Concerned About Unconventional Mental Health Interventions?

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

Wednesday, May 20, 2015

Why Was Xenia Antonova Placed in a Mental Hospital?


Yesterday I commented on the conviction and sentencing of a Georgia man, Michael Grinsmore, for the sexual abuse of his Russian adopted daughter, Xenia Antonova. Xenia was born in 1994 and had been in the United States since 2001, when she had been adopted by Grinsmore’s wife’s sister. In 2009, she was “re-homed” to live with Grinsmore and his wife. In 2010, when she was not yet 16, she was sexually abused by her adoptive father, and her teachers were fortunately attentive enough to notice that something was wrong and to bring the police into the picture. (That there was physical evidence of molestation on Xenia when she went to school suggests that Grinsmore had done his thing just before she left home; I’ve always felt uneasy about the song “Good Morning, Little Schoolgirl”, but now I don’t think I’ll care to hear it at all.)

According to Russian sources, Xenia was placed in a mental hospital until the age of 21. Not surprisingly, considering Xenia’s right to privacy, there are few specifics about this on the Internet, but the original placement was said to be in an orphanage in Georgia. Whether this actually meant a group home or therapeutic foster home has never been clear. If one of those was the placement, I would have expected the placement to end when she was 18. However, she is now either 21 or soon to be 21, so we can expect that she will be leaving any placement in short order.

Why was she placed in a hospital at all? Her story up to the time of the revealed abuse does not indicate mental illness that would need to be treated at an inpatient level. Because of her cleft palate history, she may well have needed speech therapy, but she appears to have been attending school normally, and her relationships with her teachers were good enough that the teachers noticed her distress. Her background was certainly a difficult one, but severe mental illness is not simply the result of such a background. Her experiences with Grismore could have produced PTSD or depression, but these would not normally be treated by hospitalization.

What I am about to say is the purest speculation, but as an explanation of this unusual move to hospitalize a teenager, I would submit that there may have been reasons other than Xenia’s best interests at work. To put it bluntly, who wanted her--  or perhaps I should say, who wanted her and could be considered to be suitable caregivers for her? Her first adoptive mother had already relinquished her and could not be expected to come forward at this point. The second adoptive mother, Mary Grismore, would ideally have cared for Xenia, but perhaps she can be forgiven for failing to help the girl who, she may have felt, had broken up her marriage and sent her husband to prison. (However untrue this was, it is the kind of thing people think as they strive to put together the wreckage of their lives.) Indeed, what would have happened if Xenia had stayed in the same community and continued to attend the same school—a girl of unusual background, possibly with some speech impairment, and now labeled as sexually experienced and vulnerable? As for a new adoptive family, there are few who would care to take on this set of potential problems, and those who felt they would be interested might well be too na├»ve to know what they might be getting into--  or might have motives that are all too easily guessed.  

Hospitalization may have been a solution that removed Xenia from the scene and allowed the community, including her adoptive mother(s), to forget what had happened.

However, there are other issues to consider. A group foster home might have been the right answer for Xenia, but because she was already in the Georgia system, this would have had to be in the state of Georgia (and the Internet indications are that she has remained in Georgia). Georgia, however, has been a hotbed of the “alternative” attachment therapy/holding therapy beliefs. In 2009, a year before the revelation of Xenia’s abuse, Georgia social workers published  an article approving the use of attachment therapy (Wimmer, J., Vonk, M.E., & Bordnick,P. (2009). A preliminary investigation of the effectiveness of attachment therapy for children with reactive attachment disorder. Child and Adolescent Social Work Journal,26, 351-360). In this article, and elsewhere, there is reference to a state program teaching social workers a view of attachment and of attachment disorders that is not based on evidence or conventional theory.

Contrary to the recommendations of Chaffin et al (2006), in the report of the APSAC task force on attachment issues, the Georgia version stressed the importance of early experience over actual symptoms of mental illness, encouraging parents and adoption workers to assume that if a child had been adopted, he or she was very likely to have Reactive Attachment Disorder. Xenia, of course, was adopted, and although she had been with her birth mother for the first five years of her life, her physical problems may well have entailed separations and discomfort--  events that proponents of attachment therapy consider to be causes of attachment disorders. It is certainly true that children who have certain symptoms are likely to have had problematic early histories, but it is not equally true or logical that children with problematic early histories necessarily show symptoms of any mental illness. But it has been common for adoptive parents and adoption workers to make that assumption, and therefore to attribute to adoptive children mental disorders that they do not actually have.

What if someone with authority assumed that Xenia had an attachment disorder? This might mean that she would also be expected to show some undesirable behaviors, like sexual acting-out, lying, and making false complaints of abuse. These are not actually symptoms of attachment problems, but they are believed to be so by proponents of attachment therapy/holding therapy. People holding such a belief system might well see Xenia as the instigator of her adoptive family’s problems and prefer to send her for “treatment” rather than consider what she would need in the following years in order to become an independent adult. I also have to wonder whether Xenia’s story shares some aspects with the 19th century attitude toward female sexuality that committed to mental hospitals women whose sexual lives broke the rules--  whether at the women’s desire, or otherwise.


I am hoping that when Xenia emerges from her incarceration—longer than her adoptive father’s prison sentence, by the way—that she will tell her own story. But I think we must expect that her educational opportunities and chances for normal world experience may have been few, and her wish may be only to hide for a while/

Tuesday, May 19, 2015

The Conviction of Michael Grinsmore for the Rape of his Adopted Daughter


I cannot find any U.S. news sources reporting on this story, but a Russian source (http://www.rapsinews.com/judicial_news/20150519/273744378.html) reports that a Cherokee County, Georgia man has been sentenced to three years in prison after conviction on three counts of sexual abuse of his Russian adopted daughter, Xenia Antonova.  The Russian children’s ombudsman, Pavel Astakhov, testified in this case. Astakhov has pointed out that if Russia had been notified of the transfer of custody and parental rights that took place in this girl’s case, the tragedy might have been prevented.

Xenia was born in 1994 and was adopted in 2001 by Marta Blandford, a single woman living in Georgia, who already had one biological child and three adopted children.. Xenia apparently had some special needs associated with cleft palate and was small and thin at the time of the adoption. In 2009, for unknown reasons, Marta relinquished her parental rights in connection with Xenia and the girl was adopted by Marta’s sister Mary and her husband, Michael Grinsmore. In 2010, Xenia’s teachers noticed that something was wrong, and Xenia disclosed that Michael had beaten her and had oral sex with her (an act that might be expected to be especially distressing to a young girl with a history of cleft palate). Forensic tests confirmed that this was the case. Xenia was removed from the Grinsmore home and placed in a facility referred to as an orphanage by Russian sources. Grinsmore acknowledged the sexual acts (he could hardly deny them in the face of the existing evidence), but claimed that he had documents showing Xenia to be 16, the age of consent to sexual acts in Georgia, and stated that the acts had been consensual. Later investigation showed that Xenia was in fact still 15 at the time of the abuse.

This was clearly not a he-said/she-said situation. If Xenia did indeed consent to sexual acts with Grinsmore, which can’t be known, her consent was not valid because of Georgia law. In addition, the report of beating would seem to make her consent unlikely.

However, the question that crossed my mind when I read about this case was this: was the adoptive relationship not sufficient to make the sexual relationship incestuous and therefore illegal? In the United States, of course, Federal law does not govern issues of this kind. State laws all consider some sexual relationships to be criminal incest (see www.ndaa.org/pdf/criminal_incest%20chart%20_2010.pdf), but they do not all have the same rules about this crime. Some states describe certain relationships as being incestuous without regard to illegitimacy or adoption. Others list pairings that are illegal, such as stepfather and stepdaughter, with or without mentioning adoption as an issue. Some states consider criminal incest to have occurred only if the couple marry; others list a variety of sexual acts as incestuous, including oral-sexual contact and sexual insertion of an object. Some states include penalties for persons who might reasonably know that incest would occur and fail to prevent it.

The state of Georgia defines as criminally incestuous sexual relations between “Persons known to be (by blood or marriage): (1) Father and daughter or stepdaughter; (2) Mother and son or stepson; (3) Brother and sister of the whole blood or the half blood; (4) Grandparent and grandchild; (5) Aunt and nephew; (6) Uncle and niece.” The incestuous act is described simply as “sexual intercourse”. Georgia law thus  fails to state specifically that sex, consensual or otherwise, with an adopted child is criminal incest, and also leaves it open to question what types of sexual activities would be included  as incestuous in any case.

Georgia law requires imprisonment of an offender convicted of incest for not less than ten nor more than thirty years, a substantially longer period of imprisonment than Michael Grinsmore has been sentenced to. It’s important to realize that the apparent “slap on the wrist” of this relatively brief sentence is not an indication that the judge had a cavalier attitude toward Grinsmore’s crimes. In fact, the law as it exists in the state of Georgia determined  how long the sentence might be. In Montana, life imprisonment might have been the sentence in this case. It may be hard for people accustomed to a more uniform criminal code to understand the varying laws of the somewhat loosely federated United States, but attitudes as shown by sentences in one state should not necessarily be taken as “American attitudes” in general.

Be all this as it may, Grinsmore’s crimes might have been prevented if Xenia had not been subjected to “re-homing” either completely informally or with rubber-stamping by caseworkers and the judiciary. I fully support the Russian request to be kept informed of the whereabouts of Russian adoptees in the United States. However, I must point out the number of times these informal transfers occur with American-born children as well. The recent case of Justin Harris in Arkansas involved such an exchange and came to light only when one of the little girls was molested by her “new daddy”. In the Harris case, the transfer was casual; in Xenia’s case, there seems to have been some legal processing of the change, but apparently not one that started from scratch with a home study. It’s time to do much, much better on these matters.


An unanswered question: where is Xenia now?

Sunday, May 17, 2015

PRETENTIOUSLY HAZARDOUS Treatments: A New Category, Courtesy of the Post Office

A piece in the Week in Review section of the Sunday Times today described how the writer visited a New York post office, and looking at the rubber stamps available, discovered one marked PRETENTIOUSLY HAZARDOUS. I can’t let this golden trouvaille go to waste. It is the perfect category description for the whole attachment therapy-holding therapy- Nancy Thomas parenting-industrial complex, as well as for more than a few other treatment methods.

Some years ago, the clinical psychologist Scott Lilienfeld introduced the term potentially harmful treatment (PHT), to describe therapies that were already known to have caused harm to patients, or which might logically be expected to do so. This term, of course, did not mean that every use of a treatment would end in harm to a patient, simply that there was a reasonable possibility that this would occur. The PHT concept stressed the fact that despite the etymology of their name, “therapies” might actually do harm—that safety as well as effectiveness could be issues for psychological treatments.  The idea of a PHT was not obvious to a Georgia attorney who cross-examined me in a holding therapy case; he argued that no harm had apparently been done, until I gave him the example of running across a busy highway and by some miracle not getting hit by a car--  he had to agree that this was a potentially harmful act that should be prevented, even though the runner came through unscathed this time.

The psychologist Michael Linden added to the PHT concept by pointing out that various types of harm could be associated with misconceived psychotherapies—for example, that the “emotional burden” of feeling distressed during treatment was harmful and should be avoided if at all possible.

So, why am I not content to call AT-HT-NTP potentially harmful treatments? Why not just point out the emotional burdens children experience when subjected to these methods? In fact, why not stick to the term “alternative psychotherapies”, which I have used myself to designate treatments that are without an empirical evidence basis, that are incongruent with established information about human development, and that are potentially harmful?

PRETENTIOUSLY HAZARDOUS treatments display problems in addition to those just stated as they retrofit theory and diagnosis to support treatment methods that are in fact derived from old ways of punishing children (perhaps even from the old German “black pedagogy”). Proponents of these treatments have spun out of straw a prosperous belief system which meets the definition of pretentiousness given by my big old Webster’s: “making claims, explicit or implicit, to some distinction, importance, dignity, or excellence”. The claims include the putting forward of an unfounded “attachment cycle” theory that states that attachment is affected by caregivers’ boundary-setting in the second year of a child’s life (such boundary-setting is important, but is not a factor in attachment). The “attachment cycle” concept is used to justify age-inappropriate actions like insisting on bottle-feeding a ten-year-old or hand-feeding sweets to a child. It is also used to justify intrusive and rigidly-controlling actions toward children that are defined as equivalent to boundary-setting.

The “attachment cycle” concept and related adult actions make the explicit claims to importance  mentioned in the Webster’s definition of  pretentiousness. But they in turn are based on an implicit claim that is all too easily swallowed by parents and other caregivers—in fact, that may be believed to a considerable extent by many adults. This is the claim of recapitulation, the repetition of earlier events, but it is not the old familiar but faulty idea that the development of the individual repeats events in the development of the species. This concept of recapitulation holds that it is possible to magically cause the recapitulation of past development, and to make it come right where it has gone wrong, simply by ritually re-enacting some past events that might be associated with the desired developmental change. For example, if a child is thought to have problems with attachment because she was not sufficiently cuddled as an infant, cuddling her now, feeding her with a baby bottle, and gazing into her eyes are thought of as ways to recapitulate and correct her early emotional life. If a child’s problems are thought to have come from failures of limit-setting in the second year, rituals of demanding that the child ask for everything he needs or sit motionless for long periods are considered to recapitulate and correct the earlier problems.

There are several problems that make such treatments PRETENTIOUSLY HAZARDOUS. One is that it is very unlikely that attachment does result from feeding experiences per se, and it is particularly unlikely that ingestion of sweet things is related to attachment in infancy. It is similarly unlikely that attachment is the aspect of development affected by boundary-setting. But suppose for the sake of argument we were to assume that those events did cause attachment in infancy? Why would we think that experiences characteristic of infancy would have the same effects on older children as they do on infants? To imagine that would be like thinking that an all-milk diet, healthy and appropriate for young infants, would also be suitable for older children with different nutritional needs and growth patterns. Magical recapitulation rituals cannot return children to the developmental needs and patterns of an earlier stage of life, and it is pretentious to claim that they do. In fact, one might well argue that it is fraudulent to do so.

It’s clear that AT-HT-NTP methods are PRETENTIOUS. Need I also argue that they are HAZARDOUS? Proponents of these methods have stated that they no longer lie down on top of children or do other things that have caused death by asphyxia in the past, and perhaps they do not. Nevertheless, the recent license revocation case of “Kali” Miller in Oregon has shown the suicidal response of a boy to treatments that did not risk suffocation but appear to have carried an unbearable emotional burden. In my opinion, this is hazardous enough to argue against use of any such methods.


These treatments are not prohibited, in spite of all we know about them. But there should be large PRETENTIOUSLY HAZARDOUS stamps on all their websites.  

Friday, May 15, 2015

That Reber Paper, Its History and Consequences

Periodically other people and I refer to an article purporting to discuss Reactive Attachment Disorder, published by Keith A. Reber in 1996 in a journal called Progress. This paper was cited as a foundation of the attachment therapy belief system by Chaffin et al in the 2006 APSAC task force report on attachment therapy and attachment disorders, a report that rejected the use of holding therapy and related methods. Reber’s paper used to be readily available on line, but is no longer easily to be found, and although I have it I can’t post it without exposing myself to complaints about copyright violation. However, I can write about the paper and about its author and his sources.

Let’s start by considering who Keith Reber is and what his professional history has been. He was at one time a marriage and family therapist and was associated in some way with the Phillips Graduate Institute in California (this institute was the publisher of Progress). From 1999 to 2001, Reber was a licensed MFT in Oregon, and in 2001 he was served with a notice of proposed revocation by the Board of Licensed Professional Counselors and Therapists for that state.  In 2003, his license was revoked. The explanation for this decision can be seen at www.oregon.gov/oblpct/BoardAction/Reber.pdf.

According to the Board’s statement, Reber had agreed not to use holding therapy (HT) with children referred to him by a state agency, but did indeed use HT with three children who were temporarily placed with foster or potential adoptive parents. To place this action in historical context, I should point out what is not mentioned in the license revocation material: Candace Newmaker had died at the hands of HT practitioners in 2000, and this fact was widely known and of considerable concern, but Reber continued to use this dangerous and unsubstantiated approach despite state agency warnings and his own agreement not to use HT. Reber’s methods, according to the Board statement, were not the “nurturing, cradling hold” often mentioned in more recent times, but included wrapping the child tightly in a sheet, lying on top of the child, and thrusting his fist up into the child’s rib cage. These techniques were used with a child who had been sexually abused as well as with others.

To quote the Board report directly: “Licensee treated SM and VM (from approximately 1999 through 2000) and used holding therapy including wrapping them in a sheet and blanket, laying (sic) with his body on top of the children, pushing his elbow into their abdomen and/or stomach area so hard at times causing vomiting, and occasionally required the children to try to gain freedom from the blanket wrapping themselves, despite the fact that they were wrapped tightly”. [Candace Newmaker died from suffocation while trying to escape from such a wrap.—JM]  In addition, Reber refused to release the children or stop the treatment when asked, but instead berated them.

The Board was also concerned that during its disciplinary proceedings, Reber, who had been given notice of a proposed license revocation, had applied for a MFT license in Utah and represented the license matter in Oregon as having been resolved, when it was not. (A curious bit of HT history intrudes here: Reber’s file was reviewed by David Ziegler, who stated that HT was not acceptable--  at almost the same time that he himself was publishing a paper that cited a number of European practitioners who were and still are strong supporters of HT! But--  am I just revealing that I have one of those small minds for which consistency is a bugaboo?)

So what happened next? The next part of Reber’s story is told at www.deseretnews.com/article/1001664/Orem-therapist-lost-license-over-controversial-methods.html?pg=all. Leaving the unappreciative state of Oregon, he went to Idaho and got a job as a counselor at a clinic associated with a child’s death through forced water drinking. Without his MFT license, Reber had claimed pastoral licensing through the Universal Life Church. Presently, it appears that Reber is licensed in Utah as a hearing aid specialist.

There we have a history of weak or nonexistent professional ethical standards—a background for the Reber 1996 paper itself. I will select some intriguing bits from that document.

Reber starts early in the paper to show that his assumptions are not those of conventional attachment theory, in spite of his attempts to use conventional terms and concepts. He cites Verney and Kelly, two APPPAH stalwarts, to the effect that “attachment begins with connectedness in utero”, starting before birth “on a neurological and emotional level”. He states that without critical interactions with the mother, the baby may “lose interest in the world, become ‘insecure’ or ‘anxiously attached’, or even die.” Even omitting the mistaken claim of prenatal attachment, we see here a peculiar list of problems. Insecure or anxious attachment, while not ideal, is well within the normal range and probably was the condition in early childhood of a large number of the people reading this. Losing interest in the world is a far more serious problem, but even maltreated children with disorganized attachment patterns do not show this. As for death—yes, emotionally-neglected children may die, but the causes of these deaths are much more complex than Reber implies. On the second page, we see the interesting statement that attachments “fall on a continuum between secure and insecure, with the normal child falling somewhere in the middle”. This seems to suggest that insecure attachment is really all right, even though it was ranked earlier along with apathy and with death.

But let’s abandon this entertaining journey through Reber’s ideas about attachment and move on to the specific misunderstandings this paper introduced into discussions of Reactive Attachment Disorder. After saying correctly that RAD is difficult to diagnose, Reber provides on his fourth page a table giving symptoms of RAD as collected from the files of the Family Attachment Center in Salt Lake City, Utah. Here we see the first claims in a supposedly peer-reviewed publication of the RAD characteristics that now turn up in newspaper articles. These include superficial engagement and charm, refusal to make eye contact, incessant chatter, fighting for control, indiscriminately affection with strangers but not cuddly with parents, destructiveness, cruelty to children and animals, stealing, lying, hoarding and gorging on food, preoccupation with fire, blood, or gore [I’ve always wondered what the difference may be between blood and gore—JM], lack of cause and effect thinking, lack of conscience, and abnormal speech patterns.

No doubt many children seen at the Family Attachment Center  did have one or more of these characteristics. But where is the evidence that they had Reactive Attachment Disorder, alone or in addition to some other diagnosis? Answer comes there none, it would appear. Reber’s paper provides no reason to think that any of the concerning symptoms were in fact indications of RAD. In fact, other authors associated with this belief system, like Elizabeth Randolph, have specifically said that these symptoms do not indicate RAD, but instead a posited “Attachment Disorder” which is different. Not only does this symptom list have no part in descriptions of RAD in DSM-IV, DSM-IV-Tr, or DSM-5—even other proponents of HT did not accept Reber’s association of the list with RAD. But this has not stopped the constant repetition of claims about RAD symptoms, right up to the present day. As an example, I can point to the 2014 doctoral dissertation by Vasquez  which I discussed earlier this month, a document that includes items from Reber’s list, and which gives a muddled in-text citation of Reber’s paper.

Where did Reber get his ideas? His table of information from an unpublished sources is one we can’t check on, but a look at his reference section tells a good deal. Here we see some errors suggesting that Reber is not on top of his material: the name of the psychoanalytic theorist Erik Erikson is spelled Erickson, suggesting that Reber has him confused with Milton Erickson, who advised sitting on recalcitrant children and feeding them cold oatmeal; even that ur-holding-therapist Robert Zaslow has his name misspelled. Other sources are Foster Cline, Rick Delaney (who needs discussion in himself, as he has “gone straight” but never really explained why), Jirina Prekopova, and Martha Welch--  all proponents of the most rigorous physical restraint techniques like those that got Reber’s license revoked. Finally, Reber quotes Robert Karen, the 1990s popularizer of attachment theory, and attributes to Karen the statement that in New York City there are one million children with Reactive Attachment Disorder--  this out of a population of 6 million!

Ordinarily, it might not seem very important to go over the mistaken statements of an obscure writer from 20 years ago, especially as his publication does not seem to be available on line any longer. However, the fact that Reber’s claims have been spread as factual through Internet and print journalism, and have been immortalized as checklists for diagnosis of attachment disorders, makes it necessary to trace those claims to their highly unreliable source. Even though, by a sort of psychological Gresham’s law, bad information remains likely to drive out good, it may be that a better understanding of background may help fight the misunderstandings that have spread and continue to spread.   



Wednesday, May 6, 2015

What's Up With That, Doc? A Disturbing Doctoral Dissertation About RAD

While looking for some recent comments about Reactive Attachment Disorder recently, I chanced upon a 2014 doctoral dissertation that gave me considerable pause. This was a dissertation written in fulfillment of requirements for a doctorate in social work at the University of Iowa. The doctoral candidate, Matthew Lorenzo Vasquez, titled his dissertation “The impact of Reactive Attachment Disorder on adoptive family functioning”.  This in itself was a bit attention-getting, because I would expect a dissertation done today to look at the effects of RAD and adoptive family functioning on each other, not to assume that the disorder was there to begin with, and it caused changes in family functioning. But I wanted to read the thing to see whether I was right to question the nature of the document.

You can read this dissertation for yourself if you have the stomach for it--  it’s at ir.uiowa.edu/cgi/viewcontent.cgi?article=5299&context=etd. I’ll just give you some high points that will no doubt resonate with aficionados of the attachment therapy/holding therapy belief system.

We get right underway in the abstract and the first page of the introduction. Here we are told that “[c]hildren with RAD are known to engage in self-destructive behavior, talk of killing others or themselves, [and] direct verbal and physical aggression toward peers and adults”. This is of course true, just as it is true that children with other diagnoses, or with no diagnosis, may sometimes do some of these things. What is not true is that children who engage in self-destructive behavior, talk of killing, etc., etc., therefore have RAD. Although Vasquez references the DSM-IV-Tr description of RAD, he appears to have some other, unnamed source of information about diagnosis of RAD--  perhaps the work of Wimmer et al which appears in Vasquez’s reference list and which certainly posits RAD symptoms that are not to be found in any conventional discussion of RAD diagnostic characteristics. Although he mistakenly cites Parker, Forrest, and Reber, a non-existent source, it is plain to those of us who have studied the AT/HT belief system that Vasquez really means Reber (1996), a problematic paper, hard to find on the Internet nowadays, that made a variety of unsupported claims about RAD and used to be quoted frequently by practitioners of alternative psychotherapies.

Vasquez collected information by interviewing members of five volunteer families, and some interesting information it was, I can tell you.  For example, in discussing the methods a family used to respond to a child’s “meltdowns”, he comments, “In an effort to find some relief from Adam’s rages, Nancy [adoptive mother] started to bring Adam into the bathtub [with or without water is not stated]  and would hold him there in the dark  while he continued to scream” [as who wouldn’t scream? J.M.]. Nancy states that she learned this technique when working in a nursing home with people who had transient ischemic attacks…and seizures and hoped it would help Adam. Nancy then explained:

‘That’s when the meltdowns got shorter, and shorter, and shorter. Because he lost all his power. He had no power. Because sometimes he would get me frazzled you know and I was overwhelmed, you know? You don’t want to go there but you would. So he lost all his power when it went to the tub. And they just got, I bet, six to eight months before his meltdowns were 10 to 15 minutes in length.’

Vasquez then speculates that the approach was “so effective” (a speculation in itself of course) because the child could consciously decide whether he preferred to tantrum or to be held in the bathtub; Vasquez is uncertain whether he always had this ability or was given it as a result of the bathtub treatment.    
Rather than considering the meaning from the child’s viewpoint of being immobilized in the dark (and possibly in water), Vasquez is concerned with what it all meant for the parents. “Personally, I found the image of a young child being held in a bathtub, in the dark, while he screamed uncontrollably for hours at a time both profound and moving. … It … shows… what lengths some of these parents went to provide these children comfort and solace. Undoubtedly, to sit in a bathtub for multiple hours a day, restraining a screaming child for 6 to 8 months shows an incredible level of devotion and commitment to the care and well-being of these children”. Although many of us would query whether this behavior actually shows an incredible level of ignorance or of sadism, Vasquez does not mention that alternative explanation. Instead, he stays with the AT/HT tenet that adoptive parents are loving and good, as well as able and determined to make the best choices for children.

This is very depressing, but let me mention one other topic Vasquez mentions. It’s the old Darkness Behind the Eyes (see www.attachmentandtraumaspecialists.com/attachment_disorder/symptoms and other AT/HT sources). Vasquez says “hearing numerous reports about how these rages can be seen in the eyes of their child, I began to see this attribute as a significant feature in discussing these rages. “ He inquired of one mother about the idea that her child’s eyes changed color. She said “Mmm-hmm. Her eyes change color. They all do. They go DARK.” Another parent made the following statement: “When he would rage… it would almost look like there’s a fire in the whites of his eyes. He wore the footed pajamas, and at bedtime sometimes I would have to hold him down, and he would kick, and with all the lights off there would be sparks everywhere, I mean he was raging that fast.” Vasquez did not question these reports of physical impossibilities, but did note that the parents did not seem to attribute the events they reported to demonic possession. He did not examine the possibility that alternative practitioners and support groups had told the parents these things would happen.

So, do I blame Vasquez for this piece of work that repeats without question or comment various tenets of the AT/HT belief and treatment systems? Yes, to some extent I do. The man is not a scholar, although he seems to think he is, and he has done a sloppy job at best, mismanaging citations and references. He fails to note the discrepancies between the DSM criteria for RAD and the symptom list he emphasizes. He notes his attempts to manage his own biases by journaling, but does not attempt to discuss alternative interpretations for some of his conclusions. He did not do this work with due diligence, and if I contemplated employing him, I would be most concerned that the same degree of bias and carelessness would contaminate his professional contributions.

On the other hand, though, I cannot say that all the fault lies with Vasquez. As a doctoral student, he had a supervisor and a dissertation committee, all of them apparently with doctoral degrees. Why did they sign off on this level of work? Did they not realize that a dissertation may be cited, quoted, and used as the basis for further claims? As far as I can see, none of the committee specialize in adoption issues or in childhood mental health problems. Why did they agree to support this work if they knew little about it? Given that a doctoral candidate temporarily knows more about what he or she did than anyone else in the world, why did they not at least insist that this student explore alternative explanations of his interview findings? Do they not think that the discipline of social work depends on adequate research, not just on sympathy with suffering people?

It’s my hope that this committee and others supervising social work graduate students will read the forthcoming book by Bruce Thyer and Monica Pignotti, Science and pseudoscience in social work practice (Springer, 2015). Meanwhile, the rest of us have to deal with the release of yet another AT/HT proponent armed with an apparently respectable doctoral degree.  



  

Sunday, April 12, 2015

Stealing Words' Meanings for Fun and Profit: Floortime(TM) and Tummy Time


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

"Taming Tiny Tigers", by Kali Miller: A Tale Told With Trepidation

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”.