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Monica Pignotti Responds to Adoptive Parent’s Comments

September 23, 2010
This is a response I received from someone who posted a comment to one of my previous blog articles who identified herself as Faith, an adoptive parent. I appreciate that Faith has made a real effort to address issues and thus, in order to give her the thoughtful response she deserves, rather than hide her remarks in the comment section, I am devoting this posting to responding to her. Since she raised a number of points, I will address them, one at a time. Faith’s comments are indented, followed by my point by point responses to each issue she raised. My responses are not in any way intended as specific advice to Faith or any other parent. They are only intended to be an expression of my own opinions and conclusions I have come to, having studied the relevant literature.

Faith wrote:

As an adoptive parent of a child adopted overseas from an orphanage, I must say that unless you have experienced parenting a child with diagnosed Fetal Alcohol Syndrome and Severe PTSD you really can’t know what techniques work and which ones don’t.
MP: While I would agree that someone who hasn’t experienced parenting such a child cannot understand on an experiential and emotional level what that is like, I do not agree that one has to experience something to be able to evaluate whether a treatment is effective. Here’s an analogy. Suppose someone had a child with cancer and made the same statement, that unless someone had experienced having a child with cancer, they could not know what treatments will be effective. Obviously, this is not the case. The way to know which treatments are effective is to evaluate the scientific evidence, rather than going by anecdotal word of mouth from other parents. Anyone who has the education and training can evaluate the evidence or lack thereof, for a particular treatment, regardless of whether they have had a child with cancer. The same holds true for the conditions you name.

My child was a serious danger to himself and to those around him during a meltdown.  Without the use of touching him during these times and using the safety restraints taught in professional training through the state and by a trained specialist, my son could not calm himself down.  To allow him to fling himself around the room banging his head on the floor, ect…there are times when restaints done with precision and with the motive of compassion and utmost safety are the kindest way to help the child.
You seem to be posing a dichotomy here: either do the holds Federici recommends in his book, or just allow the child to hurt himself. I never said a child should be allowed to hurt himself and I have certainly never said that one should never touch a child. What I am saying is that there are well-supported methods of of helping children to prevent escalation of behavior to that point in the first place. Heavy boot-camp type control methods, however, to show the child who is boss and what is essentially punishment, behavioral research has shown, does not work. If a child does have a meltdown in spite of these methods, restraints should only be used when there is an immediate threat and even then, only what is minimally necessary to prevent harm. Currently the recommended methods are not face-down prone restraints.

Dr. Federici teaches THAT type of hold in his book and in his practice.
First of all I have to say that I cannot comment on what Dr. Federici does in his practice as I haven’t observed him in practice and so I do not know whether he actually practices what he writes about.
[Note: in response to the latest blog slamming me for commenting on Federici’s writings, not having ever him met him in person,  professionals are responsible for what they write and publicly claim about their practices it is considered perfectly valid to criticize someone’s writings and claims without ever having met that person. Such criticism does not constitute “waging a hate campaign”. On the contrary, it is not the least bit personal. I don’t “hate” Federici. I am simply criticizing his writings and claims. One doesn’t need to observe what a person does first-hand in order to criticize their writings what they say and do in public appearances. Evidence Based Practice has nothing to do with first-hand observation of a therapist in practice and everything to do with actual evidence they provide to support the safety and efficacy of their approaches. Evidence is determined by doing a database search for peer reviewed journal publications of well-controlled studies, not meeting the therapist in person. That, along with reading his writings tells me all I need to know in order to criticize.]
I am only commenting in what he has written about in his book and what I have seen in videos such as Saving Dane or the BBC documentary and the face down prone restraint procedure recommends in his book is not one, based on my own careful examination of the current literature, that is currently recommended because face down prone restraints, particularly when people are putting weight on the child, will put a person at too high a risk for asphyxiation. The risk increases when this type of restraint is employed on an obese person or a person that is highly agitated as a child having a meltdown obviously is. That’s what the literature states and I have provided details on this in some of my earlier postings.
My child has gone from completely unattached and labeled with conduct disorder at 4 years of age to a gentleman with an open and joyful heart.
I’m glad to hear that, Faith. Are you aware that many internationally adopted children, even ones who were adopted late, do get better as time passes? There have been studies done that have followed such children through time, and many of them do improve over time, even without getting any therapy. I am not saying that this was necessarily the case with your son as I have never met your son and don’t know, but I’m just letting you know what the research has shown. Unless careful studies are done on a treatment, peer reviewed and published in journals, preferably studies conducted by people who do not have a vested interest in any particular brand of treatment, we cannot know what was responsible for a positive change.

Unless you are the
parent of a child like this, you do not know what you talking about.
Again Faith, I must respectfully disagree with you on that. Would you tell an Oncologist (cancer specialist) that unless he had cancer, he doesn’t know what he is talking about when it comes to treatment recommendations? If a parent had a child with cancer and decided that using a zapper would cure the cancer because other parents had told her they had great success with it and the Oncologist told the parent that the zapper was not something he would recommend, would you tell that Oncologist that he doesn’t know what he is talking about because he has never had cancer? I would hope not.

And by the way, although I haven’t had a child like this, I have actually worked with children and adolescents who do have very serious behavior problems. When I worked for a neuropsychologist, he saw children with extremely serious behavior problems. He got referrals from the legal system to see children who had started fires and gotten into other kinds of serious trouble, so I have seen, first hand what you are talking about, yet this person was often successful with such kids using behavior modification techniques and I never saw him recommend any radical type of program such as that described in Federici’s book and in witnessing his work with literally hundreds of clients never once heard him recommend that they do face-down prone restraint.

I love my child and have only wanted him to have his best chance at breaking through the barriers of mental illness that he was an innocent victim of in his early life.  His frame of mind was survival and manipulation.  Of course he would say, “I promise to stop….” and as any parent of a child with reactive attachment disorder and PTSD would identify with as being manipulated into letting the child continue to try to run the world through his distorted and rageful mindframe.
There is no evidence that children with RAD or PTSD are manipulative and if you look at the DSM, there is nothing in there about such behavior being part of those diagnoses. That is part of the urban legend attachment therapists have spread (for example, in the book by Magid & McKelvey, High Risk Children Without a Conscience) that has no basis in fact. The possibility that a child will manipulate, even if this were true, is not a valid reason to use restraints, if the child is not presenting an immediate, imminent threat. That’s what current guidelines state. There has to be an immediate threat and if the child backs down, then the threat no longer exists, thus restraints are being used for something other than safety — in that case they would be being used to stop a child from manipulating.
They are so scared that they lose control.  To let that go on when there are people who have used safe methods that work, to not try and help your child…is where I find the abuse.
In order to say that a method is safe and works, it must be tested in proper studies for safety and efficacy. There are no such randomized clinical trials testing Federici’s intervention for safety and efficacy. This was even stated on a BBC documentary he appeared. Face it, this is a controversial intervention that was criticized on the BBC by Peter Fonagy who stated that RCTs were needed. Dr. Fonagy is a highly published psychiatrist on attachment. Click here to read the full transcript of this program about Dr. Federici’s intervention which includes Dr. Fonagy’s criticisms and Dr. Federici’s responses. The narrator stated that Federici “eventually plans” to have such RCTs. That was in 2002 and here it is 8 and a  half years later and my own library database searches have not turned up any. Anecdotes from other parents and claims made in self-published books are not enough. Again, I use the medical analogy. Would you give your child a drug that had not been scientifically tested in randomized controlled clinical trials for safety and efficacy?

Ther real world out there isn’t going to allow their violent tantrums or verbal abuse.  From experience as a therapist and as the client of a son in Play Therapy and Cognitive Behavioral Therapy, it doesn’t work.
Actually the treatment that has the most support for behavior problems is behavior modification, not play therapy and the term “CBT” could mean many things. Many therapists who describe what they do as “CBT” might not be using standardized protocols shown to be effective.

Traditional therapies don’t go deep enough into
their preverbal traumas.
Sorry, but there is no scientific evidence that so-called “preverbal traumas” are the cause of behavior problems. This is part of the mythology of certain self-proclaimed trauma “specialists” who operate on assumptions that have no basis in scientific evidence. It is a widespread myth in certain circles of therapists, so I’m not surprised you picked it up.

Only safety and development of trust can start to heal that wound.  The real world isn’t going to have “compassion” when he socks his future boss, wife, stranger or anyone in range when his PTSD rages hit.
This is another myth, that children with attachment grow up to be violent individuals or sociopaths. Again, no evidence to support this clinical myth.

No, the real world expects him to calm himself done, and this is TAUGHT.
I agree with that, but the behavior modification techniques that I support are the most effective techniques to accomplish this, not a boot camp atmosphere that employs hard labor, punishment and the use of physical forceful face-down prone restraint, even when the child is not presenting an immediate physical threat and not the use of such restraints because the person using them believes it will stop the child from being manipulative. Stopping manipulative behavior is not what is currently regarded by current standards for safety restraints as a valid reason for using them. Only an immediate physical threat is a valid reason and they should be used only for the duration of the physical threat.
I am an advocate for doing what works, and the use of therapeutic holds as described in Federici’s book in emergency situations was totally appropriate.
In the Saving Dane video, based on my understanding of what I saw when I watched the program, his parents were shown applying these restraints after they had asked the boy to go to the bathroom and he said he didn’t have to go. Is that an “emergency situation”? I don’t think so. Emergency, in terms of restraint safety guidelines means the child is presenting an immediate physical threat of harm to self and/or others. Is it an “emergency” situation if a child backs down and promises to be good, hence presenting no immediate physical threat? Again no, that is not my understanding of current mainstream guidelines. Restraints are to be used only when there is an immediate, imminent physical threat and then, safe procedures should be used and there is a large body of literature showing that face-down prone restraints are not safe, particularly when used on an already agitated person. In an earlier blog entry, I cited a study that showed that deaths occurred from this procedure, even under highly supervised conditions when they were being done correctly. If this happens under such conditions, how safe could this possibly be when used by parents at home with their children?
I am proud to say that with Dr. Federici’s help, my son is a healthy boy today who can handle his emotions as developmentally appropriate.  Recovery is possible.  My son was a worst case scenario of complex diagnoses-and he overcame it with the help of his therapeutically trained parents and professional help from Dr. Federici.
I’m glad to hear your son is doing well and I wish you both well. I also appreciate the fact that you attribute your son’s recovery to the treatment he received. However, testimonials and success stories are not enough basis for a responsible professional to be making treatment recommendations to others. At the same time I want to clear up a misconception about my position some parents appear to have. I am not saying that these approaches are never effective for anyone at any time. What I am maintaining is that they have not been systematically studied for safety and efficacy so we do not know if they are safe and/or efficacious.
Monica Pignotti is slandering a person who she does not know and does not understand, clearly.
Actually, I have reviewed the evidence and I am reporting the evidence I reviewed and stating my opinion which the US Constitution allows me to do. Opinions are not slander. The definition of slander (or libel, which is the term that applies to the written word) means that a person has knowing and maliciously made a factually false statement that damaged someone’s reputation. My intentions are far from malicious I make the statements I made based on my review of the facts and I do it out of my care and concern for children and out of my professional obligation. Professionals are obligated to go by the conclusions they come to based upon evidence. If you believe that I have gotten some fact incorrect, I extend the same invitation to you as I have to Dr. Federici, present me with actual evidence that I am factually mistaken. So far, such evidence has not been forthcoming. And no, opinion pieces by people who also employ these controversial methods and cite as references for the efficacy of therapeutic holds, articles from the early 90s about a now-discredited use of restraints for DID is not what I would consider good evidence. Your testimonial, while I appreciate appears to be heartfelt and passionate, is still not evidence. It is your opinion and experience, but it does not refute any of the facts I have presented. Stating my conclusion that face-down prone restraints are dangerous is an opinion on my part and no different from the opinion stated in much of the literature I have cited and quoted from on this blog and no different from states such as Ohio which have completely banned prone restraints. Would you like to accuse all of those sources of “slander” as well?

It’s offensive to have such behavior from a person who claims to be a professional social worker.
On the contrary, I am upholding the NASW Code of Ethics which requires me to go by research evidence. Debate and disagreement is healthy for a profession. Attempts to bully people with whom one disagrees into silence is not healthy. I’m not accusing you of this, Faith, because you at least have addressed the issues at hand and you are one of the few who has, but if you look at the kinds of highly personal attacks I have had to endure from some of Federici’s supporters and outright lies that have been posted about me on the internet (e.g., I have not been fired from FSU, I have never done sexual favors from endorsements, to name just a few of the very ugly lies that are being posted about me), you’ll see what I mean.

If left up
to Monica Pignotti, my son would live in a group home where the staff would have no choice but to restrain him and THEY WOULD NOT BE DOING OUT OF COMPASSION.
Again, I never recommended that and I certainly have not made any kind of recommendations where your son is concerned. My purpose is only to provide information and state my opinions. The alternatives I described are approaches that are done on an outpatient basis (for example, listen to Marolyn Morford’s podcast). To me, the boot camp like intervention described in Dr. Federici’s book does not seem very compassionate and furthermore, it has not been properly studied independently with randomized controlled clinical trials for its safety and efficacy, published in peer reviewed journals, as the behavioral techniques I have supported have been. As for group homes, if you mean the sort of therapeutic parenting homes described in the Evergreen Model, I am equally opposed to those methods and would not be in favor of a child living in such a home. Far from it and I am very glad to hear your child is not living in such a home.

Love goes along ways.
I agree, but I thought that the rationale behind Federici’s treatment is that love is not enough. Yet the studies I have reviewed by researchers such as Michael Rutter who followed children who were late adoptees who spent the first several years of their lives in orphanages in Romania show that many did improve over time, just by being adopted and loved by a family. So yes, in many cases love goes a long ways and often love is enough. Time and time again, adoption itself has been shown to be a very effective intervention.

I pray that parents of adopted children with severe mental issues and attachment problems find professionals-such as Dr. Federici who can help them to help their child.

I pray that parents of adopted children consider the evidence and the degree that the interventions they select for their children have been properly tested for safety and efficacy. Again, Faith, I wish you and your son all the best and I do thank you for raising actual issues that I believe reflect beliefs that many parents share which I see as mistaken. So thank you for raising these points, as you have provided me with a much better understanding of what your own objections are to my position and where you are coming from.

P.S. Here are come further comments Jean Mercer has regarding cortisol levels:

  1. drcmann permalink

    I would agree with one important point made here by Dr. Pignotti, and experienced by me for 25 years. The vast majority of my clients are male or are children. I get this all the time — unless you’ve personally experienced something (like being male), you can’t possible render effective counseling. It is not possible to personally experience everything our clients present to us. Even if we did have similar problems, that would actually cause more problems than not because we could not be as objective. There is some kind of egomanical need by some to be treated as special, and one of the easiest ways to do this is to say “you haven’t gone through what I have”. It’s a red herring and has no bearing on effective treatment or recommendations.

  2. Faith Terrell permalink

    We both come from a different place in dealing with this controvosial subject of therapeutic restraints. I, as an adoptive mother and one who has extensively researched possible treatment options for my child and can claim a list of boring creditials, least of which is an MA in Clinical Counseling, and you who look at the scientific efficacy through the lense of graduate level social worker. I only wish someone would have found out about the “crazies” who were doing the work with Candace Newmaker before she will forced into a therapy that truly was so inappropriate…and can’t be undone.

    I agree that a healthy debate on this issue between individuals who have agreed to do so can be useful, as I have developed a passion for getting adoptive parents to PLEASE intervene when they are reporting behaviors that are symptomatic of FAS, PTSD and RAD in their internationally adopted children in our adoption group and through my work.

    First, I have a problem with comparing diagnosis and treatment of RAD, PTSD, and FAS with cancer for the reason that cancer can be pinpointed on x-rays and other methods of technology as the absolute reason for a patient’s problem. RAD, PTSD and FAS all go by symptom and observation alone. Other that the DSM, which gives a diagnosis that is based on professional interviews that are rarely done in the home where the integral part of thse problems are experienced. Yes, at least at first, a child can hide their symptoms. Then these symptoms are subject to the interpretation of the professional’s opinion that makes it conclusive. Many reports are parent-reported surveys and teacher-surverys and behavior check lists. This leads the diagnosis to be difficult, sometimes questionable, and often co-morbid with additional adaptive types of coping behaviors that have been added on top of the heap for survival, which are truly behavioral only. The latter type are the most effectively treated by Behavioral Therapy.
    The PTSD, as in with VETS, is much harder. Trauma mimics ADHD, Depression, Mood Swings like seen in Adult Bi-Polar and often Conduct Disorder in young patients. Cognitive behavioral therapy is well documented not to have made much improvement with VETS, and if it does help, it is very slow and done with adults from an adult framework.
    I’m not sure what you know about Pre-Verbal trauma, but when chronic, as in neglect, abuse and orphanage living over time, the coritsone levels are effected on a cellular level. This hormone overproduction in children causes them to develop hyper vigilance and assume actual personality development based on the high stress lifestyle. The normal serotinin levels of a child under these circumstances, can’t combat the high cortisone, which leaves the child with a lessened ability to feel pleasure, self soothe, alas develop normally-even later on when adopted. This is why I say my son came to me in a state of “survival mode.” All of this is well documented under PTSD, and is not outdtated information in the DSM.
    The condition of Pre-Verbal PTSD is the hardest type of trauma to reach by a therapist for effective rearrangement because it involves the actual neuronic connectiveness upon which the person has put together, or developed through stages of critical development. All sensory input during the time of neglect is effected. Since all learning is based on sensory integration and interpretation, the child is now severely at a disadvantage.
    Take a child with severe PTSD, at say 2 years old, and adopted into a loving family….and their is the high risk that the child will reject affection and not be able to adapt because of their biology that is firmly rooted in place by now, which leads to a diagnosis over time if continued to RAD. The underlying diagnosis, of course, would be PTSD or other mental illness respectively. Without the bases of an attachment the PTSD can’t be touched. Add to that the abundnace of children who got exposed to drug and alcohol before birth further confusing their neuro-development-and you have a combination of complex atypical diagnosis that very few doctors, specialist, therapists, psychologists, counselors and psychiatrists have much- if any hands-on experience in treating. That’s a fact. I won’t even start on how inaccessible these treatments are for parents due to how expensive they are.
    You point out that adequate alternatives should be done to help a child prone to violent tantrums. Sometimes there is a warning and sometimes there is not. I am a firm believer that restraints of any kind should only be done out of the state of emergency-on that we 100% agree. My child would say anything during a meltdown-from I’ll kill you to I’m sorry, I promise…ect. I always give ample opportunity for my son to succeed first. I consistently make use of visual cues, warnings, redirection and even a time time out if appropriate FIRST. If he doesn’t like his choices, a meltdown ensues despite all efforts to redirect first, and a violent tantrum where my son is banging his head on the wall and punching me in the face aggressively (just for being told no) then he has lost control already. The amagdyla in his brain has gone into full adrenaline and he is in fight or flight mode. This is survival mode at its best, and for some reason in his mind he percieves his caretakers as the bad guys. At this point getting him to sit down and getting behind him and pulling him close to me and wrapping my arms around him and legs over his to calm him down and “hold” him is necessary. This is the slightest type of hold. The premise here is that his heartbeat and breathing will eventually match mine, as the calm one, until he regains common sense and can control himself.
    It is important to note that very little research has been done on this topic as of yet as pertaining to post-institutionalized children, so my word on this is as good as yours of anybody elses in regards to how many warnings do you give a kid before determining that you are dealing with sheer defiance and manipulation. When life becomes a series of manipulations with your child, it has to be determined that after X number of warnings, a consequence is given. No studies on manipulation of these children does not mean they are not manipulating. You just have to know that as soon as you give the consequences (ie. time-out or loss of privilage), then a meltdown is going to follow. That’s stardard behavior for behaviorally challanged kids. Without age-appropriate consequences for severe defiance, a child does not learn how to control their own behavior when anyone disagrees with them. Instead they learn that if they bully and act out, they win and everyone runs and hides either because they don’t care or they are afraid. Either way, the behavior of defiance is reinforced without a negative consequence….does this sound like behavioral therapy…it is? So the opposite is true with positive behavior and positive consequences.
    When the agression is the worst-harshest-he would sometimes run out into the street-of course-not looking for cars. He will keep running. Since running is a great way to calm down, I’m all for this, except that he may be running in the street. Next, he also is running out of defiance and to not be responsible for his actions, and yes, he is scared at what he’s done. In this case I have to get a hold of him and sit him down and get him to lay down if necessary where I can put my legs over his legs. It takes a lot of strength to maintain any control of keeping him put like this, so it has taken both of us before. This is done until the screaming and punching rage part is over. We both put our hands on his back. He turns his head to the side and we watch him but do not talk b/c we know there is nothing we can say to his screaming protests that we are BAD BAD BAD. That is the more restrictive type of hold. When asked why he did whatever caused the consequence that he panicked about ie pushing his sister down to the ground and leaving her crying so he could take away her doll, he can’t always tell you why he did it. He’ll yell I promised I won’t do it anymore while running away…so you catch him and say you promise you won’t do what anymore…and he can’t tell you.
    Initially when trained to do therapeutic parenting and holds and initially starting the new program with my son, he responded with by taking his violent outbursts to a higher level, which is to be expected. So in the very beginning it required me to first sit him down, then lay him down, and use both my legs over his legs and both hands on his elbows. This usually took both parents to coral him because the rage with so bad, and if we slacked up at all he’d bite or punch us and run. The hold had to last until he was breathing normally-so were constantly checking in on this, and the rage was gone. Then we had to hold him facing us and touching him gently for 5 full minutes. During the 5 minutes we were to “love” on him and give reassurance that we cared and wanted him to be safe and happy, ect….no shaming. This was the most severe type hold.
    Teach your child the types of hold when they are not in a bad place emotionally, and tell them what the consequenses are for behaviors. Make visual clues. Repeat it often. Then consistently hold them to their choices. Monica, this is what Dr. Federic taught us. And he is right. The type of holds I did as a staff member of a children’s RTC was the same. The state taught the same techniques, and I have gone through another round of trainings recently and it was the same. I get upset when I hear people who have not had to use these holds, blast the professionals who are helping adoptive families to take care of their kids. Dr. Federici has clearly adovcated that he is not an attachment specialist, but what he does in the neuro-pscyh field overlaps that and the two compliment each other. These children more often than not, need medication, and his experience in this area is not questioned. We took suggestions to our developmental pediatrician.
    Experience does go a long way, and one must keep a sense of humor about life with this type of child because life can become so stressful watching your child be so out of control. I do not think there is any room for humor, however, when attachment or any type of forced re-birthing or non necessary control is exerted over a child. I don’t believe any family wants to do holds on thier child, but when it is necessary and followed by a positive holding time where the child is on my lap with no restaints, attachment follows. At least it did in our case. Doing a full severe hold for not being able to use the restroom is absurd, but having the kid sit in your lap or lay down or lay up with a leg over their legs to exert who is parent as an example in the beginning of presenting the concept of “Parent is the boss” program for a young child who is purposefully peeing on the floor when their is a bathroom in the next room is a consequence for defiance (and would also be followed by 5 minutes of positive holding time.)
    Hope that gives some clarity for where I am coming from on the parenting end of this controversial topic.
    By seeing these complex set of symptoms of RAD, PTSD and PTSD overlapping each other and being diagnosed based on symptoms present, it does make the experience of seeing it play out as important as having that x-ray for the oncologist. Moreover, the onocolgist has surgical tools and proven methods of radiation machines and chemotherapy to treat cancer. RAD, PTSD and FAS are not so lucky, so we use what works. That’s what makes it so insulting when people who have not treated these children, see others in the field who only criticize but don’t offer EFFECTIVE alternatives. Please, give me some alternatives that you have heard will work as effectively as therapeutic holding? I ask this in all sincerity, as I continue to be open on finding what works.
    A red herring is also a professional who proposes to know the answers to complex issues without more information.

  3. Thanks for your response, Faith. I will respond to you more fully soon, but I just wanted to mention one thing for now. I’m not sure where you got your information about CBT not being effective for vets with PTSD. In fact, the consensus of careful review of the scientific evidence (see the Institute of Medicine’s Report on treatments for PTSD) shows that exposure therapy or CBT that includes exposure therapy is the one intervention that did meet their standards of having enough research support for being an effective treatment for veterans with PTSD. They did find many flawed studies, but the one treatment that did meet their standards was CBT with exposure therapy. See:

    Only exposure therapies had amassed sufficient evidence of efficacy, said the committee, which grouped prolonged exposure therapy with other approaches like cognitive-behavioral therapy or cognitive-processing therapy that also include some element of exposure to reminders of trauma.

    More later.

  4. Dr. Cathleen Mann permalink

    Yes, as someone who has done many PTSD evaluations and made recommendations, CBT is the only evidence based, long term intervention. The worst intervention is hypnosis, guided imagery, or other insight oriented approaches. In order to recover from PTSD, one needs to have corrective experience, learn coping, anger management, and conflict resolution skills, and, perhaps most importantly, learn how to manage (not control) one’s emotions. Some exposure therapies are also effective, but they are not a primary intervention, but a secondary one.

  5. Faith wrote:

    I’m not sure what you know about Pre-Verbal trauma, but when chronic, as in neglect, abuse and orphanage living over time, the coritsone levels are effected on a cellular level. This hormone overproduction in children causes them to develop hyper vigilance and assume actual personality development based on the high stress lifestyle. The normal serotinin levels of a child under these circumstances, can’t combat the high cortisone, which leaves the child with a lessened ability to feel pleasure, self soothe, alas develop normally-even later on when adopted. This is why I say my son came to me in a state of “survival mode.” All of this is well documented under PTSD, and is not outdtated information in the DSM.

    I believe you meant to refer to cortisol? If so, yes, there has been a great deal of research on cortisol levels and their relationship to PTSD. I was just reading about it in a book called Clinician’s Guide to PTSD (Editors Gerald Rosen and Christopher Frueh, see ) where they presented an excellent summary of the research on biological markers for PTSD. Actually what some research has shown is that people with PTSD have lower than average cortisol levels. Researchers actually were hoping this would be a biological marker for PTSD but then other studies showed that this was not the case and so the research on PTSD and cortisol levels is inconclusive. As for heightened cortisol levels, they are associated with a number of conditions such as chronic depression, but the research on PTSD and any kind of biological marker is highly inconclusive and people who jump to unwarranted conclusions on this are in error.

    But getting back to the issue of biological markers, the fact that there aren’t any doesn’t mean that anything goes. There are valid ways to assess for PTSD and there are valid ways to develop diagnoses and so far, “Preverbal PTSD” and the concept of body memories are not well validated ones.

    As for treatment alternatives, again, I don’t agree that all opinions are just as valid as any other. There are treatments for attachment problems that do have empirical support, as referred to in the 2006 APSAC Task Force Report on Attachment Therapy. Have you read it? They reference some systematic reviews that have shown that there are some effective treatments.

    Full text available here:

    You bring up an important issue, though, of what to do if there are no empirically supported treatments for a particular diagnosis or type of problem. I will discuss this in a later posting but suffice it to say for now that clinicians still have an obligation to refrain from doing harm and to provide full informed consent to the client, which means not making claims that a particular intervention is effective if it does not have published research studies to back it up.

    Regarding the use of restraints, your position, if I am understanding you correctly appears to be that you are only in favor of using them when the immediate physical safety of the child or others is at risk. If that is your position, I agree. However, based on what I have read from Dr. Federici (again, I reiterate that this is not a comment on what he actually does in his private practice, but about what he has written in his book or stated on the BBC or Dateline) he seems to me to be going further than that. Here is a transcript of the BBC where he states:

    He goes down for hitting, kicking, spitting, cussing in your face, screaming, breaking property, slamming doors. Where he’s out of control he must go down immediately.

    The entire transcript is well worth reading, including the criticism from Peter Fonagy about this intervention. “Goes down” refers to being placed on the floor in his recommended holding position and it looks to me like it is “going down” is being recommended for behaviors such as screaming and cussing which, while not desirable behaviors, do not present a physical danger to anyone. Neither do slamming doors or breaking property, unless a human being is in the midst of the destruction. Lots of kids (and adults as well) slam doors — it is a common behavioral problem. Annoying? Yes. Cause for placing a person in prone restraints? No. Additionally, on Dateline the child was placed in this hold for not doing what his parents requested. He said he didn’t have to go to the bathroom. Again, I see no indication of any physical threat. So just to be clear, that is what I am objecting to, along with the nature of the type of restraint being used, face down prone restraints. This form of restraint has been shown to cause deaths, even in residential facilities under highly supervised conditions, which is why some states such as Ohio have banned them altogether and again, there are safe alternatives for holds that can be done, only in the event of emergencies that pose an immediate threat to one’s physical safety when there are no other alternatives.

    • Bruce Perry’s work with traumatized kids and biological markers also pretty clearly states he thinks those approaches only cause more trauma.

  6. Jean Mercer permalink

    Faith makes several interesting remarks that I’d like to respond to.

    I had previously queried whether she said “therapeutic holding” because she believed that the restraint Federici advises is not simply a matter of safety, but improves child outcomes. Faith did not answer this directly, but she made it plain that she considers both prone restraint and “cuddling” to play some therapeutic role. She did not mention whether she also considers “beltlooping” and control over a child’s food to be part of the process, as Federici recommends in his book.

    A therapist who claims that a treatment method “works” needs to provide evidence for this statement in the form of independent replications of randomized controlled trials, or of clinical controlled trials if randomization is not possible. This evidence is not available for Federici’s technique, although he stated at the Salvetti trial in North Carolina that he had treated 12,000 children.

    When researchers investigate the outcomes of interventions, they also keep records of adverse events. As Federici has not offered evidence of effectiveness, neither has he presented any statistics about adverse events. These records would be of particular importance because part of the method Faith refers to, prone restraint, has been associated with adverse events when used in different contexts. If Federici and his colleague David Ziegler want to claim that their restraint methods are harmless, they need to show evidence that they have studied the occurrence of adverse events and that the data support their claim.

    Faith has emphasized the idea that young children with conduct disorders must quickly have their behavior corrected, or it will only worsen with time. I’d like to call attention to a relevant study that partially contradicts this common view. Writing in American Journal of Psychiatry in 2009, Barker and Maughan reported a study of 7218 children’s behavior problems (“Differentiating early-onset persistent versus childhood-limited conduct problem youth”). Only about 9% showed conduct problems in early childhood and persisted with these into adolescence. 15% had conduct problems that were limited to childhood, and 12% had no conduct problems in childhood but began to have problems in adolescence.

    There were a number of factors that appeared responsible for the persistence of early conduct problems, but only one was both controllable and relevant to this discussion. This was the use of harsh parenting techniques, which may have had the effect of prolonging conduct disorders that would otherwise have resolved at an earlier stage.

    It’s reasonable for Faith to tell the story of her own child’s treatment, which she says has concluded happily. However, her family’s experiences are not grounds for stating that Federici’s methods are effective, nor are they reasons why other professionals should not criticize techniques that appear potentially harmful.

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