Concerned About Unconventional Mental Health Interventions?

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

Monday, October 5, 2015

What Adopted Toddlers Really Wish Their Parents Knew About Tantrums

A lot of people who are interested either in adoption or in child care advice have come across Sherrie Eldridge’s book Twenty things adopted children wish their adoptive parents knew. I’ve seen a number of otherwise intelligent and competent people fall for some of Eldridge’s beliefs—especially the one about the child adopted at birth who sorely misses the birth mother and has to be reminded to process that grief. One adopted mother I know spent hours and hours telling her little boy about his birth mother, making scrapbooks, etc., etc., and completely missing the point that because he went to a foster family at birth and was adopted at 15 months, if he missed anybody, it was the foster family!

Eldridge has recently reiterated this advice at She recommends that mothers dealing with toddler tantrums should use what used to be called a “basket hold”, approaching from behind, pulling the child toward them, holding his hands crossed over his chest, and maintaining this position until the child calms down. This is, in my opinion, not at all a bad thing to do if a child is thrashing around and may get hurt--  but not necessary in the more standard fall-on-the-face-kick-and-scream version. But the interesting thing in her post is that a commenter, Mirah Riben, proposes that the adoptive mother should attribute the tantrum to unresolved grief and ask the child, “are you missing your first Mommy? I bet she misses you too”--  to which Eldridge rather testily replies that she has said this many times, but it wasn’t what she was talking about this time.

A couple of issues come to mind here. One is the question: do toddlers (or older individuals) adopted at birth or in the early months remember and miss their birth mothers? Does this make them angry and cause tantrums? Answer: No, probably not, on all counts. Memory for experiences is quite limited in the first months of life, and even events that a baby learns to recognize do not give rise to long-lasting memories unless the events are repeated many times. A toddler or older child who is abruptly separated from a familiar caregiver will grieve and be depressed and irritable for some months, but this reaction does not occur before about 8 months of age at the youngest, and the child recovers completely if given good care and emotional support by a new caregiver.

What about the anger? Is a toddler who is angry only having tantrums because of a past loss? No, to tantrum is human, to forgive, the capacity of a mature adult. In fact, tantrums are not only human, they are characteristic of all the higher primates. Harriet Rheingold, an animal behavior researcher, described years ago how she saw baby baboons on the Serengeti throw themselves on the ground in full-scale tantrums when their mothers would not pick them up and carry them. (Baboon mothers are not the pushovers that humans are--  they refuse to pick up when the baby gets to 7% of the mother’s body weight.)

Tantrums are a response to current frustration, not to long-past separation. Difficult as they may be to cope with, toddler tantrums are also evidence of good development in that the child knows what he wants and recognizes that it isn’t happening, a real step forward from the  easily distracted baby. But they are also an indication of the underlying immaturity of the child, who isn’t yet able to make himself wait or to think about how best to get what he wants.

It’s all well and good to think about how normal tantrums are, but that doesn’t mean that they are easy for parents to tolerate--  especially in public, where stress is increased by people’s disapproving glares or advice to smack the child a good one. Are there things we can do during the tantrum, even when the tantrum doesn’t put the child in any danger? Probably there is nothing we can do to stop an ongoing tantrum, but we do need to keep ourselves from making the tantrum more intense by yelling at the child, hitting, etc. We also need to avoid making tantrum behavior  more likely by “giving in” after the tantrum is well underway.
Are there preventive efforts that can work? I think they are, and some of what I’m going to say about them is drawn from the work of Lisa Poelle, author of Chronic biting extinguished, a book about ways parents and caregivers can change their own ways and improve aggressive and oppositional behavior in children 6 months to 3 years old.

Poelle’s first suggestion, and mine too, is that adults must plan how to work with toddlers in ways that will reduce the frequency and intensity of tantrums. This is not just about what you do when the tantrum begins; it’s about how you structure the child’s life. Poelle suggests using an action plan worksheet, which involves a number of observations to be done before you begin to plan your approach. For each observation, the adult needs to think in terms of the apparent reasons for the behavior: did it have to do with the child’s stage of development? With previous experiences and recent changes in the environment? With the child’s verbal skills? With the child’s physical condition? Understanding these, and working on them when possible, can help reduce tantrums--  and it can improve adults’ ability to tolerate tantrums rather than to take them as personal attacks.

I want to comment on the physical condition issue first, as I think this one is the easiest to work on. Adults need to be aware when children may be hungry or thirsty, and to recognize that additional frustrations at those times may lead to tantrums. (Incidentally, Poelle points out that children in day care often do not get enough to drink.) Fatigue is another contributor to tantrum frequency. This is a situation where the sensitivity of an adult to the child’s needs may make all the difference. I am not suggesting that toddlers should always be given just what they want for fear of a tantrum--  but adults should have the empathetic ability to recognize that the child’s needs  are not the same as an adult’s. For example, imagine this scenario: Mother picks up two-year-old from day care at noon and decides to stop at a store on the way home to see if she can find a wedding present for a friend. She takes the child into the store in a stroller, and from time to time leaves him there while she steps just a few feet away, but to a place the child can’t see from his vantage point. Can we expect a tantrum? Child is  hungry and tired; mother keeps disappearing; mother doesn’t look at him, or frowns when she does so; mother is also hungry, tired, and anxious about her errand, so what else could this combination add up to? Now throw in a few shoppers giving the crying child and mother dirty looks, or clerks muttering to themselves about brats. We have a perfect tantrum-storm, but one that could have been prevented by planning that took the child’s (and mother’s) physical needs into account

Now let’s have a look at the child’s verbal skills. How do these contribute? One part has to do with the child being unable to express his feelings and wishes, another part with his being unable to understand what adults say. (I remember a massive and unexpected tantrum by one of my children when I said I would cut some daffodils for a friend, and then I would cut some forsythia. But to his extreme distress I did not cut any daffodils for “Sythia”!) It can help a lot to work closely with the child’s verbal abilities--  but as Poelle points out, a child can have excellent verbal skills but poor impulse control, so this is not always the answer.

Previous experiences and recent changes? When a child has been subjected to extremes of discipline, both too much and too little at different times, he may have a disturbing level of anxiety about his own distress, creating even more tension and frustration. And recent changes like entering or changing child care, moving to a new house, having a new baby born, and adult moving in or out of the household, may create frustration. It’s critical to remember that good changes as well as bad ones can have this effect, so that wonderful birthday party with the cake and the exciting pony rides and the hats and masks may be followed by tantrums, just as a miserable experience might be. Life doesn’t always allow us to “titrate” a child’s exposure to change, but when it does, we need to think about preventing toddlers from having too much happen in too little time. Or, if we can’t manage that, we should at least be aware that a resulting tantrum is not unreasonable as an outcome.

There’s a lot more to be said about Eldridge’s suggestions—especially at what may result from telling a child he misses someone he can’t remember--  but that discussion will have to wait for another day.

Monday, September 28, 2015

You Can't Go Home Again, or Back to the Cradle Either

I recently commented on a book by one Mary Evelyn Greene ( Greene described all the difficulties of her adoption of children from a Russian orphanage, emphasizing the little boy’s “feral” nature and violent aggression. Subsequently, I received the following comment on my post (the commenter gave other information as well, so interested readers may want to look back at both the comments):

But in this book there is nothing about the treatment of Peter but only lyric debris and accusations against Russia and the orphanage. Although she could refuse, and even had an offer from the administration of the orphanage. It is impossible to separate brothers and sisters. She had two children to adopt or reject both. There was no deception. Only 6 months after the adoption has begun a significant regression of Peter. What's foster family did wrong during these 6 months? The book does not answer this question.

"Russian Roulette: A Review of When Rain Hurts: An Adoptive Mother's Journey with Fetal Alcohol Syndrome"
November 2014
- See more at:
excerpts from the article -
"Having spent thousands of dollars and precious months filing paperwork, Greene and her husband finally took their first trip to a remote Russian outpost only to discover the boy they'd set their heart on was clearly too ill to take on. There they were introduced to a two-year-old girl, and instantly fell in love ..............
After six months, this boy "woke up in a primal scream" and became completely uncontrollable-defecating at will (though long toilet trained in Russia), and vomiting at every meal. His speech was primitive, he refused eye contact, and he was physically destructive. Greene says he went from being "like a cuddly toddler" to something "more like an explosive device."
A doctor advised them to try "attachment coaching." They needed to treat Peter like a baby, so he could experience the developmental stages he missed in the orphanage.
"At times I felt we were breaking a horse," writes Greene before she realizes: "His entire repertoire of behaviors was designed to inoculate himself against the dangers of love and intimacy. I was not breaking a horse. I was nurturing a helpless foal .  “

Of course, I have no idea of the accuracy of anyone’s statements here --  Greene’s description,  the comments, or the review. However, all of these involve ideas that I think require close examination.

The first of these is ideas that if a child suddenly shows difficult behaviors after a calm six months, the cause of these behaviors must have occurred in earlier life , and not be associated with any more recent experiences. This thinking involves a kind of primitive “infantile determinism” that assumes that all problems must come from an early stage of development—ignoring the reality that past and present experiences as well as maturational factors work together to determine an individual’s present characteristics. The idea that the child woke with a “primal scream” (not just a scream) indicates the assumption that traumatic experiences in very early life have been repressed and now are breaking through; the whole “primal” or “primal scream” concept (popular in the 1970s following the proposals made by Janov) focused on the experience of birth as terrible, and impossible to handle in a rational way unless re-experienced and re-processed.  Related to this belief in “primal” is the view that a child who defecates without control and vomits frequently must be doing these things as emotional acting-out and not because of physical illness. Greene seems to have further revealed her belief system by saying that Peter defecated “at will”, echoing the claim of the holding therapist Keith Reber and others that children with attachment disorders could defecate or vomit voluntarily.

The second issue that needs addressing is the recommendation for so-called “attachment coaching” and for causing Peter to “experience the developmental stages he had missed in the orphanage”. This belief has a long history  (50-100 years of it) among the wilder psychoanalysts like Ferenczi and Fromm-Reichmann, who were convinced that by acting out nurturing  events for patients, they could somehow “re-do” the patients’ early experiences, which the therapists blamed for all mental illness including schizophrenia.  This view--  which naturally appeals to the wish we all have to be able to “fix” emotional disturbances—was also encouraged by claims that hypnosis or other techniques could cause age regression (these claims were strongly contradicted by systematic investigations).

It is not plausible that existing psychological development can be undone and started over, however unsatisfactory were the conditions in which it occurred. Think of that claim and what it would mean if it were made with respect to physical development. A child may be of unusually small stature or may have an unusual pattern of bone development due to early malnutrition. Could we rationally expect a good diet in later years to “regress” the child to a state of infantile skeletal development, and to cause new growth and bone maturation that will create a more typical body? The answer is NO, of course, and I would point out that all the present emphasis on brain development as the basis of emotional development should be considered analogously; no experience can undo the existing synapses or change the history of migration of neurons to different parts of the brain, any more than diet can alter salient characteristics of bones that have already formed.

Third, let’s consider Greene’s statement that Peter’s behavior was designed “to inoculate himself against the dangers of love and intimacy”. This is one of the mantras of attachment therapy/holding therapy, and has been repeated in woozle-like fashion for many years now. No doubt this is what Greene was told before the adoption occurred, and what she heard on many occasions afterward. However, this belief is based not on evidence from child behavior, but on an analogy to the feelings of adults whose companions have chosen to leave them--  post-divorce, for example. These people are often irritable with others and may be preoccupied with the dangers of intimacy, sometimes rejecting possible new mates on the grounds that “women/men are all alike and you can’t trust them”. But is it possible for a young child to do the same?

In the 1940s, Bowlby and Spitz put great emphasis on the idea that young children separated from familiar caregivers would become depressed, eat and sleep poorly, and be unable to accept care from other adults. Bowlby’s film “Nine days in a residential nursery” showed the physical illness and emotional distress of a two-year-old left in a nursery while his mother had a baby; the child rejected his mother when she came back to pick him up. But that film showed that the child received little attention from caregivers (or from his father, who dropped in briefly every day) and was overwhelmed by other children in the nursery. Bowlby’s colleague James Robertson later showed that young children separated from familiar people but given plenty of sensitive, responsive care did not in fact seem nearly as badly affected as the child in Bowlby’s film.

The belief that adopted children intentionally reject love is one that assumes that the adopted child is adult-like in abilities and reactions—indeed, that he is more capable than an adult of controlling his own behavior. Curiously, that school of thought does not assume that nonadopted infants are rejecting love when they cry nerve-wrackingly, have tantrums, or do that trick that enables them to weigh 40 pounds extra when they do not want to be picked up.  Somehow, the adopted child is considered to do on purpose all sorts of things that in other children would be thought to be outside their control. She is also said to do these things because she does not want to be loved, on account of the losses or disappointments she has already experienced. These ideas are simply assertions, because there is no evidence to suggest that a child does not want affection, and it is more likely that he or she has no experience of the codes adults use to signal the giving or receiving of love.

I am not one to quote Freud frequently, but there was a term he used about implausible treatments of these kinds. He referred to their proponents as having a furor sanandi—a frenzied wish to heal. Unfortunately, unless that furor is turned to methods that are at least plausible, and better yet evidence-based, the wish to heal may well culminate in the fact of harm. 

Tuesday, September 22, 2015

Is Parental Alienation Child Abuse?

For some years now, some psychologists and some divorced parents have been arguing that one parent may alienate a child from the other parent by systematically manipulating and exploiting the child’s beliefs and needs. The child then rejects contact with the noncustodial parent simply because of the alienating behavior of the custodial parent, and not because of any realistic fear or expectation of abusive treatment. This process and outcome have been referred to as “parental alienation”, presumably a term derived from the old legal term “alienation of affections”, referring to the seduction of someone’s adult partner.

Accusations of parental alienation have often been used in the courtroom as part of divorce strategies, but over the years such accusations have been met more frequently by counter-accusations about the manipulative and controlling motives of the parent who feels rejected. Although most of the initial discussions about PA focused on the rights of each parent to have contact with a child, and were quite often embedded in fathers’ rights claims, such a focus was obviously an open invitation to accusations of selfishness, egotism, even (of course) narcissism. Possibly as a result of this, possibly because of ongoing research, within the last several years the strategy shifted to the claim that PA is a form of child abuse, and to attempts to support this view by demonstrating poor adult outcomes for children who experienced PA.

Is PA child abuse? Well, the real answer to that is, it is if we say it is—“we” being the public whose shifting attitudes help to determine how child abuse is defined legally and otherwise.

The historical changes in definitions of child abuse are very obvious. To begin with, the very term emerged only with the work of Henry Kempe and his colleagues in the early 1960s. Before that, an adult who was shown to have harmed a child directly might be prosecuted in the same way as would have occurred if he harmed another adult--  or, he might not, any more than if he had harmed his wife. Some levels of abusive treatment (by today’s standards) were considered the perquisite of a parent, and more especially of a father. (In Samuel Butler’s novel The way of all flesh, set in about 1860, a father beats his four-year-old with a stick for saying “tum” rather than “come”, and is thought to be an excellent parent and excellent clergyman by all who know him.)  In addition, behavior that would now be considered abusive, like putting a child in a dark closet or limiting their food,  would usually have been considered just good old-fashioned parenting.

Today, treatment that is considered abusive from a legal viewpoint is not necessarily the same as treatment defined as abusive for research purposes. In Andrea Sedlak’s 2001 document published by the Department of Health and Human Services, for research purposes, spousal abuse in the child’s presence is regarded as child abuse, for example. Sedlak also described how the standards had relaxed from a requirement that an act actually harm the child before it was considered abuse, to a standard in which endangerment, or potential for harm, was defined as abusive. Under the harm standard, for example, failure to give a child adequate emotional support would count as abusive only if judged as serious, but under the endangerment standard could be counted under less serious conditions.

An important point about changing definitions of child abuse is that developmental outcomes of an action do not need to be demonstrated to be negatively affected in order for the action to be considered abusive. Use of terms like “harm” or “endangerment” implies that we consider an action to be abusive because it is known to cause harm to a child in the short or long run. But this is not necessarily the case, nor is harmfulness necessarily the criterion for identifying an act as abusive.

Obviously, many acts considered abusive are thought of in that way because they cause harm, or have the potential to cause harm, either in the short or in the long run. However, some actions that are argued to be harmful in the long run, like spanking, are not considered abusive unless they cause direct harm in the short run. Other actions, like any interaction with sexual implications, may be seen as abusive whether or not either immediate or later harm has been demonstrated. (For example, Cindy Hamilton’s nude photographs of her children[“Hold Still”] were seen as highly controversial  and possibly abusive.) Susan Clancy’s research on people who as children had experienced non-coerced, non-penetrative sexual contact with adults suggested that harm did not result from these experiences, but such contact is nevertheless considered deeply repugnant by most adults in the U.S. and is identified as abusive.

We can see, then, that there is an overlap between acts considered abusive and acts shown to be harmful, but the categories are somewhat different. This leads to a look at efforts to show that PA is abusive and that a parent shown to be alienating deserves to be treated as an abuser and separated from the child, for the child’s own good. Amy Baker, in her book Adult Children of Parental Alienation Syndrome, reports that she has interviewed 40 adults whom she contacted because of their statements on the Internet or by word of mouth. Baker looked at interviews with     these people in terms of their experiences with emotional abuse, as defined some years ago by James Garbarino, and including actions like isolating the child, terrorizing the child, and corrupting the child. She reported that these emotionally abusive acts were recalled by the adult interviewees as accompanying or forming part of parental alienation efforts, and that the adults remained troubled by their experiences.

Was this approach a good way to demonstrate that PA is child abuse? As a beginning for research, it was probably the best that could be managed for the time being. However, take a look at some of the problems about drawing any clear conclusion from this work. First, we have the fact that the persons chosen for interviewing were already so concerned about their present situation and past history that they were telling their stories on the Internet. These were not the people who say, “My father always made nasty remarks about my mother and didn’t want me to see her, but actually I got along fine and am doing well now. I think I understand where both of them were coming from, although of course I didn’t want them to divorce when they did.” Baker’s work of necessity focused on people who felt that PA had occurred and that it still influenced their lives in a negative way.

Second, Baker’s work completely conflates PA with emotional abuse. It would not be surprising if the interviewees whose parents were emotionally abusive would be unhappy and troubled as they recall those events--  whether or not there had been PA involved, or even whether or not there had been a divorce (and indeed Baker acknowledges that a child may reject a parent while the marriage remains intact).
To show that PA is harmful in the short or long run would require longitudinal studies in which children who appeared to be in a PA situation were followed into adolescence and adulthood and evaluated with respect to adaptive coping and mood. These individuals would need to be compared with a similar group without the PA experience, but matched on experiences like divorce and emotional abuse. That work is not very likely to happen, for many reasons—but unless it does, we cannot responsibly say that PA in and of itself is harmful, and, therefore, abusive.   
As I said earlier, there are a number of actions toward children that are considered abusive without evidence that they are harmful, just because we as a society find them reprehensible. It’s possible that PA might someday join that category, but at present it appears to me that American and Canadian society in general see PA as bad manners and a bad example to children, but not as harmful to children, and not to be considered abusive because of its effects. Because this is the case--  evidence of harm is not clear, and the consensus does not see PA as child abuse--  I believe it is a mistake for the courts to accept arguments about PA as a reason to alter custody arrangements or to order children into therapies claiming to treat PA. I consider it an especially egregious mistake for courts to refuse a parent contact with a child because that parent will not confess to PA-related actions; this is all too reminiscent of the old Satanic Ritual Abuse accusations, in which a parent could not be with a child if he or she denied SRA, but certainly could not contact the child if he or she “confessed”.

Sunday, September 20, 2015

More on Craig Childress: A Reader Comment and Responses

For reasons unknown to me, this reader comment disappeared from my blogspot page twice when I tried to post it. Because it is a thoughtful and civil statement, I am posting it here--  but since I must still query Childress’ claims, I will follow it with some further comments of my own. Here is the reader’s comment:

“Dear Ms Mercer, I am a parent whose children are living through the profound trauma and dysfunction of parental alienation. I have read quite widely on the subject during the year since our nightmare began. Having encountered Childress' work in the last couple of months, my judgement is that, while it does not provide an answer to every question one can ask, it has taken the theoretical understanding and conceptualisation of parental alienation forwards in huge strides. I think that his work might be looked back on in years to come as ‘game-changing’.

His blog posts are indeed, on occasion, somewhat abrasive towards others in the field of mental health. However, aside from the fact that given the persistent failure of mental health to respond at all effectively to this desperate problem his blunt criticisms might well be considered justified, I suspect that he is deliberately seeking to provoke in order to stimulate debate, raise awareness, project his work into the mainstream discourse - all of which will lead to more work by others on this subject.

I wonder if your slightly snarky initial response to his work might at least in part a reaction to his manner, and that your response to his style might be colouring your response to his substance. As an informed lay person who has read every document on his website, part of his book ‘Foundations’, and viewed every Youtube video he has posted, I can only say that I have found his work to be illuminating, clearly articulated, persuasive and coherent.

The experience of rejected parents has been described as a ‘living bereavement’ and this resonates deeply for me. Work exploring the experience of adult ‘survivors’ of childhood parental alienation (e.g. by Amy Baker), attests to the serious, lifelong effects of parental alienation on child victims. Yet, your post is not imbued with any apparent empathy for the heart-breaking plight of children and parents whose loving relationships are utterly destroyed by parental alienation. That would be welcome in any further blog posts you might publish on the subject.

I note Childress responded to your post on his blog and invited further discussion. I do hope you take up this offer.

Thank you.

P.S. Childress works at the University of Phoenix. He was invited to present lectures by California Southern University. 

It is certainly true that Childress’ Facebook remarks set my teeth on edge. Professional discourse does not usually include statements about the ignorance of those who disagree with one. In addition, I am concerned about the proliferation of references to “attachment” and “trauma” as if these factors can be worked into explanations of every human outcome. As a developmental psychologist, I am very much aware of the potential confounding of variables that can lead to wrong answers to apparently simple questions. As a student of and author on attachment issues, I am also aware of the possibility that claims about attachment may just reflect the fact that “good things go together” in development.

The commenter rather gently chides me for an apparent lack of empathy for families embroiled in the rejection of one parent by one or more children. I am sorry to have given this impression, as I am sure I would have gone through hell and high water to keep in contact with my children if they had been separated from me.

But, strange as it may seem to some readers, it is my real concern for children that has led me to query statements by various mental health practitioners about the effectiveness of treatments they offer. In a series of articles in the journal Research on Social Work Practice, I recently evaluated the plausibility of and empirical evidence for several psychotherapies for children. In my 2014 book, Alternative psychotherapies (Rowman & Littlefield), I did the same for a variety of mental health and educational interventions that make strong claims without real justification.

Some of the treatments I have evaluated are potentially directly harmful and have already injured and killed a small number of children (I am far from suggesting that this is an issue for Childress’ methods, please note!). Others are indirectly harmful, in that they take time and family resources without having a positive effect, and in that they may interfere with the seeking of more effective treatments.

I believe that this work, although not experienced as warm or supportive by families in trouble, can in fact be very beneficial to them by pointing out possible realities of offered interventions that may be presented in an attractive way but that are not likely to be of genuine help. Most psychologists are uneasy about asking pointed questions about practitioners’ theories and methods. I am not--  I was broken in on this by my investigation of the death of Candace Newmaker at the hands of “attachment therapists” (see Mercer, Sarner, & Rosa, Attachment therapy on trial. Praeger, 2003).

I hope that the author of the comment quoted above will see my position here. I have been commenting on Childress’ blog, where I am asking him to fill me in on a couple of points: What would be the earliest age at which he would think the issues he addresses would emerge? What is the age of the youngest child he has treated? How does he ascertain whether a rejecting child actually has been abused or frightened by the rejected parent? In what proportion of cases, in his experience, has a case brought to him as a matter of parental alienation actually turned out to turn on abusive behavior? These seem to me to be simple but important questions, and I am hoping for some simple answers.

Sunday, September 13, 2015

Randomization? Yes; Isolated Variable? No: Claims About QST for Autism

Last week, I received a message forwarded from an old colleague, with a link to an article in an open access journal. Here’s the reference: Silva, L.M.T., Schalock, M., Gabrielsen, K.R., Budden, S.S., Buenrostro, M., & Hortin, G. (2015). Early intervention with a parent-delivered massage protocol directed at tactile abnormalities decreases severity of autism and improves child-to-parent interactions: A replication study. Autism Research and Treatment.

I was curious about this because I know my old colleague is a fan of DIR/Floortime, and DIR/Floortime has been accompanied quite frequently by various alternative, non-evidence-based treatments like SIT. The Silva et al study was introduced as dealing with a treatment said by the authors to be shown to be evidence-based--  QST, or Qigong Sensory Treatment. QST involves a whole-body massage usually done at bedtime. According to the Silva et al article, “the protocol has 12 parts that follow the acupuncture channels down the front and back of the body. Massage is carried out in a downward direction towards the hands and feet in the direction of capillary blood flow.” Children who were treated with QST experienced a massage lasting about 15 minutes on most nights for a five month period. They also received 20 sessions of massage by therapist.

Children were recruited to the study by advertising and by invitation letters to those who were already receiving autism services from the state of Oregon. After screening, children were assigned at random either to a treatment group, receiving the treatment just described, or to a waitlist group, receiving no treatment other than what they had been getting before (two children were receiving ABA treatment). . Evaluation scores for the two groups were compared to each other statistically at the end of a five month treatment period. Professional evaluators did not know which group a child was in, but information was also collected from parents, who, of course, were aware of the child’s treatment status.

The study authors concluded that QST could be considered an evidence-based treatment, because significant advantages for the treatment group were found in this randomized, controlled study. But here is where it all goes agley, because although randomization is necessary for collection of evidence supporting a therapy, it is not sufficient.

There is a purpose to randomization. It is not simply a ritual carried out so the research gods will smile upon a study. The reason for randomization is that it is a step that helps to isolate a variable—to make sure, in the old phrase, that we are comparing apples to apples, not to oranges or tutti-frutti. Randomizing participants to groups is useful only if the researchers have previously designed the groups so that they resemble each other closely on as many particulars as can be managed, except for the specific factor whose effects are being studied. If the groups are given very different experiences, it is impossible to nail down which factor  or factors caused the observed outcome.

Randomizing the participants in this study made sure that there were not more boys than girls, or more older than younger children, or more or less severely-affected children, in the treatment group than in the comparison group. That was an excellent step and made sure that  the treatment was not made to look good just because, for example, the children in the treatment group were less troubled to start with. But then the problem began, because the children in the treatment group did not have experiences that were different in a simple way from the experiences of the control group. Yes, one group got QST, and the other didn’t, but when we unpack those facts, we find that there were a number of unnecessary differences between the groups’ experiences—differences that confuse the issue of the effects of the treatment.

The group of children that got QST, with its downward massage along acupuncture channels, also received more than 30 hours of intimate contact with their parents, and 20 hours of contact with massage therapists, over about 150 days. Parents were taught to modulate their massage efforts in response to a child’s apparent acceptance or rejection of a kind of touch, so the children also experienced some number of events of successful communication with a parent--  possibly an important factor, considering the difficulty of autistic children with communication.

Parents of children in the treatment group received warm treatment and training from the therapists who taught them to do massage, and frequent repeated contacts as the researchers tried to keep the parent massage at the desired standard. For parents suffering from the stresses of caring for autistic children, the social and emotional support of the research group, and the sense of hope engendered by learning this new approach, may have helped them tolerate both ordinary daily problems and the constant concern about their children’s future; increased hope and tolerance could improve the parent’s ability to interact positively with a difficult child. Like the children, the parents could well have been affected by nightly interactions involving a predictable ritual and providing a chance to experience success. All of these factors had the potential for actually helping the parent do a better job with the child in general (separately from the QST) and to regard the child more positively, perhaps yielding better parent evaluations.

What about the waitlisted control group? The children may not have been very much aware that a new form of treatment might be available, so they may have been affected only by the absence of QST and of the related factors described above.  But what about the parents? Presumably they were eager to try QST, or they would not have gone to the trouble of answering the research invitations. When assigned to the waitlist, some may have reacted philosophically, realizing that their children would get a later chance for treatment.  However, many may have been deeply disappointed and contemplated with distress another five months in which their children--  whom nothing had helped much so far—were still not getting the help that had seemed to be on the horizon. Discouraged parents with waitlisted children may have said to each other, “I was so excited about this new thing, but now we have to wait some more. I don’t have much hope that our kids will ever get any better.” Such reactions could affect both attitudes and behavior toward children, and evaluations of children’s conditions.

Naturally, I can’t say which, if any, of these things actually did happen. But I can say how the researchers could have designed the study so that the results had much more meaning. While the treatment group received QST, the control group could have been given a similar massage treatment that did not involve the “channels” claimed as the essence of the treatment.  If parents were simply taught one or the other massage, and were not informed which was the “real” QST and which was a sham, the problem of blinding and of parent attitudes would be solved. A study in which QST outcomes were significantly better than sham outcomes would justify the researchers’ claim that QST should be considered evidence-based.

Unfortunately,  Silva et al are not alone in erroneously claiming that randomization and control alone are sufficient to provide evidence of a treatment’s effectiveness. There is a lot of this around just now.  Studies of DIR/Floortime have shown very similar problems. A few months ago I pointed out on this blog that the Bucharest Early Intervention Study failed to isolate the variable under investigation, even though randomization was used.

Catchphrases like randomization, control, RCT, evidence-based treatment, are deceptive for those who do not fully understand them. Like the alcohol rub for fever discussed long ago by Dr. Spock, they smell important, but they can be used incorrectly. The difficulty is that somebody really has to read the work in order to know whether, like alcohol, it evaporates on contact.


Thursday, September 3, 2015

When Nonsense Hurts: Mary Evelyn Greene's Adoption Book

With her 2013 book, When rain hurts, Mary Evelyn Greene has added yet another dramatic chapter to the ongoing trauma-mama narrative. This is certainly her privilege, and there is no doubt that her experience of adoption was a painful one in which she came up against some disturbing advice that she may have been too distraught to recognize for what it was. However, like other material in this genre, Greene’s commentary offers the potential for harm to other adoptive families as it features nonsensical explanations and interventions.

The summary of Greene’s book on Amazon contains some significant details about the story and the attitudes presented. Greene adopted a three-year-old boy (as well as another child) from a Russian orphanage. The boy, called Peter, is described as suffering from Fetal Alcohol Syndrome and as being “feral”. Greene is said in this summary to have sought “a magical path of healing and forgiveness for her son”. The summary material alone is enough to raise some concerns.

The first is the description of Peter as “feral”, suggesting that he, like “the wild boy of Aveyron” in the 19th century, may be incapable of being socialized; this terminology also calls to mind the words of Greene’s adviser Ronald Federici, as he was quoted in a Harper’s 2013 article: “the kids I see are feral as animals… I’ve dealt with four Russian kids who’ve murdered their parents…”. Readers who accept the word “feral” as being an accurate and chilling description are having their attitudes manipulated, potentially causing them to regard Russian-adopted children with expectations of seriously disturbed behavior--  and while such behavior can certainly exist, its description can become a self-fulfilling prophecy for otherwise na├»ve readers.
A second issue in the summary is the reference to a “magical path.” Yes, this is without a doubt just what Greene wanted—an approach that would cut straight through logic and scientific evidence to the outcome she envisaged, whether or not such an outcome was actually possible for Peter. This path was also to involve forgiveness, and while I assume this means the questionable assumption that the maltreated child is full of rage and must forgive those who harmed him in order to improve, I cannot help feeling that Greene also recognized her own need to forgive herself and the world for the position she had chosen to be in.

I mentioned a couple of paragraphs ago that Greene was advised by Ronald Federici. Federici, a self-proclaimed world expert on adoption, is the author of a self-published book, Help for the hopeless child, in which he recommends what he calls “therapeutic holding”. This technique, which Federici shares with David Ziegler, head of the Jasper Mountain, OR, residential treatment program for children, is strongly related to the “holding therapy” done by Zaslow, Cline, etc., etc. The difference between the two is that “therapeutic holding” is brought to bear when the child is already distraught, whereas  “holding therapy” includes a period in which a calm child is brought to a distressed state. In his Help book, Federici recommends forcing a distressed or noncompliant child to lie prone, then holding him or her down by having the parents put their body weight across the upper back and the legs. The prone position is well known to offer unusual dangers for asphyxiation; although Federici has never changed the material in Help in response to reminders of this, he apparently did not tell Greene to restrain Peter in that way. Instead, according to Greene, he advised a variant of the use of the “prolonged parent-child embrace” form of treatment, as advocated by Martha Welch and Jirina Prekopova.  In this variation, the child is initially held in what used to be called a “basket hold”, with his back against the adult’s chest and the adult’s arms around him. When the child has been quiet for three minutes, he is turned around for a face-to-face embrace (Greene does not say how long this is to last, but in Welch’s and Prekopova’s methods, it can last an hour). The problem, of course, is the same for all these techniques: the child may not quiet sufficiently until after an hour or more of physical struggle. There is no question that the experience of this lengthy restraint can give the child a clear message about the authority of the adult and place the child in a state of fearful dependency, as described by Federici in his Help book. Why it should be done is another matter, especially in the absence of any systematic data providing evidence for its effectiveness.  But of course, if Greene was seeking a “magical path”, this would not have mattered to her.

Federici and Ziegler have both denied being “holding therapists”,  but in Greene’s case Federici seems to have tolerated or encouraged the presence of one Suzanne d’Averna, a social worker who advised the use of a number of adjuvant treatments of the kind used by “holding therapists” for some 30 years or more. These included the use of joint compression (an alternative treatment primarily designed for autistic individuals). “strong sitting” ( immobility on command, a specialty of holding therapists who believe they are treating attachment disorders, but clearly yet another exertion of authority over the child), and “re-parenting” by means of spoon- and bottle-feeding children who are capable of and accustomed to feeding themselves. Greene attempted bottle-feeding with the school-age Peter, and when he resisted, attributed his reaction to an inability to “handle intimate, physical contact”, not to the ridiculously age-inappropriate position he was being placed in. No evidence exists to support the effectiveness of any of the interventions employed. If Greene was indeed seeking a “magical path”, she found a version of one here, as only magical thinking would lead to the idea that ritual re-enactment of infant care routines could return a child to developmental square one and then bring him back to today, with all long-term problems erased.  There is potential harm in this claim for readers who believe it appropriate to adopt for their children the same “recipe” followed by Greene.

So much more could be said here, but one more point will have to do. Was Peter actually suffering from the effects of prenatal alcohol exposure? His head circumference appears to have been normal, and the major reason for speaking of him as FAS-affected seems to have been the absence of a philtrum or fetal groove in the area between the upper lip and the nose. This and some other symptoms may be shared by children with FAS and  by those who have been affected by Dilantin prenatally, or those with genetic problems like Prader-Willi syndrome. Greene also discusses the possibility of mitochondrial disease.  What is the issue here? It’s that Greene has somehow transformed this ambiguous situation into one that is declared to involve FAS—even the book’s subtitle says so. So we end with a sort of nonsense that is potentially harmful to readers who want to find out what happens to FAS children, how they develop, and how they should be treated, but who somehow miss the point that Peter may not after all even have been a victim of FAS. And if he was not… is it possible that his escalating problems were iatrogenic in nature? Greene’s dramatic depiction of life with Peter fails to touch on the possibility that some of his problems may have resulted from the treatment efforts described--  efforts that may in fact prove harmful to the families of the readers who are attracted to this book.

Wednesday, August 19, 2015

Craig Childress Tries to Drag Attachment Theory Into the Parental Alienation Swamp

It was only a few weeks ago that I first encountered the name of the California psychologist Craig Childress. The context was a discussion with advocates of the concept of parental alienation (PA to its familiars). If you have not yet encountered PA, you have been lucky so far, but that luck is about to run out if you keep reading. There may be such a thing as PA—no doubt there sometimes is—but it is embedded in a morass.
PA is a designation for the events and results that may occur in a divorce if one parent influences a child to reject the other. The rejection is evidenced by the child’s willingness to remain in the care of one parent but fear of and reluctance to be with the other. If the first of these people is seen to be persuading the child to fear and avoid the other parent, the former is sometimes described as the alienating parent, and the latter as the alienated parent (although this last is rather confusing because it is the child who feels alienated from the rejected parent, not the parent himself or herself). My own preference would be to call the people the accepted parent and the rejected parent, respectively.

 Some students of PA, especially, it seems, those connected with fathers’ rights groups, propose that a child cannot develop in a mentally healthy fashion without relationships with both parents, and that therefore the alienation must be resolved for the child’s own sake. As a result of this assumption, they define situations of PA as child abuse, unless there are rational motives for the child’s rejection, for example that the rejected parent has been frightening or abusive in the past. If PA is abusive, the accepted parent is an abuser, and needs to have his or her behavior corrected; the rejected parent is a victim, and needs the relationship with the child restored in order to facilitate the child’s emotional development. When courts are in the picture, of course, the treatment of the accepted and rejected parents can include the threat or reality of custody or visitation changes as means to stop PA, or court-ordered therapies designed to correct the situation and foster good relations between the child and the parent(s) who cooperate in the process.

Advocates of PA have argued that there is a definable parental alienation syndrome (PAS) that should have been included in DSM-5. The DSM-5 group rejected this proposal on the grounds that there is no evidence that PAS exists in some way that makes it separate from other diagnoses in the manual. Similarly, there is at this time no support for the idea that any treatment used for PA is an evidence-based treatment. (This is why I refer to all this stuff as the parental alienation swamp.)

Now, here’s where we get to Craig Childress. Childress, a licensed clinical psychologist in California with a Psy.D. degree, and a faculty member at California Southern University, a distance-learning, on line outfit, has attacked others’ claims to treat PA and has presented his own claim that he knows 1) what causes PA behavior by accepted parents, and 2) how to treat the child’s rejection of one parent. He has published a book with a “boutique” publisher, Oaksong Press, about how this all works, and maintains an elaborate Facebook page and web site to argue for his views.  There he comments on the “abject ignorance” of his opponents, a statement no doubt entertaining to some of the FB audience, but certainly not professional discourse. (Childress’ on line CV appears to show no activity between 1985 and 1998, raising more than one question about his professional history.)

Let’s have a look at Childress’ claims about the sources of PA behavior by the accepted parent and the impact it has on a child. Childress attributes a parent’s persuasion of a child to reject the other parent to re-enactment of the accepted parent’s own traumatic attachment history.  Where such a history exists, he proposes, the affected parent develops a narcissistic/borderline personality, with a tendency to “split” the world into all-good and all-bad components. Childress chooses two aspects of a problematic development of attachment as critical here: the early existence of disorganized attachment, and relationships that involve role reversals, so that, e.g., child cares for mother. These characteristics, according to Childress, make the accepted parent a “pathogenic parent”.  This is an interesting set of ideas, and eminently testable by empirical means. But… Childress has not done this testing, and although on his web site he refers to his claims as “well established in the scientific literature” (notably omitting a list of references), this is certainly not the case if we assume as many do that “scientific literature” involves empirical work beyond the level of anecdote or clinical report. Yes, attachment theory is based on careful observational work and on longitudinal studies, but the fact that there is a scientific foundation for some aspects of attachment does not mean that the foundation can properly be generalized to every statement that shares concepts with attachment theory. (There is a good deal of this kind of thing around just now, I’m afraid.) As for pathogenicity of any parenting pattern, this requires longitudinal study to ascertain.

Let’s look at Childress’ claims about treatment of PA effects on children. He rejects the idea that reunification can be facilitated by work with the child and both parents. Instead, he proposes that help can be given only by “protective separation” of the child from the accepted parent. During this period of separation, the child experiences treatment as described by Childress on his web site, with the goal of coming to enjoy and seek to be with the formerly rejected parent. If the child is successful in meeting this goal for 10 weeks, two one-hour Skype or phone sessions per week with the formerly-accepted parent will be allowed. According to Childress, this method empowers the child: “It is in the child’s power to extend or shorten the Treatment period. If the child continues to remain symptomatic [i.e., express rejection of the parent], then the Treatment period can be continued to six months or longer. However, if the child chooses [sic, N.B.] to become non-symptomatic, then the Treatment period can be ended in as little as 8 weeks or less, based on the child’s behavior. “ Childress argues that a study design can be used to demonstrate the effectiveness of this method, but he does not appear to have done this, nor does he take into account the effect of maturational change.  

Is Childress’ approach less supported by empirical work than other PA approaches? No, it is not, although his pugnacity and undue confidence about his statements tend to obscure that fact. Actually, all of the PA discussions of which I am aware, as well as many judicial decisions concerned with parenting relationships, have the same flaw. They completely neglect  to consider the effects of developmental change on the child’s interactions with the social environment and their effect on him or her. The effects of parenting patterns on children involve transactional processes in which each person affects the other in ways that change over time; the changes occur because of learning by both parties and because of maturational changes, rapid in the child and slow but present in the adult. This means that when treatment is appropriate (an enormous issue), the way it is done, especially if it is to involve separation from the accepted parent, must be congruent with the child’s developmental needs for attachment and for exploration. These are vastly different in toddlers and in kindergarteners, and different from both in teenagers. Perhaps Childress does not mean to suggest that a two-year-old who resists going with his father should be separated from the mother for 8 or 10 weeks or longer--  but if he does not mean this, he would do well to say so.

There are many more issues to be considered here. I am still taken aback, I must say, by Childress’ view that a child may “choose” whether or not to show fear and rejection of a parent; there is a flavor of “breaking the spirit” about the whole thing. But the main considerations, I think, are 1) show us the evidence for these claims,  2) tell how developmental age should be taken into account, and 3) describe the treatment goals in transactional terms. This is a challenge that I hope will eventually be addressed not only by Childress but by other PA proponents.