foster motor development. A large number of young parents during this period have not done tummy time, because the babies don’t like it right away, but this is not the point; they have heard about tummy time and how you are supposed to do it to encourage your baby’s development.
But-- along come some other people and steal “tummy time” for their own meaning and purposes. I encountered this first in reading about the case of Kali Miller (http://obpe.alcsoftware.com/files/miller.debra%20(kali)%20a.f._559.pdf), the Oregon psychologist whose professional license was revoked because her recommendation of Nancy Thomas parenting methods was followed by the suicide attempt of a 12-year-old boy who was the target of the intervention. Miller apparently used the term “tummy time” to mean having the child crawl on hands and knees—an activity inappropriate for a 12-year-old, and without the slightest known developmental benefit for anyone whose motor development had been typical until that age.
Searching for other uses of the stolen phrase, I came across this: www.bestpractices4teaching.blogspot.com/2013/03/tummy-time-for-10-year-olds.html. This blogger states,”[I] sometimes wonder if ‘tummy time’ would work for a 10 year old”. She then refers to an article given to her by her (or, her children’s?) occupational therapist-- https://mysweetchaos.wordpress.com/2010/01/24/neurodevelopmental-reorganization/. Here we find a mother of children she speaks of as “RADishes” (I haven’t come across that one for a while). And mysweetchaos provides a post jam-packed with misinformation-- not only misinformation, but misinformation with a strong tang of Attachment Therapy beliefs about it.
I hardly know where to begin here. Mysweetchaos has provided what Barbara Pym would have called “such richness”. Starting at the top: “When a baby is on their tummy and they turn their heads from left to right to left to right and so on, this is developing their brain for reading. READING! [caps sic] When a baby moves their head up and down, they are developing their brain for math. MATH! Makes sense when we read left to right and solve equations top to bottom.” What to say about this farrago of nonsense? (I always think a farrago should be a kind of porridge, but that would work here too.) Let’s start with the simple fact that a large part of the world’s population does not read left to right. As Lerner and Loewe wrote, “the Hebrews speak it backward, which is positively frightening”, though perhaps not as frightening as mysweetchaos’s assumption that she knows what she’s talking about. Then, let’s look at the idea that “equations” go from top to bottom. Yes, children are taught to do arithmetic in columns, because that enables them to line up ones, tens, hundreds, etc. in ways that would be more difficult if the numbers were placed horizontally. But the equation, the actual arrangement that takes into account the principle of equality, can be horizontal, vertical, or diagonal. What’s more, if anyone understands equality, they know that it does not make the slightest difference whether you start on the left or on the right.
Skipping a bit, let’s go down to where mysweetchaos’s source tells her that many familiar problems (cf. “attachment disorder” checklists), like lack of empathy, overeating, poor appetite, and picking at scabs and other people, being superficially charming, etc., are due to “pons dysfunction”. The pons is a part of the brainstem that has multiple functions, including carrying messages from higher to lower areas and contributing to sleep, breathing, and bladder control. According to mysweetchaos, the developing functions of the pons have to be guided by appropriate movement experiences, and if they were not guided, they will not develop. However, re-enacting those experiences, including crawling, patterning (honest, she says this), and vestibular movements (there are some movements caused by vestibular stimulation, but I don’t know exactly what she means) can recapitulate development and rebuild the pons. Ergo, children will develop empathy and stop being superficially charming if made to crawl around, and this is a part of “tummy time” (presumably, as recommended by pediatricians all over the U.S.). Of course, this whole discussion omits to mention children who never crawled because of paralysis or atrophied limbs, but are well-developed intellectually and emotionally, and children of previous generations who slept prone and did plenty of crawling, but who still had some cases of lack of empathy and superficial charm.
Where did mysweetchaos get all this stuff? Yes, I’m sorry to say, it appears that we have to look to her occupational therapist as her source. I don’t want to attack the whole OT profession, because I appreciate very much the ways they do things like check out people to see whether they’re competent to drive, and teach premature babies to nipple-feed. But I am tired of waiting for some OT to get up on her (usually) hind legs and state that Sensory Integration theory has never been supported by systematic evidence, or that recapitulation of development by re-enactment of early experiences is simply primitive magical thinking. I think it’s probably true that the person who connected the pons with superficial charm was probably a rogue practitioner—although not the only one around. Nevertheless, ideas apparently supported by the whole OT profession are behind these extravagant claims and the continuing commitment to patterning three decades after it was summarily rejected by physicians and psychologists.
And to call these methods “tummy time”, using the familiar words as if pediatricians recommended making older kids crawl! Is this for fun or profit? Is it ignorance, or just the old human urge to benefit from others’ ignorance? I don’t know, but I for one find it “positively frightening.”
Wednesday, April 1, 2015
Let me note first that the trepidation I’m talking about is my own, as Kali Miller does not seem to experience any. And my trepidation is about two things-- first, whether by discussing this at all I’m simply offering some unintentional paid advertisement for a disturbing attempt at intervention, and second, how well I can untangle the ideas so well braided in a document that mingles established concepts with fantasy.
The document I’m referring to is called “Taming Tiny Tigers”, by Debra “Kali” Miller, whose psychology license revocation I described in a post a few days ago. As I noted at that time, Miller is becoming a parenting coach now that her license has been revoked for her role in the treatment that culminated in a 12-year-old’s suicide attempt. As a coach, she will still be in a position to use the advice she has given in “Taming Tiny Tigers” (http://c.ymcdn.com/sites/opa.site-ym.com/resource/resmgr/imported/E1%20Handout.pdf).
“Taming Tiny Tigers” is an excellent example of the Trojan Horse approach that brings unsubstantiated ideas into discussion under the cover of established information. For example, Miller provides some accurate (though not particularly relevant) material about brain development. She also quotes directly the diagnostic criteria for Reactive Attachment Disorder from DSM-IV; these have changed, of course, but what she uses was correct at the time “Taming Tiny Tigers” was written. She references the much-respected Dante Cicchetti in the documents bibliography. She also points out that physical and emotional abuse are not good for kids. All good stuff, right? She must know a lot about early emotional development and later mental illness-- or so you would think until you see what else is in there.
Now let’s look at what’s inside this handsome Trojan Horse (we’ll see that much of it is similar to something that’s inside real horses). I’ll just begin at the beginning and go on until I can’t stand it any more.
The first problem that comes into view is on pp. 3-4: the good old first- and second-year bonding cycles. Once again, I will point out that these have no parallel in conventional, evidence-based views of the development of attachment. Naturally, if a baby is not fed or cared for regularly, both physical and mental development will suffer, but attachment develops as a result of pleasant social interactions with a caregiver, not because that caregiver feeds the baby. In real life, of course, chances will be great that a lot of pleasant interaction is mingled with feeding and other care routines, but it’s the interaction and not the care that brings about attachment (which, by the way, is a very robust phenomenon, and does not often fail to happen if a few adults regularly care for a baby). The “second-year attachment cycle” focuses on rage and capitulation as contributing to some unstated aspect of attachment, whereas established information focuses on sensitive, responsive parenting that helps the child tolerate the inevitable frustrations of this period of development. A large but unstated difference between the “attachment cycle” approach and conventional thinking about early emotional development is that the “cyclists” equate toddler attachment with obedience and compliance, whereas conventional thinking focuses on attachment as a function that helps young children explore and learn. I’ve gone into some detail about this at http://thestudyofnonsense.blogspot.com/2012/08/parsing-attachment-cycle-fox-terrier-of.html.
Let’s move on to p. 7 of “Taming Tiny Tigers”, where we’re given symptoms that are supposed to let us know that a child has Reactive Attachment Disorder by looking at events that may occur before six months of age. Here we have an interesting hint that what is being talked about here is not attachment in the conventional sense at all, but something else (undefined). It is quite remarkable to claim that a child’s recognition or nonrecognition of the mother in the first six months tells something about Reactive Attachment Disorder, as attachment is not indicated behaviorally until after that age. Be that as it may, the symptoms Miller lists are serious problems indeed, including withdrawal, difficulty with touch, poor muscle tone, delayed motor development, and decreased vocalization. Any baby showing these symptoms does need early intervention for both physical and cognitive problems, there is no question about that . However, what they do NOT need is treatment for Reactive Attachment Disorder, especially the types of treatment Miller recommends later in the document. To tell parents of developmentally delayed toddlers or preschoolers that these early symptoms showed that they had Reactive Attachment Disorder all along is in my opinion little, if at all, short of criminal.
Slogging onward, we come to pp. 11-13. Having listed the DSM-IV criteria for diagnosis of Reactive Attachment Disorder, Miller now turns right around and introduces the infamous checklists of Walter Buenning and Gregory Keck. These completely unvalidated lists include such items as poor eye contact, wanting to hold own bottle, and preferring Dad to Mom as indicating Reactive Attachment Disorder in infants and toddlers, and for older children list the usual Attachment Therapy-related group, such as being superficially charming, not making eye contact on parental terms, “crazy lying”, and abnormal speech patterns. These lists contain a number of items like lack of impulse control that are indeed of concern, but are not aspects of attachment problems and are not likely to be treatable by the interventions Miller offers.
What are the interventions Miller recommends? On p. 15, she suggests “brain building activities” as suggested by Bruce Perry, and of course by Nancy Thomas. In typical Nancy Thomas fashion, the list of these activities is headed by the injunction that they must be led by the adult, not the child; this injunction reflects the belief that displays of parental authority create attachment, and that a child’s obedience shows that he is attached to an adult. The activities include many that would ordinarily probably be fun for children, ping-pong, playing catch, and jumping on a trampoline. However, when these are to be done as recommended, five or six times each day, for ten minutes at a time, at the command of an adult caregiver, the “fun” aspects seem to be a good deal lessened.
To continue with the recommendations for intervention, we see on p. 14 of “Taming Tiny Tigers” a page that is startling in its simplicity. Without elaboration, and under the heading of “Therapeutic Continuum”, this page shows a line with the words “non-directive play therapy” at the left and “holding therapy” at the right. What can Miller mean? What is she recommending? She doesn’t come right out and tell, but a look at the bibliography shows publications by the heavy-duty masters of the intrusive and potentially dangerous holding therapy, Foster Cline and Martha Welch, and by Ronald Federici, who advises restraining adopted children in the dangerous prone position. And of course, it shows many publications by Nancy Thomas, the woman who recommends that foster children not be permitted to say grace at meals, “because you don’t know who they might be praying to.”
All in all, “Taming Tiny Tigers” is a pretty disconcerting package, but Miller doesn’t have to conform to any rules to be a parenting coach. What’s more, the First Amendment permits her to pass out all this disinformation. Fortunately, it also permits me and others to have our say about Miller and her “Tigers”.
Monday, March 30, 2015
Every state in the U.S. has a professional licensing board that can grant licenses to clinical psychologists, and can revoke or limit those licenses under certain circumstances. If you Google your own state’s licensing board, you will probably see that dozens of licensees have been disciplined during the last year. The online information given will state whether a license has been revoked, whether corrective action has been required (like further study of ethical issues), or whether supervision of the person’s work by another psychologist is needed. In most of the cases you’ll see, the problem has to do with personal relationships with clients, with financial or billing problems, with drug or alcohol use, or with criminal conduct.
Only rarely are licensees disciplined because of harm done to clients as a result of incorrect diagnosis or choice of treatment, even when children or other vulnerable persons are in question. In this post, I will describe the events surrounding the revocation of a license in one such case, that of the Oregon child clinical psychologist Debra “Kali” Miller. I’ll also point out that, far from being impressed by the revocation, Miller is starting a new career as a parent coach—such people are not licensed, so she needn’t fear another loss. How do I know she’s not impressed? It’s that she is doing this coaching in association with Nancy Thomas, the self-styled foster parenting expert, and the very person whose methods led to the license revocation.
A lengthy document (http://obpe.alcsoftware.com/files/miller.debra%20(kali)%20a.f._559.pdf
-- kindly forwarded to me by Linda Rosa) describes the investigation of Miller’s actions by the Oregon Board of Psychologist Examiners, including an Order of Emergency Suspension of her license in March, 2014, and a final order for revocation in September, 2014. Miller appealed these findings, which were recently (March, 2015) upheld by two administrative law judges.
What events culminated in the license revocation? Because psychotherapy for children is confidential and known only to the therapist, the parents, and the children (who are in no position to complain), only the occurrence of real harm to a child is likely to bring treatment methods to the attention of a professional licensing board. In Miller’s case, the precipitating event was the arrival of a twelve-year-old boy (“Client A”) at an Oregon hospital following an attempt to kill himself by strangulation. At the hospital, the boy disclosed that as a result of Miller’s recommendations for treatment, and her diagnosis of Reactive Attachment Disorder, he had received distressing treatment: “Client A reported that his father and step-mother required him to engage in routines that were causing distress, to include being directed to sit in his father’s lap for directed feeding of milk from a baby bottle while maintain eye contact with his father, to crawl on the floor for 20 minutes a day, to urinate into a jar in his room, to be confined to his room for extended time periods with his bedroom door set up with an alarm, and being directed to address his step mother using the term ‘Queen’ before her first name.” Client A’s father said that their therapist had told them to use certain treatments, “having Client A drink from a baby bottle while being held in his lap, having Client A engage in physical exercises to include crawling on the floor and doing jumping jacks, and directing Client A to in a specified way for time out (‘strong sit’).” In addition, investigation revealed, Client A was examined and recommendations for his treatment were made by unlicensed persons, and he was supervised by unlicensed persons as “respite” for various periods of time.
Client A was diagnosed at the hospital as suffering from depression and was placed in foster care.
Readers of material about Attachment Therapy will recognize in Miller’s diagnosis and recommendations a strong resemblance to ideas and methods promulgated by Nancy Thomas; other material (www.advancedparenting4kids.com ) shows that Miller had been for many years a volunteer worker at Thomas’s “camps” that are intended to cause attachment between children and their adoptive parents. These methods are based on two beliefs, neither one supported by evidence. The first of these is the claim that emotional attachment is brought about by a cycle of recurring infant needs and their gratification by caregivers. The second belief is that a failed step in early development can be created by imitation or reenactment of the needed early experiences. In addition to accepting Thomas’s basic beliefs, Miller also was committed to the idea that Reactive Attachment Disorder, rather than being characterized by the symptoms described in DSM, was a matter of frighteningly violent and angry behaviors, shown initially in disobedience and lack of affection toward adult caregivers. These beliefs of Thomas’s are exactly what led to APA cancelling continuing professional education credits for a presentation by Thomas that had been scheduled to earn CEUs.
The Board of Psychologist Examiners found that Miller had violated a series of ethical standards that licensees must comply with:
- Immoral or unprofessional conduct or gross negligence in the practice of psychology
- Practicing outside the boundaries of her competence (“Licensee relies upon her own methodology and unreliable sources in assessing whether a child has a diagnosis of reactive attachment disorder and then recommends treatment that poses the risk of harm to the child”)
- Failing to use appropriate bases for scientific and professional judgment (“Licensee uses a methodology in diagnosing and treating reactive attachment disorder [RAD] that is not based upon established scientific and professional knowledge in the profession”)
- Failing to avoid harm (“Licensee … made specific recommendations… that focus on establishing parental power over the child through psychological aggression and physically challenging demands, which when implemented exposed the child to the risk of harm”)
- Failing to use an appropriate basis for assessments (“Licensee diagnosed Client A with RAD without substantiating the diagnosis with clinical findings in the chart to support her conclusions and recommendations for treatment”)
- Failing to obtain informed consent to therapy (“Licensee failed to inform Client A’s father that her methodology in diagnosing RAD and her recommended forms of treatment do not conform to recognized diagnostic criteria or practice recommendations…”)
It was as a result of these violations of ethical standards that Miller’s license was revoked. I congratulate the Oregon Board of Psychologist Examiners for their meticulous work in this investigation and their courage in declaring Miller’s methods improper.
But is the small fact of a revoked license stopping Miller? Not really-- as we see at www.advancedparenting4kids.com/oregon-trainers/kali-miller/ . The license revocation is not mentioned. Instead, Miller is said on this Nancy Thomas-related website to have “transitioned from clinical practice and [to be] bringing her heart for healing to parent coaching and providing consultation for other therapists”—activities that remain under the professional radar and without the restrictions of licensure for meeting ethical standards”. We won’t be finished with regulating potentially harmful child therapies until licensure for coaches and others is required; even then, of course, quacks will find a way to cheat.
I plan in a few days to add to this discussion by a look at Miller’s parent-education material called “Taming Tiny Tigers”.
Sunday, March 29, 2015
Some days ago I received an e-mail from one, Justin Taylor, representing Sundance Canyon Academy, a residential treatment facility in Utah that appears to treat teenagers who are said to have Reactive Attachment Disorder. Justin said that since I had been trying to educate people about this disorder, I would like to embed in this blog the Sundance infographic describing Reactive Attachment Disorder. This suggestion led me to have a look at said graphic, and I was most interested to see the amount of mis- or dis-information that could be crammed into a few pictures. You can see it too, at http://www.sundancecanyonacademy.com/reactive-attachment-disorder-infographic/. (But I'm finding that I sometimes get an error message for this; if you go to the home page and scroll all the way down, you'll see a link to this thing.)
Let’s look at this display under the usual strong light. First, in an introductory passage plagued with writing difficulties, Sundance states that “Reactive attachment disorder is a serious condition that some children and teens must live with”. This claim ignores the fact that RAD is not a diagnosis used for children of school age or older, and no diagnostic method exists for assessing such a problem after the preschool period. In addition, Sundance seems to be uncertain about whether any treatment would be helpful, otherwise why say that the children “must live with” the problem?
To continue looking at the introduction and the infographic: it’s notable that Sundance seems to have ignored the publication of DSM-5 and the change in terminology that limits the term Reactive Attachment Disorder to what used to be called the “inhibited” type, a developmentally-inappropriate emotionally-withdrawn behavior combined with irritability, sadness, and fearfulness even during nonthreatening interactions with caregivers. What used to be called the “disinhibited” type is now categorized as disinihibited social engagement disorder (DSED), and this involves a lack of preference for unfamiliar people (note that some lack of preference for familiar adult caregivers would be quite developmentally appropriate for adolescents). Sundance still references the two types, disinhibited and inhibited. Be that as it may, they provide an interesting, though somewhat notional, list of symptoms for each, apparently having read a bit of DSM-IV and a bit of DSM-5-- though not very carefully.
Here’s what Sundance says about the disinhibited type of RAD (now known as DSED): the symptoms are “being highly selective” (?), “readily interacting with strangers, rather than showing natural strangers anxiety” (copy editor to the rescue, please!), “seeking unnatural comfort from strangers” (whoa!), “exaggerating the need for help doing basic daily tasks”, “taking part in inappropriately childish behavior”, and “appearing overly anxious”. Nowhere does the infographic clarify how children of different ages might show such “symptoms” in different ways, or deal with the issue of developmentally appropriate practice and diagnosis. The “highly selective” part is a mystery to me, and certainly does not come from any edition of DSM. Ready interaction with strangers is something I would expect from any well-developed teenager, and woe betide the poor child who is sent to any residential treatment facility if he or she does not have that capacity. “Unnatural comfort”-- well, I’m sure that doesn’t mean what it might be taken to mean, but the use of the terms “natural” and “unnatural” is without meaning except as a way to scare parents. As for needing help in basic daily tasks, this “symptom” comes straight from Attachment Therapy, where it’s regarded as a way in which disturbed children manipulate and exploit credulous adults; it’s not in the DSM description. “Inappropriately childish behavior” depends on how old a particular child is, as well as on the possibilities the environment presents. Finally we have “appears overly anxious”, but wait, hasn’t the person been declared to lack “strangers anxiety” and to approach strangers, normally a source of serious anxiety for young children? Apparently the children are simultaneously anxious and not anxious (but from the Attachment Therapy viewpoint, that only shows how cunning they are).
All right, if you’re not too depressed already, let’s have a look at the statements about symptoms of the inhibited disorder (now the only type called RAD). Here we have “avoiding eye contact” (oops, is there some confusion with autism spectrum disorders?), “unresponsive or resistant to comforting”, “steer clear of physical contact” (never mentioned in DSM), “excessively holding back emotion”, “preferring to play alone”, and “detaching from others”. The DSM description considers children with this inhibited disorder as inhibited and emotionally withdrawn, with negative emotional response to interactions with others. Although eye contact might be interpreted as an emotional interaction, it is not a very useful measure because it is characteristic of other disorders and can occur because of cultural restrictions on children’s looking directly at adults.
Sundance’s infographic goes on to inform parents that children of all ages may have Reactive Attachment Disorder (their definition) if they do the following: “cruelty to animals for no reason” (perhaps there are some good reasons Sundance could suggest?), “watching others closely, but not engaging in social interaction” (school, perhaps?), “destructive to self and others”, “impulsive negative behaviors”, and “abnormal eating patterns”. Some of these, of course are matters of extreme concern, and although they may occur in typical children in the toddler and preschool period, in older children and teens they would be evidence of a serious need for treatment. However, except for a tendency to hypervigilance, they are not mentioned in DSM in descriptions of either RAD or DSED.
As you can see, Sundance Canyon Academy either does not have a very good understanding of these disorders, or may see some benefit in offering confused material to parents. Certainly some parents who have been reading about Attachment Therapy on the Internet will find some of these ideas familiar and therefore acceptable.
It’s quite a labyrinthine process to find out what treatments are used at Sundance Canyon Academy, and what their basis in empirical evidence might be. They use a method described at www.whytry.org, whose website offers claims at evidentiary support, none of which appear to have been published in peer-reviewed journals, and most of which seem to be simple before and after studies. There are some other issues, too, but this post is getting too long already.
One more point of interest: a major figure at Sundance is described as having been the owner and operator of Odyssey Youth Transport, an organization that comes into the home at night to waken sleeping teenagers and to take them away to residential treatment facilities. How this outfit worked when owned by the Sundance staff member, I have no idea. However, at present its website (www.odysseytransport.com) includes a parent handbook that speaks of transport workers as Guides and inquires whether the child knows that the Guides are coming and whether he or she has alternative or favorite routes out of the house. Parents are told that after they converse with the Guides on their arrival at the house, they are to awaken the son or daughter in his or her bedroom and introduce the Guides. They provide a letter to the child telling what is happening. They are then to leave the house and asked “Please do not return to the residence until the Guides contact you, or until the rental car has left the premises.” As I said before, I have no way of knowing whether this draconian approach was taken when the Sundance staff member owned Odyssey, but the possibility is an eyebrow-raiser.
In a second e-mail, Justin Taylor asked whether I could point out changes needed on the Sundance website. I think I’ve done so. Now let’s see whether they alter their infographic.
Thursday, March 19, 2015
There’s no question that psychological as well as physiological trauma is very real and can have long-term ill effects. Infants and young children are not “too young to remember”, but can be harmed not only by their own experiences but by what they see happen to others. A trauma-informed approach is essential for understanding that children’s “naughty” behavior-- like roaming around in the night instead of staying in bed—can be the effects of earlier traumatic experiences and won’t be corrected by punishment.
There’s a big push on recently to make sure that caregivers are aware of the effects of trauma, especially in foster and adopted children. But as often happens, there seems to have been a good deal of “criterion creep” so that definitions of trauma and its effects have expanded dramatically. The same thing happened some years ago with ideas about attachment problems, and in fact it’s often those who used to focus on attachment as the cause of all difficulties, who now point to trauma as the great problem. (Or they may even link the two, as in the “Attachment and Trauma Network”.)
But, in spite of the ill effects trauma can have, it is not all about trauma. Claims that trauma is behind all kinds of behavioral and maturational difficulties should be regarded with suspicion and examined under a strong light.
Jessica Pegis and Lisa Sainsbury have passed on to me information about a Toronto organization, the Gap Academy (www.gapacademy.ca), which seems to have its major focus on children with learning disabilities or attention deficit disorders. However, their website also references Reactive Attachment Disorder and something they call “adoptee trauma” or “abandonment trauma” (www.gapacademy.ca/adopteetrauma.html. All three of these diagnoses are discussed on the same page and appear to be equated with each other, although the site notes that the term Reactive Attachment Disorder will not be used. (It’s not quite clear why this should be, as RAD is an agreed-upon diagnosis with “official” criteria, and the others are not-- or could that be the reason for their decision, which muddies the waters a good deal?) The site seems to connect all three categories with learning difficulties.
Having declared by fiat that Reactive Attachment Disorder is a matter of response to trauma, the Gap Academy site goes on to describe what that trauma must have been. The DSM description of RAD includes experiences of neglect and abuse, and the latter certainly can be associated with trauma, but these possible traumatic experiences are not sufficient for the argument that’s brought, and additional traumatic possibilities need to be introduced. According to the site, “Many psychologists now believe that the separation of an infant from its mother leads to immediate and permanent trauma.” Now, strangely enough, although I am a member of Division 37 of the American Psychological Association (child maltreatment section) and of the World Association for Infant Mental Health, I have never met any of those many psychologists or read any of their work in any peer-reviewed publications. Who may they be? Ah, here we have it: “One doesn’t have to go much farther than Thomas Verny’s The secret life of the unborn child or… Neilson’s A child is born to clearly identify the primal connection. Psychologists and psychiatrists dealing with patients who exhibit the RAD set of symptoms have long ago identified a group of trauma related effects.” Later on the page, we see a link to a paper by Nancy Verrier, a marriage and family therapist (not a psychologist) and author of The primal wound, in which she argues that a child’s emotional attachment to its mother occurs prenatally, and separation from the birthmother leads to intense, traumatic grief and rage, even if it takes place immediately after birth.
In a few easy jumps, we seem to have gone from the existence of a diagnosis called Reactive Attachment Disorder, to the role of traumatic experiences in creating that disorder, to the idea that there are many more traumas at work than have ever been discussed before, and that these have may already have occurred shortly after birth. In other words, all adopted children have by definition been traumatized, and the effects of the trauma may be with them permanently, causing all kinds of problems, including (to return to the original focus of the Gap Academy) learning disabilities.
Why do I think this is probably not so? I have two kinds of reasons. First, there is what is well-known about early development; second, there are the sources of the ideas of Verny and Verrier.
Let’s look at what is known about early development. The first point is that babies in the first few months do not show distress when their care is transferred from one adult to another. They don’t show fear of any of the things that scare older babies, either. They are capable of expressing distress and do so frequently, when hungry or when getting medical treatment, but they don’t seem concerned about separation from familiar people. By about 8 to 12 months, however, they show fear-- of falling, of loud noises, of people moving suddenly, but most of all of the approach of strangers and the movement away of familiar caregivers. This is the point at which we say that attachment has occurred; attachment is above all a way of finding comfort where there are threats to well-being.
So, why do I say that if a 2-month-old baby does not display fear or distress at separation, he or she is not feeling such feelings? Obviously I can’t know what is happening inside the baby, I have nothing to go on except the behavior that lets me infer what may be inside. Verrier and other advocates of her Primal Wound ideas believe that they can know what the baby’s emotions are in spite of having no behavioral cues to support their guesses. There is no point arguing about this, because to do so would be to engage in the unwinnable battle between those who look for evidence to support their contentions, and those who “just know”.
This leads us to the second issue I mentioned. Given that research evidence does not support the belief that newborns are traumatized by separation from the birthmother, where did this idea come from? It dates back to some ideas suggested by a British theologian/psychologist, Francis Mott, who claimed among other things that prenatal development involved the pattern of a universal sexuality, including an erotic experience involving the connection of the umbilical cord with the placenta. His later colleague, Frank Lake, “confirmed” Mott’s views of the conscious and emotionally complex life of embryo and fetus by LSD experiments in which people reported what their prenatal experiences had been. Arthur Janov, the “primal scream” man, followed these two, and all of them provided the foundations for the Association for Pre- and Perinatal Psychology and Health, the organization that continues to advocate for Verny, Verrier, etc., etc. To my way of thinking, these beliefs do not provide evidence that unborn babies have emotional or learning experiences that are similar to those of older children or adults. LSD experiences, whatever they may be like, don’t show that newborn babies are traumatized by separation from their birthmothers.
One more issue I want to deal with here: what does the Gap Academy (which apparently employs three staff members) do to treat “adoption trauma”? First, they describe the symptoms they expect to find: “defiant behaviors, disconnectedness, stranger familiarity, lack of understanding of basic trust and familial responsibility, aggression, severe withdrawal, poor self-esteem, enuresis, inattention, and so on”. Except for stranger familiarity in preschoolers, none of these are symptoms or Reactive Attachment Disorder, so it’s clear that the Gap staff are on different ground here-- ground that they share with Attachment Therapists and their posited “attachment disorder”. What do they do about these symptoms? Like Attachment Therapists, they deny that any conventional treatment like behavior modification can be of help. They state, “We have found that treating these kids in a behavioural way…causes further deterioration”; considering that the three staff members could not have had many cases to “find”, one can only guess that they adopted this claim from one of many Attachment Therapy sites. They also say: “we use a collection of methods designed to break down their rejection-oriented impulses… We also believe in teaching the student directly about their problem, which in this case, translates into the teaching of a mini-course on the effects of trauma.” In other words, the treatment consists in part of pressing the children to accept the staff’s implausible view of the cause of their troubles, and indeed teaching them to expect themselves to be psychologically handicapped by past events that may in fact have had no developmental impact whatsoever.
When an organization claims to be trauma-informed, or to teach other people to be so, it’s very important to find out what they mean by trauma. Public funds should not be paying for the sowing of confusion and for potentially harmful interventions.
Wednesday, March 18, 2015
Unless you read only the New York Times (which hasn’t mentioned a word of this), you are probably aware of the Arkansas case of Justin Harris, a state legislator, and his wife, who adopted two little girls, exorcised them, treated them with harsh “parenting” methods, and passed them along privately to another family, where one was sexually abused. The most recent discussion of this case and its background is at www.arktimes.com/arkansas/harris-therapy-controversial/Content?oid=3755237). Before writing this article, Leslie Peacock, an Arkansas Times editor, talked at length to me and to Jean Crume, a DHS social worker, as well as doing a great deal of reading and considering the testimony of the babysitter who took care of the little girls for a period while they lived with the Harrises.
When Leslie and I started our discussion, one of the first issues that came up was what some terms meant. If the Harrises were using “attachment therapy” with the girls—a method that Jean Crume says she sometimes uses—exactly what did that amount to? We looked back at the 2006 APSAC-APA Division 37 Task Force Report, and saw that in 2006 the authors had stated, “The terms attachment disorder, attachment problems, and attachment therapy, although increasingly used, have no clear, specific, or consensus definitions.” This continues to be true a decade later, and in my opinion this is the reason why conventional treatments focusing on parent-child relationships are usually called “attachment-focused” or “attachment-based” therapies, or words to that effect, rather than “attachment therapies”. For myself, I would define “attachment therapy” as a form of intervention derived from the older Holding Therapy, and popularized at the time in the early 2000s when the dangers of Holding Therapy were being publicized. I would add to this that “attachment therapy” is based on a conflation of child attachment with child obedience and compliance, and on the belief that re-enactment of posited infant experiences in later life causes a child to become emotionally attached to an adult caregiver.
I don’t know whether these would be Jean Crume’s definitions of the “attachment therapy” that she considers suitable in some cases. I do know, though, that as the Arkansas Times pursues its proposed investigation of DHS, terms must not be allowed to go undefined. “Attachment therapy” is an especially problematic term, because for many readers, “attachment” sounds good, and “therapy” must be good, so “attachment therapy” is definitely more than acceptable—even though some practices associated with that label would probably be rejected if they were called “isolation treatment” or “no-toys intervention”. The investigation of DHS must clarify this point.
But of course “attachment therapy” is not the only problem word. Jean Crume is quoted as calling Nancy Thomas methods “controversial”. What do people mean or understand to be meant when they use this word? My big old Webster’s says it means “debatable”, which seems not to be much of a description, as most things more complicated than the time of day are open to debate. It seems to me, however, that in fact the principles and practices of “attachment therapy”, including the “parenting” techniques, are not at all debatable. On the contrary, there are a large number of psychologists and other mental health professionals who would regard those beliefs and practices as totally wrong and unacceptable. Opposed to those thinkers are a small number of persons with various backgrounds who claim not only that “attachment therapy” is effective, but that conventional methods exacerbate children’s problems, and that even the most basic conventional ideas about attachment are incorrect. There is no debate here. These ideas are mutually exclusive. If the conventional attachment theory and treatment methods are right, “attachment therapy” approaches cannot be right, and vice-versa—if “attachment therapy” views are correct, 75 years of research on attachment must be overturned and forgotten. Where is the controversy? Could it be that Jean Crume and others really mean, “A lot if people don’t like these ideas, but I think they’re all right, and there’s no law against the practices unless somebody really gets hurt”? If that is not what they mean by “controversial”, I can’t guess what they might mean. But I think it would be essential for any investigation to be sure what is intended.
Toward the end of Leslie Peacock’s article (linked earlier) a DHS spokesperson says that the agency is working toward educating foster parents about trauma and its role in determining children’s later behavior. She noted the focus on a “trauma informed” approach and the intention to use Trauma Focused Cognitive Based Therapy, an evidence-based treatment for children who have been sexually abused or hurt by domestic violence. But the spokesperson goes on to say. “Training has also been provided to a number of foster parents. We think a trauma-informed approach is critically important and we’ll be working…on how we can accomplish training for all foster parents.” So, investigators-- what is going on here? TF-CBT is indeed an evidence-based method, but it is taught to and used by qualified professionals. The foster parents are not going to become psychotherapists in the professional sense. What are the foster parents being taught about trauma, about what experiences have traumatic effects, on the behavioral outcomes for children, and on what methods can be helpful? I ask this question not out of general suspiciousness, but because the term “trauma” has “crept” to a much wider meaning than it originally had, just as happened years ago with “attachment”; trauma is now sometimes used to mean practically any bad thing, just as attachment came to mean all good things when present, all bad things when absent. Just a few days ago, I published a post on this blog on the subject of an adoption agency in Ontario whose website baldly stated that all adopted children have been subjected to extensive trauma because of the separation from the birthmother, to whom, it was claimed, they had developed a powerful emotional attachment during their gestation—an idea completely at odds with established research on attachment, but certainly popular with Nancy Thomas and “attachment therapy” advocates . What are the foster parents being taught? The term “evidence-based” seems to be intended to describe their training as well as the professional training, but I don’t see how that can possibly be. Investigators need to explore this, because the attitudes and expectations of foster parents are a good deal more likely to affect children than their occasional visits to therapists.
There are a lot of questions to be asked before anyone understands exactly what has been going on in Atkansas, as well as in many other states’ human services departments.
Sunday, March 15, 2015
When anybody gets caught harming children by applying attachment therapy and parenting as proposed by Nancy Thomas, you can bet the Internet wagons will be circled quickly. This was apparent after Connell Watkins and Julie Ponder were convicted in the “rebirthing” death of Candace Newmaker in 2001. The practitioners’ supporters got on line to claim that the 10-year-old had died on purpose in order to cause trouble for the hated adults.
Now, with the latest concerns about the actions of the Arkansas legislator and his wife toward their [briefly] adopted daughters, culminating in “rehoming” and the rape of one young girl, we are beginning to see the same kind of thing. I give you for example http://blog.attachmenttraumanetwork.org/representative-harris-rehoming-controversy/ . This post begins with the mistaken claim that instead of squashing a guinea pig, a three-year-old killed the family cat-- an animal that would take a lot more work to kill than a guinea pig, and would bite and scratch effectively if hurt. (Next week: a German shepherd puppy? That’s the animal that Nancy Thomas most often claims children have killed.)
This little “mistake”, of course, escalates the whole situation and fleshes out this effort to point to the girls as well as the bureaucracy, rather than the Harrises, as the true villains. Incidentally, the former foster parents of the girls denied any such disturbing behavior, but of course a typical explanation of attachment therapy advocates would be that this simply shows how cruel and cunning they were, and how they fooled the naïve foster parents, to have their true natures appear only when the adoptive parents were in range. The ATN blog thus calls the one girl “extremely troubled” in spite of evidence against this assessment. Interestingly, the blog post is unsigned, and the site only says that posts are written by a core of volunteers.
The ATN blog, having set the stage, now takes advantage of the story not to express sympathy with the little girls, but to pity the Harrises, and to propose administrative changes to prevent such problems. They state two problems that I too strongly agree need correction. One is the use of threats of abandonment charges when adoptive families feel overwhelmed and want to back out; I have certainly heard of such threats being used, and if they were used with the Harrises I consider that regrettable (especially as it has provided a nice red herring to distract from other issues.) The other problem is the requirement that parents relinquish parental rights in order to get state support for mental health care for their children. This is a fight that has been going on for some years and has been supported by the Bazelon Center among others. However, it is not at all clear to me what this has to do with the Harrises’ situation, unless there was some fear that relinquishment would be treated as abandonment and other children in the home would also be taken as a consequence. State laws differ on this point.
The ATN piece goes on to say that there should be uniform provision of Medicaid-paid services for children, including mental health services, and that these should “go with” the child who is placed in a different state. That’s all as may be. May the issue not actually be the wish that Medicaid would pay for the types of services the Harrises used-- attachment therapy methods of various kinds? Members of ATN, like its founder Nancy Spoolstra, are themselves proponents or practitioners of these methods. The methods are “alternative psychotherapies”, implausible, without an evidentiary foundation, and potentially harmful. Medicaid does not pay for such treatments unless practitioners bill dishonestly and give specious descriptions of their services. And Medicaid should not pay for mental health services that are not supported by strong evidence of effectiveness.
ATN has done its collective best to distract attention from the Harrises and to focus it on the claimed disturbed behavior of the girls, and the failure of the bureaucracy to support the Harrises. Let me bring back the focus to what the Harrises actually did to create the situation that led to a range of genuinely traumatic experiences for the little girls.
- They insisted on adopting the girls in spite of recommendations by the foster parents and others against placing the girls in a home with three boys.
- Although they stated their concerns about attachment disorders in the girls, and therefore presumably wanted the girls to form emotional attachments to them, neither of the Harrises appears to have spent much time with the girls. According to their babysitter’s testimony, the girls attended the Harris-owned day care center 5 days a week and had a teenage babysitter for the rest of the afternoon after they came home.
- Rather than seeking help from a knowledgeable, licensed clinical psychologist or psychiatrist, the Harrises called in exorcists and used the treatments recommended by the erstwhile dog-trainer Nancy Thomas. They apparently believed that the girls could communicate with each other telepathically, against all scientific evidence.
- Given their intention of “rehoming” secretly, the Harrises could have had an assessment of the proposed home done privately, to make sure that their judgment of the appropriateness of the parents was correct; they did not, but relied entirely on their own judgment, beliefs, and personal relationships.
- They encouraged their sons to be afraid of the girls, as shown by Justin Harris’s report that the boys came to sleep with him, and thus communicated to the girls that there was something very wrong with them.
No one could reasonably contend that children from the background the girls had would be emotionally and behaviorally the easiest to care for. Neither can anyone deny that the bureaucracy surrounding adoption is often inconsistent, prejudiced, hostile to parents, and downright Kafkaesque. But those facts do not outweigh the reality that the Harrises insisted on having their own way, for their own reasons, and made a series of decisions contrary to what any well-educated mental health professional would have told them. They knew they were right because they knew they were right. The girls have paid and continue to pay the price for this, but that seems to be the least of the problems as far as the Harrises and the Attachment and Trauma Network are concerned.
Some time ago, I wrote a post about how misinformation sneaks into public thinking when braided together with accurate information (http://childmyths.blogspot.com/2014/12/mistaken-attachment-beliefs-persuasion.html). I referred to the practice of combining information with misinformation as a Trojan Horse. (I tried to work out another metaphor involving Odysseus and his men escaping from the cave by hiding under the sheep, but that didn’t seem to be what was needed-- besides, I’ve always thought those must have been awfully large sheep. Or small men.)
Jessica Pegis recently alerted me to an egregious Trojan Horse being parked outside Canadian castle walls at http://www.adoptontario.ca/childhood-trauma. This is a site run by AdoptionOntario, an organization that is partially funded by the provincial government. It presents a rather thoroughly braided group of statements, and I think it would be valuable to disambiguate them.
Let’s look at the accurate information that is given there. The site points out that very young children may be affected by traumatic events, and that they are sensitive to events that threaten their caregivers as well as threats to themselves alone. Domestic violence and natural disasters can create situations that are traumatic for young children, as can painful or frightening medical procedures or abrupt separation from familiar people. Some traumatic events occur once and never again, but the site notes that it’s common for children who experience a traumatic event actually to have more than one associated traumatic experience. (A natural disaster like an earthquake, for example, is frightening and even painful in itself, but may be accompanied by the sight of injured or dead people and the confusion and distress of the adults the child usually can trust to provide safety. ) But repeated traumatic events, like sexual abuse, are even more likely to have ill effects on children’s emotional and cognitive lives than single events are.
So far, so good. There’s nothing wrong with what adoptontario.ca has said up to this point. But on closer inspection, here’s what we find:
“Trauma for an adoptee begins at the moment of separation from a birthmother. Whether adopted from birth or later in life, all adopted children have experienced some degree of trauma. Until recently, the full impact of trauma on adopted children has not been fully understood. Since infants do not see themselves as a separate entity, it is believed they see themselves as a part of the person they physically attached and bonded to for 40 weeks. When separated, infants may naturally feel they have lost part of themselves. When an adoptee is separated from a birthmother, extensive trauma is experienced. The trauma will not be remembered, but it will stay in the subconscious as it was lived. Any event in infancy can and will stay with an individual through life.”
Later, the site states:
“Theoretically, adopted children have experienced being unwanted before they are born. In addition, they may have experienced the loss of the mutual and deeply satisfying mother-infant bond. This experience can affect them in more than one way, including
· Grieving the loss of their birthmother
· Being emotionally vulnerable
· Shutting people out, depression, or overcompensation” (this list is in addition to other claimed results of childhood trauma)”
With this material, we see the Trojan Horse at work. Under cover of accurate information, the web site has now brought in some completely inaccurate statements-- and even worse, a group of statements that can lead adoptive families to misinterpret normal behavior, and adopted individuals to believe that they are doomed to emotional disturbance. A quick glance at the accurate information could easily lead readers to believe that everything on the site was of equal value.
What’s wrong here? What has entered inside the Trojan Horse supplied by the correct information?
The essential point to consider is that there is no evidence that unborn infants do form emotional attachments to their mothers, or that they recognize their mothers at birth. The possibility that attachment could have started 40 weeks before birth is ludicrous-- first of all, because 40 weeks before birth is the average date of the first day of the mother’s last menstrual period before pregnancy, not the date of conception! It would be even more absurd than the rest of this stuff to assume that an ovum, ripening but unshed, and certainly unfertilized, has already begun to develop an emotional bond to a woman who may not even have intercourse during the time window that would allow for fertilization. If this were true, how tragic to think of all those unfertilized but attached ova being swept away from Mommy in the course of her next period—enough grief each month to overwhelm the cosmic plan, especially when Mom (callous bitch that she is) says to somebody, Thank goodness, I got my period, I was getting worried.
Emotional attachment of infants to familiar caregivers takes place over months of social interactions and begins to show up behaviorally at about 7 or 8 months of age in most babies, when fear of strangers and of separation first emerges. Younger babies welcome social interaction with strangers and show little distress when separated from familiar people. If some prenatal form of attachment has occurred, it certainly does not show up in infant behavior or mood, or in any other measurable way.
Okay, let’s say that the 40 weeks is just a clerical error. Let’s place the time at 38 weeks before birth. The ovum gets fertilized. Does it have a nervous system to remember or learn things with? No; but this doesn’t matter to those who believe (as seems to be a possibility for someone at adoptontario.ca) that it’s “cellular memory” that’s at work, a kind of memory in each cell that represents events in the deepest way and survives mitosis each time, so that all cells have the memory of whatever happened to that ovum. This belief is completely contrary to everything we know about learning and memory. If it’s true, all scientifically-based statements about this or false. I’m not saying there could not be such a new paradigm-- but really, what are the chances?
What about the idea that everything experienced in infancy is preserved “as it was lived” in the “subconscious”? Study after study of memory tells us that memory does not preserve material “as it was lived”. On the contrary, when memory works (which is not always), it maintains not a photograph but the gist of an event, which the rememberer then reconstructs to create a belief about what “must” have happened. The adoptontario.ca author seems to be embroiled in what has been called the “trauma-memory war”—the claim that early traumatic experiences cannot be consciously remembered, but are nevertheless directing matters from behind the cognitive scenes.
Basically, without saying so (and this is another sign of a Trojan Horse), adoptontario.ca has stated a belief in the claims of the California marriage and family therapist Nancy Verrier that every adopted individual has experienced, and continues to suffer from, a Primal Wound, from which he or she can recover only with difficulty or not at all. This belief system can be traced to the “psychohistorian” Lloyd DeMause, who presented a bizarre description of what unborn babies must really be experiencing. (DeMause was able to promulgate this for quite a while because he was quite well off and started his own journal with papers about his claims.) DeMause, and Verrier too, received much support from the Association for Pre- and Perinatal Psychology and Health (APPPAH), whose members would be in complete agreement with adoptontario.ca.
Canadians, your provincial money is going to support this unfounded material, and to contribute to beliefs that are potentially harmful to adopted people, adoptive families, and birth parents who consented to adoption! How about speaking up?