Talk:Dyadic developmental psychotherapy/Archive 1

N.B. Reference 3 needs to be removed, as the article is no longer on line, nor will it be printed in CAMH.

In addition, note that large sections of this material are verbatim copies of a published paper by Becker-Weidman.Jean Mercer 18:20, 20 September 2007 (UTC)

Its now ref no 4. Fainites 11:02, 7 October 2007 (UTC)

Warning
To all professional and other readers of pages relating to attachment, its theory, disorders and therapies. Also complex post traumatic stress disorder and emotional dysregulation in children. All these pages and topics on Wikipedia were, until a recent arbitration, dominated by an army of sockpuppets promoting an attachment therapy theoretical base, diagnosis and treatments. "Attachment therapy" is a largely American based, non-mainstream, unvalidated and highly controversial form of therapy for children, frequently adopted or fostered children. Following arbitration in July and August 2007 the sockpuppets were banned. However it is likely that similar attempts will be made to promote the same views and therapies on Psychology Wikia. The promotion included misrepresentation and misquotation of sources, edits designed to obscure the nature or even existence of attachment therapy, smear campaigns against opponents, edit warring and mass sockpuppetry to achieve fake 'consensus'. Anybody reading these pages would be well advised to be cautious and to consult reputable sources on the subject such as the Taskforce Report commissioned by the American Professional Society on the Abuse of Children (APSAC) on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems. This report was compiled by Mark Chaffin, Rochelle Hanson, Benjamin E. Saunders, Todd Nichols, Douglas Barnett, Charles Zeanah, Lucy Berliner, Byron Egeland, Elana Newman, Tom Lyon, Elizabeth Letourneau and Cindy Miller-Perrin and covers the whole topic. Also the follow up letters and the Taskforce Reply to Letters. Other reputable sources include a special issue of Attachment & Human Development devoted to the subject, at September 2003, vol. 5, issue 3, pp219-326 by Zeannah and O'Connor, a 2006 publication by the Royal College of Psychiatrists Research and Training Unit (Jessica Kingsley Publishers) called "Understanding Attachment and Attachment Disorders" by Vivien Prior and Danya Glaser  and "Enhancing Early Attachments" edited by Lisa Berlin, Yair Ziv, Lisa Amaya Jackson and Mark T. Greenberg, part of the Duke series in Child Development and Public Policy, with particular reference to the chapter at p.313 by Thomas O'Connor and Wendy Nilson.Fainites 15:11, 20 September 2007 (UTC)

Another good mainstream source is "Handbook of attachment: Theory, research and clinical applications" edited by Cassidy and Shaver. Concerning signs to watch for are highly exaggerated claims of the prevalence of Reactive attachment disorder or attachment disorder, often by conflating statistics on attachment styles with disorders, claims that high numbers or most maltreated children or adopted or fostered children are likely to suffer RAD or attachment disorder, attempts to obscure the nature of attachment therapy or pretend it is limited to certain extreme forms such as rebirthing or holding, links to attachment therapists sites and the promotion of attachment therapies as mainstream to cure all this. Fainites 16:12, 22 September 2007 (UTC)

Controversy
i find it concerning that this article makes no mention of the controversial nature of this therapy. Indeed it goes so far as to claim it is in compliance with APSAC recommendations when in fact there are specific criticisms of claims of proponents and the claimed 'evidence base' in the APSAC Taskforce Report and Reply. Time may prove the Taskforce wrong, but at the moment this article is not remotely encyclopaedic or in accordance with available sources and indeed reads like an advertisement.Fainites 20:32, 22 September 2007 (UTC)

Evidence basis
i have altered the statement about supportive evidence to note that the study was nonrandomized. If anyone reverts this, I trust that they will also note why they believe it is correct to say that the study is randomized. Jean Mercer 23:27, 1 October 2007 (UTC)


 * The statement does not belong in the intro. A discussion of the specifics of the design of the studies should be in another section...or the reader can be directed to the articles.  The introduction is supposed to be a brief introduction to the article's subject.  Also note that no where in the article is the work "randomized" used to describe any of the research.   Dr. Becker-Weidman   Talk 23:59, 1 October 2007 (UTC)


 * Then why does a statement saying that it's evidence-based belong in the intro? And since when does nonrandomized design= evidence basis?  J.M. Dr. Mercer, Please sign in when you edit or make comments ( Dr. Becker-Weidman   Talk 01:49, 2 October 2007 (UTC))


 * The intro is a summary and presentation of an over view. Suggest you take a look at the following re EBT:
 * []
 * Oxford Centre for Evidence-based Medicine Levels of Evidence and Grades of Recommendation
 * Craven & Lee, which you've already read, I believe: Craven & Lee, (2006), "Therapeutic Interventions for Foster Children: A systematic Research Synthesis," Research on Social Work Practice, Vol. 16, #3, May 2006, pp. 287-304.
 * Child Physical and Sexual Abuse: Guidelines for Treatment (2004). National Crime Victims Research and Treatment Center
 * Saunders, B., Berliner, L.,&Hanson, R. (2004, April 26). Child physical and sexual abuse: Guidelines for treatments (Rev. Rep.).
 * cheers.  Dr. Becker-Weidman  Talk 01:41, 2 October 2007 (UTC)

'Evidence based' has a generally accepted meaning at this current stage in the debate. DDP does not fall within that. It may be that in the future different standards pertain - but at the momnent it is not evidence based. Anyway its OR. You need a secondary source to say 'DDP is evidence based' (and don't tell me Craven and Lee say it cos they don't). At the moment the main secondary source on this issue is the Taskforce which says it falls way short of the necessary criteria. You've put in Saunders and Berliner twice. I asked Lee from Craven & Lee if his placing DDP in the 3rd category (supported and acceptable) meant it was 'evidence based' and he was amazed that such a thing would even be suggested! I know I can't put my e-mails in as a cite - but really you are out on a complete limb here in thinking a couple of studies means its OK to call a therapy evidence based.Fainites 07:28, 2 October 2007 (UTC)


 * By definition Dyadic Developmental Psychotherapy is evidence-based using the Craven and Lee article and Saunders et. al as cited in Craven & Lee. I know you strongly disagree about this and my communications have yielded different responses.  It is important to understand that evidence-based is not a unitary concept with one specific criteria.  As you accurately and appropriately point out, there are different categories and levels of evidence based empirical research.  Cheers.   Dr. Becker-Weidman   Talk 14:40, 2 October 2007 (UTC)


 * I think what might be helpful here would be a section entitled Critique of the existing research. This might help readers weigh the value of the evidence from the peer reviewed journal articles. It would also help if this discussion lead to some constructive suggestions for the design of future studies to adress any identified methodological shortcomings. For my own interest can Jean clarify the categories of degrees of evidence used in the area. There may be an article in this to make it clear for all concerned. I would also reorder this article so that a description of the approach comes first, followed by the review of the evidence. Hope these suggestions help. Dr Joe Kiff 17:57, 2 October 2007 (UTC)


 * Dr. Kiff, those are excellent suggestions. Regarding the delineation of evidence-based, I'd suggest the Saunders article, Saunders, B., Berliner, L.,&Hanson, R. (2004, April 26). Child physical and sexual abuse: Guidelines for treatments (Rev. Rep.). Retrieved September 8, 2005,.  It spells out the levels of evidence.  Dr. Becker-Weidman   Talk 19:01, 2 October 2007 (UTC)


 * Joe-- that's a good idea. I've believed throughout these various arguments that it would be quite adequate to add a critique section to counterbalance some of the claims that are made about DDP and other interventions.


 * Unfortunately, the Saunders methodology has received much criticism-- including Eileen Gambrill's statement that it provides ways to lie about research. Although it's kind of Art to provide a reading list for me, there are quite a few other papers of interest, as well as issues that have not yet been covered thoroughly by many writers(e.g. choice of statistical test).


 * I don't understand Art's comment that "evidence-based is on a unitary concept...". Surely the very fact that there are levels of support means that there is more than one criterion being used? (And actually I don't even understand what this grouping of words signifies.)


 * Anyway, I'm prepared to provide a critique of the DDP research, based on my paper with Monica Pignotti. But i don't want anyone to just delete the whole thing rather than discussing or editing it. Is this okay with you, Joe? Jean Mercer 16:37, 3 October 2007 (UTC)


 * Jeanie, I meant not.  Dr. Becker-Weidman   Talk 17:53, 3 October 2007 (UTC)

Oh... okay.

Don't you like to be called Art? I thought that was what you called yourself. Really, I thought we could drop all this doctor stuff-- it's a bit too Marx Bros., don't you think? Jean Mercer 18:04, 3 October 2007 (UTC)

Good but be gentle with us Jean! Can someone lift out the categories of evidence with acknowledgment and reference and put it in this article Criteria for the assessment of clinical studies so that we can all share a view of the standards. Our NICE body over here has a similar list and I will try to add this in when I can get hold of it so we can develop a concensus view that we might apply elsewhere. One of the reasons I started the site is that it is not easy for me to get access to papers (Though thank you for the various offers) and often the summary of key passages and ideas is what one needs. Can we include links to fulltext where possibleDr Joe Kiff 18:32, 3 October 2007 (UTC)

I will do it tippy-toe and with velvet gloves-- but the thing is, it's not so simple to just list a list of standards. I recently submitted a paper that dealt with 5 different partly-overlapping sets of standards and with suggestions for combining those into a more complete assessment. There are also the issues about how the outcomes are reported, with standards like TREND to be considered. It is a can of worms, believe me, but it's one that will have to be opened before people can agree on evaluations of outcome research. So where to begin? Art likes the Saunders criteria-- he could describe those in the "Criteria" article (but don't forget that they require a manual for any assessment at all). As for me, i have to think about how closely I can quote my unpublished paper without causing various kinds of trouble later. But I'll be along-- Jean Mercer 19:48, 3 October 2007 (UTC)

We also ought to distinguish between what is currently understood by the phrase, and by whom, and proposals to do things differently. eg the Taksforce think that some kind of official body (they name several) should really award the title 'evidence based' almost like a medal. Is this the standard accepted throughout psychology/psychotherapy? Fainites 22:06, 3 October 2007 (UTC)

I think that proper recognition of the complexity around standards for evaluation in outcome research is very important in easing feelings around our recent confusion about the use of the term. If we are talking about a manual being needed we can see that the ordinary meaning of the term "evidence-based" can have a very technical meaning in some quarters, I await Jean's account with interest it will very much help us to develop our own thinking in the area. I would like to see all the available criteria factually laid out side by side for a start - would this compromise your article Jean? Do we have webreference for the Saunders criteria and manual so we can access it? To answer Fainities point I would think that there is no one criteria accepted. WIn the UK we have our NICE procedure which partly functions to identify viable treatments but presuamably that not followed elsewhere Dr Joe Kiff 07:34, 4 October 2007 (UTC)


 * "Evidence-based" is not a unitary concept. As various articles describe, there are levels of evidence-based practice.  Dr. Becker-Weidman   Talk 12:25, 4 October 2007 (UTC)


 * You might like to wonder, if 'evidence based' is currently such a vague and moveable feast as is being claimed, why it is tenaciously hung onto and repeated ad nauseum in relation to DDP (alone), why the Taskforce cite the inappropriate use of the term as one of the specific criticisms of attachment therapy proponents and methods, why the Taskforce took the trouble to devote a substantial part of their Reply to the very same issue in detail, why there a number of articles and reports as to its meaning and indeed published guidelines, why the Taskforce thought the job of designating a therapy 'evidence-based was a job for the major professional bodies. Finally, why did Saunders et al feel the need to devise a new graded system, not using the term 'evidence based' (though their category 1 is similar), if the current phrase 'evidence based' means any old little bit of evidence? This is not to say it is not a matter of ongoing public debate as to what precisely it covers and whether or not there should be a scale of grades of evidential foundation and so on. All that can be covered here. That however is entirely different thing to the misuse of an exisiting term that has a broadly accepted meaning. The leaders in the field and commentators use it very sparingly and carefully. Marvin et al (Circle of Security 2002) in 'Enhancing Attachment' 2005 make it clear they are aiming to be evidence based and set out where the work is being replicated and tested across the country. They have published 'preliminary results' - set out in Prior and Glaser 2006. 'further results are anticipated' and evaluation is said to still be 'in progress'. This is the kind of thing 'evidence based' requires - randomized blinded clinical trials, replicated by others - more than once. Not one non-randomised, non-blinded trial by a proponent. That would be the start whereby you would hope to encourage others to conduct their own studies of your therapy.Fainites 15:30, 4 October 2007 (UTC)


 * I am not saying by the way there is no evidence for DDP. Of course there is and it should be fully set out and explored. There's no shame in not being "evidence based" within the accepted meaning of that phrase. It takes time and money. (Therapies proposed by well known theorists such as Circle of Security or ABC got some kind of governmental funding). However I think calling it 'evidence based' in the way that at is all over the Wiki and in its article, accompanied by extreme claims as to efficacy and the inefficacy of everything else actually looks suspicious. Proponents of evidence based therapies don't do this. We have to consider Daniel Hughes here. He is entitled to have his therapy fairly and scientifically set out. He may, like many scientists, find the criticism of his peers constructive. What he says in the forward to 'Creating Capacity for Attachment' by Dr BW (2005) is " At this point in time there is a need to establish an "evidence base" for DDP, .......The recent study by Arthur Becker-Weidman serves as an important beginning of this process". Are there any more recent published comments by Hughes on this ? Fainites 16:05, 4 October 2007 (UTC)


 * I am not saying that evidence based is "a vague and moveable feast." I will copy my remarks on this subject that I made to you on just this same subject and questions you raised on another talk page:

I understand that as a lay-person you may not be familiar with the literature on this subject and the complexities involved. Let me direct your attention to the following references for further reading:
 * Saunders, B., Berliner, L., & Hanson (2004, april 26). Child physical and sexual abuse: Guidelines for treatments.
 * http://www.bmj.com/cgi/content/full/312/7023/71
 * Oxford Centre for Evidence-based Medicine Levels of Evidence and Grades of Recommendation
 * http://www.ahrq.gov/clinic/3rduspstf/ratings.htm
 * http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=11728302&dopt=AbstractPlus
 * Evidence based medicine
 * In addition, I encourage you to read the references I suggested previously in this thread:
 * []
 * Oxford Centre for Evidence-based Medicine Levels of Evidence and Grades of Recommendation
 * Craven & Lee, which you've already read, I believe: Craven & Lee, (2006), "Therapeutic Interventions for Foster Children: A systematic Research Synthesis," Research on Social Work Practice, Vol. 16, #3, May 2006, pp. 287-304.
 * Child Physical and Sexual Abuse: Guidelines for Treatment (2004). National Crime Victims Research and Treatment Center
 * Saunders, B., Berliner, L.,&Hanson, R. (2004, April 26). Child physical and sexual abuse: Guidelines for treatments (Rev. Rep.).
 * I hope this helps you regarding understanding this complex area. Cheers.   Dr. Becker-Weidman   Talk 16:58, 4 October 2007 (UTC)

Is that a yes or a no to Hughes having said anything more recently on the subject of 'the important beginning of the process' of the 'need to establish an evidence base'? Fainites 20:49, 4 October 2007 (UTC)


 * Actually I've now found what Hughes said. p 284 of BTBOA, 2nd Ed. "There have been some early efforts to develop an empirical foundation. Dr A. B-W has authored an office based research study in which he compares the results of this treatment model with a control group of children with similar histories and behavioral problems. Though the study is small and it lacks the elaborate measures and controls of a research centre, the results are very favourable regarding the efficacy of this model of treatment for children similar to Katie. A follow-up study by Dr B-W (in press) demonstrates that the treatment gains secondary to this model of intervention are stable for 3 years after the treatment, whereas the children who received traditional treatment were actually functioning with more severe symptoms." Fainites 23:22, 7 October 2007 (UTC)

Edits and query
It's getting hard to find your way around here-- I wrote something a while ago but can't find it now, so i'm starting a new section. I have put some material on the Assessment page and have edited this article in congruence with what's on that page. I propose that anyone who states an evidence category should also note which assessment protocol is being used. I also want to point out that most protocols require some intervention fidelity assurance like a manual, and can't even be used if this doesn't exist.

My query is, I don't understand the 3.2 prior treatment episodes. Does this mean 3.2 individual sessions, or 3.2 sets of sessions devoted to a particular treatment? Jean Mercer 17:21, 4 October 2007 (UTC)

Unfortunately Jean its all been reverted. I suppose as a mere lay person fit only to gasp in awe at the intellectual capacities of my betters I'm not allowed to say that Craven and Lee don't use the term evidence based so it must therefore be OR. Whats wrong with being supported and acceptable anyway? Fainites 20:47, 4 October 2007 (UTC)

I fail to see how the S B & H classification can make the work "by definition evidence-based" when the classification does not use the wors. But i guess it's now my job to add a "critique of evidence" section, unless Art would like to do this himself.Jean Mercer 21:46, 4 October 2007 (UTC)

3.2 treatment episodes means three point two separate episodes of treatment, each episode of varying number of sessions...some just a few some years and years. <font color="#FF9933" face="monotype"> Dr. Becker-Weidman  <font color="#00FF00">Talk 22:27, 4 October 2007 (UTC)

Oh-- so the point is how many other treatments were tried, not how many sessions there were in comparison to how many DDP sessions? Or is it a matter of what you might call "bursts" of treatment, not necessarily different kinds?Jean Mercer 22:54, 4 October 2007 (UTC)

If you read the article you will see that there were several points. For example, that the children had various other treatments, but with no successful outcomes. <font color="#FF9933" face="monotype"> Dr. Becker-Weidman  <font color="#00FF00">Talk 22:57, 4 October 2007 (UTC)

I have read it, but i don't think you explained this. I'm just trying to figure out what their previous histories were-- i'm assuming that the outcomes weren't good, or they wouldn't have come back for assessment.Jean Mercer 23:52, 4 October 2007 (UTC)

I think this discussion shows how important it is that we understand the scales of scientific rigour that now underpin the term "evidence-based". I am inclined then towards having a template that would record a score for each therapy against each of the scales. So DPP could be seen as having a lower score on scales where it needs a manual and a higher score on another scale.

How rigourous, in these terms, Art's work is not clear to me and I was awaiting a balanced account of criticsms of the methodology before I made up my mind. Would you prefer to do it yourself Art? I feel for you and I am clear that you are not under attack for the sake of it here, but in wrestling with these problems and refining our thinking I feel we are making important, if painful, progress which will help us assess the standard of evidence in many different areas. I am learning a lot myself and am grateful for your forbearance.

From what I saw on Arts website it looked as though there was a control group. Have we all got full uptodate accounts of his papers? Are we clear what evidence has been produced after the completion of the Taskforce report and after Hughe's comments went to press and does such evidence increase the ratings enough to warrant the term "evidence-based" in the context of the new scales which seem to have redefined the term professionally.

To muddy the waters further I looked for more references on DPP and only came up with one we have not mentioned:	Sturt, Stanley M [Ed]. Source	(2006). New developments in child abuse research. ix, 150 pp. Hauppauge, NY, US: Nova Science Publishers. ISBN	1-59454-980-X (hardcover); 9791594549808 (hardcover). Is this of relevance, has anyone seen it? Dr Joe Kiff 15:05, 5 October 2007 (UTC)


 * (Sturt is where the second study - the 4 year follow up is published) Fainites 17:06, 5 October 2007 (UTC)

The article in the Sturt book describes the follow-up data from the original groups. There was a comparison group, but the study did not address confounding variables affecting outcomes in these nonrandomized groups. Like you, Joe, and I guess like Hughes, I consider this report an interesting and useful contribution-- I simply object to its being described as providing a higher level of evidence than it actually does. It's unfortunate that Craven and Lee made the mistakes they did in classifying the study... this has led to a lot of unnecessary ill feeling.

I wonder whether Art would be willing to supply his raw data so an analysis of variance could be done, by the way (not that this would neutralize some of the design problems).

I'm afraid that the term "evidence-based" has also become an advertising gimmick, at least in the U.S. Commercial web sites talk of evidence when what they have is testimonials.Public education is very much needed on this point.Jean Mercer 15:21, 5 October 2007 (UTC)

Actually, Jeanie, the two empirical studies did address the issues of confounding variables between the treatment and control group. The discussion section discusses the statistically insignificant differences between these groups on many many dimensions such as demongraphics, pre-treatment test scores, etc. Dr. Kiff, that empirical study in Sturt is a detailed description of a four-year followup in which we see that those who received treatment with Dyadic Developmetnal Psychotherapy had statistically significant improvements continuing four years after treatment ended, as measured by the CBCL while children in the control group, all of whom continued to recieve "usual care" at other centers by other providers of other treatments, actually had statistically significant worsening on several of the scales. The Craven & Lee classification would be even higher, probably, since they did not have access to the text I edited, the recent text by Dr. Hughes, my original study in Child and Adolescent Social Work, or the four-year followup...they based their classification on preliminary partial data reported on my website. <font color="#FF9933" face="monotype"> Dr. Becker-Weidman  <font color="#00FF00">Talk 16:19, 5 October 2007 (UTC)

Actually you couldn't be in category 2 yet. The criteria are : 1. The treatment has a sound theoretical basis in generally accepted psychological principles. 2. A substantial clinical-anecdotal literature exists indicating the treatment's value with abused children, their parents, and/or their families. 3. The treatment is generally accepted in clinical practice as appropriate for use with abused children, their parents, and/or their families. 4. There is no clinical or empirical evidence or theoretical basis indicating that the treatment constitutes a substantial risk of harm to those receiving it, compared to its likely benefits. 5. The treatment has a book, manual, or other available writings that specifies the components of the treatment protocol and describes how to administer it. 6. At least two studies utilizing some form of control without randomization (e.g., matched wait list, untreated group, placebo group) have established the treatment's efficacy over the passage of time, efficacy over placebo or found it to be comparable to or better than an already established treatment. 7. If multiple treatment outcome studies have been conducted, the overall weight of evidence supports the efficacy of the treatment.
 * 2. Supported and Probably Efficacious Treatment

I think though you are being unecessarily defensive Dr BW. I don't see a problem in initial studies by a proponent of a new therapy reaching category 3. Its quite an accolade really. Presumably if the preliminary studies like yours show promising results, that may encourage other independent therapist researchers to try and replicate them and thats what you need isn't it? Other researchers to replicate the results in RCT's. Fainites 17:04, 5 October 2007 (UTC)

These are the two citations for the studies Dr Kiff.
 * Becker-Weidman. Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy, Child and Adolescent Social Work Journal. 23(2), April 2006[1]
 * Becker-Weidman, A., (2006b) Dyadic Developmental Psychotherapy: a multi year follow-up. in Sturt, S., (ed) New Developments in Child Abuse Research. NY: Nova

If you look on the Wiki page you can find these and other citations and some links - also to Daniel Hughes who devised the original therapy which is contained in papers rather than books. I can e-mail you a copy of his 2004 one. Fainites 17:10, 5 October 2007 (UTC)

Dr. Hughes latest book, "Attachment-facilitating family therapy," (2007) NY:Norton describes the current practice of DDP. The text Ico-edited, "Creating Capacity for attachment," (2005), Oklahoma City, OK: Wood 'N' Barnes, also describes DDP with transcripts of sessions and case examples used to demonstrate principles and has chapters written by several practitioners of DDP. Dr. Hughes text, "Building the Bonds of Attachment," 2nd. Edition (2006) also described DDP, but in a much less formal or rigorous manner; using the format of an extended case history and story. Cheers. <font color="#FF9933" face="monotype"> Dr. Becker-Weidman  <font color="#00FF00">Talk 18:03, 5 October 2007 (UTC)

I think its quite important when looking at a therapy's theoretical base to look at the original papers where it is first set out in the round as it were and then see how it develops. Fainites 22:36, 5 October 2007 (UTC)

My copy of Building the Bonds of Attachment is the second edition, 2006, whereas the quotations on the ACT webpage are from the first edition 1998. They provide several quotes that would seem to indicate holding therapy and 'sitting' is used and that Foster Cline, Deborah Hage, Connel Watkins and Martha Welch are paid tribute to in the 1998 version. This is not the case in the 2006 version which specifically seeks to distinguish DDP from some of these other authors and omits mention of others. The book appeas to contain the same course of therapy with the same child though. Does anybody have a copy of the 1998 version which could perhaps shed some light on this? Fainites 13:57, 7 October 2007 (UTC)

On the 'extended case history format', Hughes says in the introduction that "Katies early life is unchanged and her behaviors as she came to live with Jackie are also the same. However, in this edition Jackie and Allison relate with her somewhat differently than they did originally. Since Katie's story first appeared in in 1998, I have continued to develop my ways of understanding children like Katie. I have continued to refine my interventions with such children, both in the treatment sessions as well as in the home. My recommendations to parents continue to evolve. For Katie's story to reflect these changes; a second edition is required". In the circumstances this can hardly be called a 'case study'. Fainites 16:57, 7 October 2007 (UTC)

Saunders etc
Another interesting point on the Craven and Lee paper is that they also classified Myeroff, 'holding therapy' (one of the main forms of attachment therapy) as Category 3. Saunders et al however in their original paper on the new system where he went through about 23 or so therapies put what he called 'corrective attachment therapy', citing the same Myeroff study, in Category 6 "concerning treatment"! The only therapy that made it into Category 6. Fainites 22:30, 5 October 2007 (UTC)


 * In the April 2004 version they correct their appelation of attachment therapy as 'corrective attachment therapy', and just call it attachment therapy. Fainites 09:48, 8 October 2007 (UTC)

I quite like the neologism "demongraphics"-- that's a trouvaille we ought to keep. However, Art, perhaps you can explain why you altered my "multiple t-tests"? Are you saying you did not do multiple t-tests? Also, please note, for the umpty-umphth time-- all together now-- Saunders et al require assurance of intervention fidelity, in plain English a manual! Without one, the intervention cannot be classified at all. So, lucky you, you don't belong in category 6 either. Jean Mercer 00:57, 8 October 2007 (UTC)
 * Jeanie, you mis-read Saunders. They do not require a "manual."  "Treatments for which manuals, books, or other writings describing their components and application were readily available were given preference" (pg18.). Note: "books or other writings describing their components and applications..."  cheers <font color="#FF9933" face="monotype"> Dr. Becker-Weidman   <font color="#00FF00">Talk 01:12, 8 October 2007 (UTC)


 * In Craven and Lee they say:
 * a)Category 3 says "The treatment has a manual that clearly specifies the components and administration characteristics of the treatment that allows for replication." p289. The other categories except 5 say "The treatment has a manual that clearly specifies the components and administration characteristics of the treatment that allows for implementation.
 * b) Saunders (April 2004 version) does say "Treatments for which manuals, books, or other writings describing their components and application were readily available were given preference" but this was for inclusion for consideration within the Guidelines, not as criteria for achieving any particular category. They set out the criteria for this in the same para, p19 "Criterion 3. Writings describing the treatment protocol are available to clinicians in the field." They then go on to say for every Category, "The treatment has a book, manual, or other available writings that specifies the components of the treatment protocol and describes how to administer it." This may look a little different to how it is set out in Craven and Lee in the variations of the word manual but it must mean whatever the writings are they must operate like a manual in that it enables others to implement the therapy from the writings. Perhaps Jean can shed some light on this if this a misunderstanding or if Saunders has amended his criteria? Fainites 09:00, 8 October 2007 (UTC)
 * I don't think S B & H changed their criteria. The term manual or whatever indicated what other writers call "assurance of intervention fidelity" -- that is, there must be some way for people to know whether the same procedures were used within a study or between different studies. It doesn't appear to me that DDP has sufficient descriptive material to equate to this, and some of the written material appears questionable. For example, in Art's material "The book about me and Dr.Art", there is reference to an event where Art took the child's shoes and made him work in some way to earn them back. Is this to be taken as an example of DDP work, and is there intervention fidelity without it? This is not clear.
 * In addition, it would seem that parent training would be of the essence for DDP. If parents are to practice "attunement techniques", how do they learn to do this? Are we talking about videotaped feedback, about one-way mirrors with an observer cueing the parent-- of the many ways this could be done, what actually is done? Is there written material provided for the parents? These are all questions that need to be answered in order for anyone to replicate the study with some assurance of intervention fidelity.Jean Mercer 14:21, 8 October 2007 (UTC)


 * Jeanie, it is clear that by manual they mean, "Treatments for which manuals, books, or other writings describing their components and application were readily available were given preference" (pg18.). Note: "books or other writings describing their components and applications..." and then, rather than repeat this cumbersome listing, merely refer to a manual, which means a written description of the treatment.


 * Regarding parent training, that is described in detail in several texts: Building the Bonds of Attachment, 2nd. Edition, Creating Capacity for Attachment, and in several training tapes as well.


 * cheers. <font color="#FF9933" face="monotype"> Dr. Becker-Weidman  <font color="#00FF00">Talk 15:54, 8 October 2007 (UTC)

No. The bit about 'preference' is obviously about selecting therapies to consider - not the actual criteria which are plainly set out. Please read p18 and 19. As for parent training in BTBOA, which version? 1998 or 2006? Fainites 20:44, 8 October 2007 (UTC)

Evidence based
Look guys, Craven and Lee don't say its 'evidence based', Daniel Hughes doesn't say its 'evidence based', no commentators in the field say its 'evidence based'. The only major commentator in the field who addresses the issue is the Taskforce and they specifically say it is not evidence based and complain that the author says it is. In the circumstances can we stop wasting huge amounts of time over this and just describe the therapy, the theoretical basis, the research basis, any controversy - and leave it at that? The talkpage on this one obvious point is now 10 screens long. Fainites 09:24, 8 October 2007 (UTC)

Critique
I've added a critique section, and I trust I will still see it here in some form when I look again.Jean Mercer 14:56, 8 October 2007 (UTC)
 * Jeanie, again you seem to have either not read the material, forgotten it, or misrepresent it. I understand you POV.  As one of the three leaders of ACT it is clearly spelled out on your website.  However, the control group and treatment groups had extensive comparisions and the reason for those being treated or only evaluated was also stated in the article......etc. cheers. <font color="#FF9933" face="monotype"> Dr. Becker-Weidman   <font color="#00FF00">Talk 16:01, 8 October 2007 (UTC)


 * Yes, it was the parents' choice. So, why did the parents choose one thing or the other? I'm quite sure you understand the problem of confounding variables in self-selected groups. Look, you have an adequate pilot study here. Why not just use it as the foundation for more advanced work? Nobody is saying that you shouldn't have done it or that DDP is harmful-- you just have to go farther to produce the kind of evidence you're claiming to have.
 * As for the manual issue, please provide page numbers for the descriptions of parent training you allude to.
 * If you'd like to provide me with your raw data, I'll do the ANOVA for you. Jean Mercer 16:24, 8 October 2007 (UTC)
 * I suddenly understand something: NPOV means, say what Art wants said; POV means, give an alternative viewpoint. Given that I allow you, Art, to run on about DDP unedited, how does it come about that you can alter my critique? The criticisms I made are ones that have appeared in print in a peer-reviewed publication; why should they be removed? Jean Mercer 16:31, 8 October 2007 (UTC)


 * The article explains why the difference in eval or trt choosen by the family, I suggest you read it carefully if you wish to comment on it. The two groups were compared on a large number of dimensions and found to be no different (statistically ) on those many many dimensions.  Cheers. <font color="#FF9933" face="monotype"> Dr. Becker-Weidman   <font color="#00FF00">Talk 18:47, 8 October 2007 (UTC)

We seem to have the "won't versus can't" problem here. It disturbs me very much to think that you may not be able to understand or to answer my questions. On the other hand, if you can but won't, there also seem to be distressing implications.Jean Mercer 20:00, 8 October 2007 (UTC)

These constant suggestions that if other people disagree with you Dr BW, it means they haven't read the material properly or at all is very ill-mannered and also rather silly since many of these points being made on the evidence are the same ones made on Wiki for months - with a similar lack of result until 6 sockpuppets were blocked. It is also somewhat ill-mannered to instantly revert other editors edits without due consideration or even allowing others time to consider them. Still - 'plus ca change...' eh? Fainites 20:49, 8 October 2007 (UTC)

I've added back most of your removed passages Jean and also added a similar critique from the Taskforce reply. I believe these edits have a life expectancy of about 5 minutes. Fainites 21:07, 8 October 2007 (UTC)

Ladies and gentleman can I call you to order please! I turn my back for one evening and this is what I return to! This is a professional site and we should be able to find a way through this maze. I think we need three sections here


 * A critique section
 * A ideas about the design of further studes section
 * An evaluation of the evidence section - where we categorize the body of work against the sets of criteria that exist.

The quote from the task force should go into the evaluation section.

The critique section (which is not the evaluation section!) should be written so that each point is is made in a seperate numbered paragraph. We can locate disagrements to each paragraph and try to find a form of words to suite all parties. For example it seems perfectly proper on the point of characterizing the samples to add Art's point that they were compared. We dont need to be psychologists here to know that the critical discipline involved here is painful for workers in an area. It can feel like a personal attack which I am convinced it is not at bottom, here is an attempt to apply the principles of science appropriately in a way that will allow us to build for the future. It would be helpful if we talked about the work in general terms rather than personalize it with Art's name.

There is proper respect for Arts work here. We take Jean's point "you have an adequate pilot study here. Why not just use it as the foundation for more advanced work? Nobody is saying that you shouldn't have done it or that DDP is harmful." Art feels the work can lay claim to more. We will see in the evaluation section when we can dispassionately weigh the updated picture of the evidence against the sets of criteria. The key for me is that we work to formulate the way forward. This is how science works. Dr Joe Kiff 07:43, 9 October 2007 (UTC)

Ok - but lets stop with the instant reverts shall we and actually discuss. There's no big rush. Those top-notch RCT's are difficult and expensive and I would have thought most therapies start with something more preliminaryFainites 11:02, 9 October 2007 (UTC)

critique format
Joe, this sounds to me as if Art gets to say what he wants about his study twice, once in the body of the article and once in response to the critique. I don't think this is appropriate. In addition, his statement that baseline measures and demographics were compared is not and can never be a rebuttal of my statement about self-selection by parents. To answer one question with a response that belongs to another is a type of non-transparency that should be prohibited if you want a web site of professional quality.

I say "Art", by the way, because that's who he is-- we all know that, and there's no point pretending that his study just suddenly made itself manifest without human agency.

Fainites is right, RCTs are difficult and expensive and complicated. Few of us would expect a preliminary study to involve that kind of design. But there are important criteria to be met by a CCT, and the claims that can be made depend on how many of those criteria were met. My position is that Art claims a level of evidence that is not supported by the design or analysis of his study, and he fails to make the case that the study meets the criteria that would be needed for that level.

If a critique is to be done according to the model you offer, Joe, I would suggest that Art's responses should be confined to statements that actually do serve to make his case. And once again, I find it problematic that his statements should be made twice while rebuttals occur only once.

Now Shakespeare scholars, what have i done here? Is this the "reproof valiant" or the "countercheck quarrelsome"? I'm not sure myself! Jean Mercer 14:29, 9 October 2007 (UTC) Jean (not sure if my log-in has worked)


 * I am working on the principle of joint statements here. It makes perfect sense to me for you to make some criticisms on for example, the basis of selection of the subjects and to add in Art's mitigating point that there is evidence that they were in some sense checked to be representative. I dont think they are mutually incompatible readers can then judge for themselves. This is not a winner takes all contest. I feel I understand your position as out lined above and am hoping that now we have the criteria clear we can lay the arguments out on the evaluation page in a fair and balanced way. Dr Joe Kiff

It is also absolutely necessary if a proponent is writing about his own study to make that absolutely plain - as to be fair Dr BW does on the talk page - but it would need to be in the body of the article too. This is basic good practice. Fainites 16:24, 9 October 2007 (UTC)


 * My concern here is to acknowledge that we ought to maintain a professional tone and avoid language that may be read as personal attacks. Part of a professional stance is to absorb a great deal of personal stress and to continue to perform to appropriate standards. It is also important for somebody to support Art morally in what is a very difficult position, his work is being publically evaluated and I appreciate his courage in continuing the debate Dr Joe Kiff 17:36, 9 October 2007 (UTC)

Well I certainly think the accusations that people have either not read material when they plainly have, or are misrepresenting it should cease. Not everybody has access to all the papers but it is usually not difficult to provide the context of any particular statement. I also think pertinent questions should be answered rather than be allowed to drift up the talkpage in a sea of repetition. Like Jean, I have no problem with the DDP studies as such, but am concerned about their representation in the article. Can we agree a format to work to?
 * introduction giving a brief outline of DDP, including target population, basic principles, name of developer etc, but avoiding controversial terms like 'evidence based'.
 * theoretical basis and theoretical development.
 * practical application of the intervention.
 * evidence basis including the studies
 * notable or peer reviewed commentary/evaluation on DDP and/or research
 * Wikia critique
 * Wikia evaluation  Fainites 17:55, 9 October 2007 (UTC)


 * This looks good, although I would still like to include the proposals for future research section. I have also discussed with Art doing a section on recommendations for professional safeguards, eg supervision etc and also training, qualification for the approach etc Dr Joe Kiff 20:38, 9 October 2007 (UTC)

Proposed Intro
Dyadic Developmental Psychotherapy is a treatment approach for adopted or fostered children who are thought to have symptoms of emotional disorders including those related to attachment. It was originally developed by psychologist Daniel Hughes, as an intervention for children whose emotional distress resulted from earlier separation from familiar caregivers. Hughes developed Dyadic developmental psychotherapy with the express intention of developing a therapy removed from the coercive practices of attachment therapy. Hughes cites attachment theory and particularly the work of John Bowlby as the theoretical basis for dyadic developmental psychotherapy. . Other sources for this approach include the work of Stern, who referred to the attunement of parents to infants' communication of emotion and needs, and of Tronick , who discussed the process of communicative mismatch and repair, in which parent and infant make repeated efforts until communication is successful.

Dyadic developmental therapy principally involves creating a "playful, accepting, curious, and empathic" environment in which the therapist attunes to the child’s "subjective experiences" and reflects this back to the child by means of eye contact, facial expressions, gestures and movements, voice tone, timing and touch, "co-regulates" emotional affect and "co-constructs" an alternative autobiographical narrative with the child. Dyadic developmental psychotherapy also makes use of cognitive-behavioral strategies.

A study and a follow up study published in 2006 concluded that the treatment was more effective for the treatment of Reactive attachment disorder and emotional trauma than "usual treatments".

(or "'Two preliminary and exploratory studies, the second being a follow up of the first concluded that the treatment was more effective for the treatment of RAD and emotional trauma than "usual treatments". +refs) Fainites 22:13, 10 October 2007 (UTC)

Theoretical basis
What do you think of this? I wrote it for the Wiki article - its almost entirely from Hughes description of the therapy in his 2004 paper so should be pretty uncontroversial. I think it needs Tronick adding somewhere as he did cite Tronick. Could we use it as a starting point?
 * ==Theoretical basis==

Dyadic developmental psychotherapy is based on the theory that maltreated infants not only frequently have disorganized attachments but also, as they mature, are likely to develop rigid self-reliance that becomes a compulsive need to control all aspects of their environment. Hughes cites Lyons-Ruth & Jacobvitz (1999) in support of this theory. Caregivers are seen as a source of fear with the result that children endeavour to control their caregivers through manipulation, overcompliance, intimidation or role reversal in order to keep themselves safe. Such children may also suffer intrusive memories secondary to trauma and as a result may be reluctant or unwilling to participate in treatment. It is anticipated that such children will try to actively avoid the exposure involved in developing a therapeutic relationship and will resist being directed into areas of shame and trauma. Hughes proposes that an attachment based treatment may be more effective for such foster and adoptive children than traditional treatment and parenting interventions.

It is stated that once an infants safety meeds are met (by attachment) they focus on learning and responding to the social and emotional signals of caregivers. (Schore, 2003ab). Hughes posits that this 'affective attunement', described by Stern (1985) is crucial in the development of both a secure attachment as well as a positive, integrated sense of self. Attunement is seen as primarily a non-verbal mode of communication between infant and carer. Hughes states "Whether it is a motivational system separate from attachment as is suggested by Stern (2004), or a central aspect of a secure attachment dyad, it remains vital in the child’s overall development." Through this process, children co-construct the meaning of their experience and co-regulate their affective response, with their carer. This leads to the capacity for self awareness and eventually development of autonomy.

The therapy attempts to replicate this or fill in the missing gaps in a maltreated childs experience.


 * (The therapy attempts to replicate this and supply experiences that will substitute for those missed earlier and correct the distorted developmental trajectory. Fainites 22:30, 10 October 2007 (UTC))

Fainites 19:14, 9 October 2007 (UTC)


 * I feel both the above are constructive contributions. I particularly like the more neutral tone of the introduction. I dont know enough about the theory to comment on the content but it seems fair. Dr Joe Kiff 20:38, 9 October 2007 (UTC)

Fainites, do you really really mean to say that infants "focus on learning and responding to the social and emotional needs of their caregivers"? This seems not only impossible in terms of their development of Theory of Mind, but undesirable if it could happen, as it would lead to an internal working model where the weak have to help the strong. Might you mean the social and emotional communications of caregivers?
 * that was my understanding of what Hughes said Schore said. I'll check it. Fainites 23:04, 9 October 2007 (UTC)
 * sorry the word is 'signals'. Slip of the typos. Fainites 23:07, 9 October 2007 (UTC)

A problem with the theory as it is stated by Hughes and others (other than this issue of who helps whom)is that there is no rationale for claiming that a normal parent-infant interaction, part of typical emotional development, can be intentionally repeated by a therapist or parent with an older child, and fill in gaps in the child's social history. I don't say that no rationale is possible, you understand, just that none is given. As the matter stands, it's as if we said that because breastfeeding is the ideal form of nutrition for young infants, a child who has been malnourished for years can be fed on human milk and this will undo his nutritional deficiencies and their physical effects. Anyone hearing that statement would ask for the Ts to be crossed, etc. I ask the same for the connection between Tronick's description of communicative events, and why attunement practices should work for an older child...that is, work in any way beyond the way reflection of feeling works.Jean Mercer 21:46, 9 October 2007 (UTC)

With respect to Lyons-Ruth, by the way, I think it would be agreed that she is talking about a very specific population-- not that these controlling behaviors are characteristic of all children with poor attachment histories. A comparison to Zeanah and Lieberman's categories confirms this. And of course the DSM criteria don't refer to this behavior at all. My point is that unless DDP is directed only toward children with these specific behaviors, it doesn't seem that this concept should be a major part of the theory.Jean Mercer 22:01, 9 October 2007 (UTC)

You may well be right, but is it a fair summary of Hughes theoretical base? Fainites 23:08, 9 October 2007 (UTC)

It seems fair to me. Just one other point-- where you say "the children co-construct..." do you mean the child and the adult co-construct? Co-constructing seems to require at least two people, and i don't think it means two children.71.125.136.168 00:33, 10 October 2007 (UTC)

In that bit he's talking about "normal" children with the parent/carer. It sort of follows on from the previous bit but I'll try and make it clearer. As I understand it, the idea of the therapy is to replicate this later with children who've missed out on, or had a bad experience of, the process originally.Fainites 07:33, 10 October 2007 (UTC)

I'm not sure 'fill in the missing gaps' is a very elegant way of putting it. Any ideas? Fainites 21:57, 10 October 2007 (UTC)

Well-- the gaps aren't missing-- the gaps are present, that's how you know something's missing!
 * (clever clogs)Fainites 22:28, 10 October 2007 (UTC)

How about "supply experiences that will substitute for those missed earlier and correct the distorted developmental trajectory"? I guess that's what's meant.Jean Mercer 22:11, 10 October 2007 (UTC)

Here's a handy recent synopsis from Hughes which may help with drafting the theoretical basis:

The relevance of attachment theory to psychological treatment has been described by many authors, beginning with John Bowlby. Bowlby stressed the importance of the therapist providing a “Secure Base” from which the client can begin to explore his working models of self and other (1988, p. 138). A crucial question involves how the client does explore—how he does develop a model of self and other—in therapy. Bowlby suggests an answer to this crucial question in the same volume and he finds the answer within the attachment relationship between the parent and infant:
 * Parental and Therapeutic Principles for Children with Difficulties Developing Attachment Security

“There are, in fact, no more important communications between one human being and another than those expressed emotionally, and no information more vital for constructing and reconstructing working models of self and other than information about how each feels towards the other. During the earliest years of our lives, indeed, emotional expression and its reception are the only means of communication we have, so that the foundations of our working models of self and attachment figure are perforce laid using information from that source alone. Small wonder, therefore, if, in reviewing his attachment relationships during the course of psychotherapy and restructuring his working models, it is the emotional communications between a patient nd his therapist that play the crucial part.” (1988, pp. 156-157).

When children are exposed to intrafamilial abuse and neglect they are at risk for manifesting severe difficulties in all areas of their development including their ability to develop secure attachments to their present and future primary caregivers (Hughes, 2004, 2006; von der Kolk, 2005). For these children to be able to achieve such attachment security and to develop a coherent autobiographical narrative, it is crucial that they experience the same types of “emotional communications” with their parent (or therapist). It is crucial that we now understand the nature of these communications so that we can provide them to older children, youth, and even adults, who have been denied them earlier in life. The following represent a summary of the principles of such communications:

1.	They are intersubjective. They involve a sharing of the subjective experience of both members of the dyad. Being intersubjective they occur “between” the two. Both need to be impacted by the experience for it to be intersubjective.

2.	These intersubjective experiences consist in joint affect (attunement), shared awareness or attention, and complementary intentions. 3.	They are primarily nonverbal. They consist in the meaning conveyed in facial expressions, voice prosody, gestures, posture, expressed with varying degrees of intensity and rhythm. 4.	All verbal expressions are embedded within the nonverbal context. Together, they form the basis of affective/reflective dialogue that facilitates the reorganization of experience.

5.	The attachment figures stance is one of follow-lead-follow. The initiatives of the child are followed within a playful, accepting, curious and empathic attitude. The parent, or therapist, often leads the child into events which they would rather avoid or which they have not managed well. The parent, or therapist, then follows the child’s response to these “leads” with the same attitude.

6.	The parent, or therapist, continuously repairs breaks in the intersubjective experience as they occur. The child develops the security of knowing that all conflicts will be repaired and the relationship will remain.

7.	Both the parent and therapist clearly differentiate the inner life (thoughts, feelings, wishes, intentions, perceptions) of the child from his behaviour. The inner life receives acceptance, curiosity, and empathy. Any evaluations are reserved for behaviours.

These principles reflect how the “emotional communications” spoken of by John Bowlby are central in the development of attachment security and its manifestation in a coherent autobiographical narrative. The mind and heart of the child are likely to remain responsive to such communications when the mind and the heart of the parent, or therapist, are able to communicate with the child who lives under the symptoms and who developed in response to the trauma and loss.

Bowlby, J. (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. New York: Basic Books. Hughes, D. (2004). An attachment-based treatment of maltreated children and young people. Attachment & Human Development, 6, 263-278. Hughes, D. (2006). Building the bonds of attachment 2nd Ed. Northvale, NJ: Jason Aronson. Hughes, D. (2007) Attachment-focused family therapy. New York: W.W.Norton. Von der Kolk, B. (2005). Developmental trauma disorder: toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35, 401-408.

Fainites 13:59, 11 October 2007 (UTC)

Are "mind and heart" defined? This seems to me an important point for the theory. How are these entities different, and if they aren't, why are both terms used? I'm not critcizng the theory, just thinking that this might be clearer to a reader if it were limited to emotional communications as a topic, and leave the heart and mind out.Jean Mercer 14:35, 11 October 2007 (UTC)

I don't know Jean. I just copied it as it was written! All I can say is, I can see the idea but you'd have to be a damn good therapist to achieve it. Miss something or get a bit of attunement wrong and the effect could be disastrous - like parody. It would also be very draining I would think. Also - I can see the empathy bit and the coherent narrative bit and how it may well improve sense of self, relationships and the capacity to form them. What I can't quite see is where attachment comes in in the sense of making up for early attachment experiences by trying to replicate them. Hughes himself says in relation to attunement "Whether it is a motivational system separate from attachment as is suggested by Stern (2004), or a central aspect of a secure attachment dyad, it remains vital in the child’s overall development." Fainites 18:03, 11 October 2007 (UTC)

Same old recapitulation problem. But actually, about the mistakes and parody, Tronick and Gianino talk about the advantages of having this happen from time to time in infancy-- teaching the child that communicative mismatches can be repaired and persistence may be needed. Is it the same for an older child with a poor social history? Dunno!Jean Mercer 23:28, 11 October 2007 (UTC)

Tricky bit of research to do - that. Fainites 22:12, 12 October 2007 (UTC)

Author's assessment
May I point out that Becker-Weidman's article in the Sturt book assesses the research in these terms: "This study is preliminary and exploratory. While the results are intriguing, the small sample size and limited number of families located at this time limit the strength of the findings" (p.44). The paragraph appears to refer to the follow-up study reported in the Sturt book. The statement seems to suggest a far more modest evaluation than the current claims about the evidentiary foundation of DDP.Jean Mercer 14:37, 10 October 2007 (UTC)

Thats very odd indeed. Its even more modest that Daniel Hughes assessment of it. Also, if I'm right in my understanding that the first study wasn't published in a peer reviewed journal until April 2006, it appears that DDP was being described as 'evidence based' on the website when the Taskforce looked in 2004 and on Wikipedia at the end of 2005/early 2006, by Dr Becker Weidman, before either of the studies was published in peer reviewed journals.Fainites 20:27, 10 October 2007 (UTC)

Perhaps part of the problem is the swiftly altering and ever uncertain status of the term "evidence-based". But various web sites of the attachment industry have used this term when they simply meant that they had testimonials posted. There are no evidentiary police to stop them, and in the U.S. it's not possible to prove fraud unless you can show that someone was injured by misinformation, and the misinformation was given by someone who knew it was wrong. Ethical guidelines for clinical social workers in New York state do prohibit deceptive advertising, but again, there's no one to enforce this.

As for peer-reviewed journals, I'm not really sure what role such publication should play. If someone had fantastic data, but hadn't submitted them to a journal yet, does that mean they don't contribute to evidence? Also, some peer-reviewed journals don't peer very closely (e.g. Craven & Lee), so you can have poor data that are published in a journal that claims effective review. It's a puzzlement.Jean Mercer 20:41, 10 October 2007 (UTC)

Well it seems to me that at the moment it may be easier to say what evidence based isn't rather than what it is. 'Evidence based' does not mean 'published in a peer reviewed journal'. Neither does it mean any old category in Saunders. Neither does it yet mean any and all of the various proposed categories in the various systems. Chambless and Hollon may be the 'gold standard', it is the APA after all. But they, like the Taskforce and like Kaufman and his 'Best Practice' approach all presuppose some kind of outside evaluation or assessment by some kind of board or evaluator that denotes acceptance by the 'establishment'. There is no provision anywhere for self assessment! The fantastic data would be evidence - but they wouldn't be morally entitled to call themelves 'evidence based' until the 'psychology community' said so in some form or other I supposeFainites 21:50, 10 October 2007 (UTC)

Ho ho ho about the 'peer/peer' one by the way. Fainites 21:53, 10 October 2007 (UTC)

The former president of my college used to say we had peers but no equals-- try that for size!

As for self-assessment, we're all supposed to have learned to do this, but it's not always so easy to do it correctly.Jean Mercer 22:14, 10 October 2007 (UTC)

Well as Dr Becker-Weidman describes it that way himself, suppose the last sentence reads 'Two preliminary and exploratory studies, the second being a follow up of the first concluded .....'. The other issue is the method of diagnosis of RAD used as I understand the RADQ was used in addition to Achenbach's CBC. Fainites 22:09, 10 October 2007 (UTC)

Proposal
Lets just set out the theory, the practice, the studies, the critique, the evaluation and avoid any value laden language and let the reader decide. One of the readers may be the person who goes on to undertake RCT's. Fainites 13:51, 11 October 2007 (UTC)

I don't know that it's possible to avoid language that conveys values-- if you evaluate, you are talking about values. however, it's a good goal to have.Jean Mercer 14:37, 11 October 2007 (UTC)

Lets do it Dr Joe Kiff 16:22, 11 October 2007 (UTC)

OK. Avoid value laden language except in the evaluation. Fainites 18:01, 11 October 2007 (UTC)

Okay, I tried. See if I've managed to avoid inappropriate language. .. But I ended up repeating some other things that had been said.Jean Mercer 23:24, 11 October 2007 (UTC)

Sounds very measured. Three points. 1. What do you mean by 'unusual adjuvant techniques' from material on the internet. 2. I think there needs to be more about the RADQ - perhaps in the critique? How was RAD diagnosed? Had the children already been diagnosed elsewhere? How did he measure for reduction in signs of attachment disorder and what was meant by attachment disorder? 3. How are we going to title this bit as opposed to eg outside comments like the Taskforce. Fainites 23:35, 11 October 2007 (UTC)

What i mean by unusual adjuvant techniques is Nancy Thomas, but i don't think that matters-- the point is that the DDP procedure may not have been the only thing happening. As for your other two questions, here's what it says in the Sturt book ( a descendant of Kng Chrles, that Sturt):

"Subjects were selected from among the case files of the Center for Family Development... using the following criteria:

1. The case was closed in [sic] within a twelve-month period. 2. The child received a diagnosis of Reactive Attachment Disorder, 313.89, using the criteria in the Diagnostic and Statistical Manual IV (DSM IV, 1994).

3.[treatment description] 4. The child had a significant history of physical abuse, physical or psychological neglect, sexual abuse, or institutional care. These children were experiencing complex Post Traumatic Stress Disorder." (pp. 47-48).

I realize that this doesn't answer your questions, but all i can do here is report the news. I don't know whether they were thought to have both RAD and PTSD-- it sounds like it. I don't know whether all children who met these criteria were included, or whether all that were included met these criteria.Jean Mercer 00:13, 12 October 2007 (UTC)

Does this mean that the use of Nancy Thomas parenting techniques could have accounted for the results? Fainites 17:29, 13 October 2007 (UTC)

Yep-- that's one of many confounding variables whose effects could have been confused with that of DDP. Or, it could be that DDP is effective only when combined with NT-- or only when done by a practitioner with allegiance to it-- or only when parents believe in it-- that's why people try to disambiguate these things.Jean Mercer 20:45, 13 October 2007 (UTC)

In the paper in Sturt it says ""During this part of treatment, the caregiver is instructed in attachment parenting methods (Hughes, 1997; Gray, 2002; Thomas, 1997)." (p.50). I take it that's Nancy Thomas then. Also the Hughes cite of 1997 is pre-DDP isn't it? Doesn't Nancy Thomas claim a pretty good success rate with RAD or attachment disorder with her parenting methods? Fainites 22:30, 13 October 2007 (UTC)

Yes, like many members of the attachment industry, NT (who is a dog trainer) claims 80% or more success-- and, don't forget, she says that most of the children she's worked with have killed (victim species or size unspecified). In one of her books she describes two preschoolers running (or maybe one has a tricycle) around a large field, and every time they reach a grassy spot where the adults can't see, one sodomizes the other--- then they pop out and go around again. This is either a different definition of sodomy than any I'm familiar with, or the one kid is really a quick worker, because the adults don't notice a thing. Anyway, I suspect that the killing is also subject to definition. But be that as it may, she claims her methods work, in conjunction with holding therapy.And since ATTACh still has her as a presenter at their annual conference, maybe they agree.Jean Mercer 23:23, 13 October 2007 (UTC)

Crtique
I'm unclear about how the assessment measures were used. The study says the children fulfilled criteria for RAD as per DSM. Am I right in thinking the Achenbach wouldn't 'diagnose' this and the RADQ was used? The seven hypothoses contain things that were presumably checked against Achenbach. But where does RAD and the RADQ fit in? This should be adressed both in the critique and in the suggestions for further research.Fainites 18:55, 11 October 2007 (UTC)

I had in mind that much of the material Jean has added recently should go in the critique section - Addressing technical issues of design and implementation etc. The evaluation section is for consideration of how the studies measure up to the explicit criteria. I am trying to get away from unproductive discussions about is it evidence based or not by giving readers the information to adjudge this themselves. I dont think our role should be as judge and jury on the studies, but to be clear on what the issues are, lay the arguments out with an emphasis on constructive proposals for the next step of the research. I had reorganised and edited Jeans critique section before. Would you like me to do it again Jean or do you take a different view? Dr Joe Kiff 16:20, 12 October 2007 (UTC)

Joe, could you define what you mean by the evaluation section and the critique section? I thought i had done what you said for the evaluation, laid out criteria and noted how the studies complied with them. I didn't propose further research, but i didn't see that as a part of the evaluation. Perhaps you need to list what you see as parts of each of these sections.Jean Mercer 17:10, 12 October 2007 (UTC)

Just thinking about your reference to "technical" issues-- so often this word is used to mean "details that would be dismissed as trivial by anyone other than a member of the audit culture". Certainly there are such issues in every investigation, but I don't think i mentioned any of them in the evaluation piece. Everything i commented on is closely connected with the question of whether there is, or is not, adequate evidence to support the efficacy of DDP.

For example, Becker-Weidman's studies would never have been published had there been no report of statistically significant differences. However, the statistical test he chose to do was the wrong one, and its use much increased the probability that a difference would be judged as meaningful when it had occurred by chance alone. What would the results have been if the correct statistical analysis had been done? We don't know, and therefore we don't know that the claim of treatment efficacy has been empirically supported. This is no trivial matter, especially as Becker-Weidman has not come forward to re-analyze the data or to make his raw data available to others.

My highest priority here is to try to make sure that treatments presented to the public as evidence-based actually have adequate support behind them. Otherwise, the Internet serves as an advertising medium, to the benefit of practitioners, but not necessarily to the benefit of those seeking treatment. This is not, of course, to suggest that DDP is directly harmful to children, although clearly some interventions are so; but there is a problem if the evidence of benefit is not clear. It is indirectly harmful and contrary to professional ethics if we encourage people to choose unsubstantiated treatments over those with a strong evidentiary basis.Jean Mercer 20:11, 12 October 2007 (UTC)


 * I think this last paragraph is absolutely to the point and that it is fair and right to highlight scientific criticisms of the evidence for the reasons you say. I think on this site we should seperate these criticisms from evaluative comment, as this runs into problems of prejudice and entrenched positions. I think it is not helpful to go beyond the peer review process. For any of us could raise criticisms about any study by raising these types of issues. I think we have to accept that studies have been published in good faith and this is why we rely on replication to take evidence to the next level. I take your reasonable point about alternative statistical analysis but on this site it needs to be made professionally and objectively in a way that leads to constructive proposals for future work. Your points can be made here in a way that let your arguments speak for themselves, as can Art's. If the two sides are put clearly and fairly readers can make up their own minds and we get away form the the fruitless arguments on both sides. We should let science speak, not speak for it. Dr Joe Kiff 12:28, 14 October 2007 (UTC)

Can we be clear here as to whether this is a discussion about style or substance? Are you simply suggesting that the material Jean has put under 'evaluation' should go under your headings under 'critique' and then 'evaluation' is measuring the study against the various criteria? Do we then need a separate section for 'outside' evaluations like the Taskforce or Craven & Lee? Fainites 22:09, 12 October 2007 (UTC)


 * Yes that's what I am suggesting. I also like your suggestion that the published evaluations should be quoted in a seperate section, I would include that Hughe's quote too, if it has not been superceded. This would then complement the evaluations against the criteria. I am quite interested to see how we can apply the criteria objectively without getting tied up in argmentative debate. Working through this section may give us ideas how we can clarify the criteria and in time see how Jean's proposals take us forward. Dr Joe Kiff 12:28, 14 October 2007 (UTC)

I thought I was measuring against the various criteria-- I chose criteria from various protocols. I think the only one that doesn't appear on most protocols is transparency of reporting, but that has a whole protocol of its own.Jean Mercer 13:40, 13 October 2007 (UTC)

Can you define how the criteria can be applied objectively without evaluation? The point of the criteria is to evaluate, isn't it? And one of the reasons for evaluation is that the peer-review process doesn't always do a good job or insist that the conclusion be supported by the evidence. For example, Rubin and Parrish (2007) looked at 138 published outcome study reports and found that in 70% of them the conclusions stated were not justified by the design.

Or, maybe, Joe, you'd care to take what I've written and remove from it what you believe are subjective responses.I myself wouldn't want to evaluate good faith, which seems to me to be quite subjective.

This is "your" web site, so I will limit my advice about how to run it. But I think you should be careful about being motivated by "pseudosymmetry": seeking the appearance of objectivity by including material that does not have much support.Jean Mercer 15:19, 14 October 2007 (UTC)

I have combined the critique and evaluation sections into their respective topics removing all duplicated material from the critique bits. This may actually make it easier of anyone wants to separate out critique from evaluation again. Fainites 20:54, 14 October 2007 (UTC)

On pseudosymetry, you may be interested in some bits of the Wiki policy on the reporting of 'pseudoscience'
 * The task before us is not to describe disputes as though, for example, pseudoscience were on a par with science; rather, the task is to represent the majority (scientific) view as the majority view and the minority (sometimes pseudoscientific) view as the minority view; and, moreover, to explain how scientists have received pseudoscientific theories. This is all in the purview of the task of describing a dispute fairly.Fainites 21:52, 14 October 2007 (UTC)

Parenting techniques used
I have now obtained a copy of "Facilitating..." Hughes 1997 book cited by Dr Becker-Weidman along with Nancy Thomas for adjuvant parenting techniques. The book contains extensive material on parenting, including age regression approaches. Much of the material has significant similarities to Nancy Thomas' material. I would have though this was a very significant 'confounding variable'. Fainites 20:58, 14 October 2007 (UTC)

Its also a bit of a conundrum because I added a link to Hughes site where he lists the therapeutic and parenting techniques whi ch he says are not part of his therapy, but some of them do appear in Nancy Thomas. Heres Hughes list from his website:
 * 1. Holding a child and confronting him/her with anger.

2. Holding a child to provoke a negative emotional response . 3. Holding a child until s/he complies with a demand.

4. Hitting a child.

5. Poking a child on any part of his/her body to get a response.

6. Pressing against "pressure points" to get a response.

7. Covering a child's mouth/nose with one's hand to get a response.

8. Making a child repeatedly kick with his/her legs until s/he responds.

9. Wrapping a child in a blanket and lying on top of him/her.

10. Any actions based on power/submission, done repeatedly, until the child complies.

11. Any actions that utilize shame and fear to elicit compliance.

12. "Firing" a child from treatment because s/he is not compliant.

13. Punishing a child at home for being "fired" from treatment.

14. Sarcasm, such as saying "sad for you", when the adult actually feels no emapthy.

15. Laughing at a child over the consequences which are being given for his behavior.

16. Labeling the child as a "boarder" rather than as one's child.

17. "German shepherd training", which bases the relationship on total obedience.

18. Depriving a child of any of the basic necessities, for example, food or sleep.

19. Blaming the child for one's own rage at the child.

20. Interpreting the child's behaviors as meaning that "s/he does not want to be part of the family", which then elicits consequences such as:
 * A. Being sent away to live until s/he complies.
 * B. Being put in a tent in the yard until s/he complies.
 * C. Having to live in his/her bedroom until s/he complies.
 * D. Having to eat in the basement/on the floor until s/he              complies.
 * E. Having "peanut butter" meals until s/he complies.
 * F. Having to sit motionless until s/he complies.

Giving the above consequences in a "loving, friendly tone" does not make them appropriate. That tone may actually cause greater confusion about the meaning of love, parenting, and safety which we want children to understand." Fainites 21:48, 14 October 2007 (UTC)


 * The 1997 text is outdated and not representative of the practice of Dyadic Developmental Psychotherapy. <font color="#FF9933" face="monotype"> Dr. Becker-Weidman  <font color="#00FF00">Talk 21:55, 14 October 2007 (UTC)

That may well be true now as DDP is clearly a developing therapy but the point I am making is that it was what was being used when your studies were done. This would seem to be a significant confounding variable. It may also make the studies of somewhat limited value in supporting the current practice of DDP. Are there any studies on the current practice underway? Fainites 22:05, 14 October 2007 (UTC)

Also - I was referring to adjuvant parenting techniques above. However, I note that in the first study you cite Hughes 1997,2003 and 2004 as the source of DDP. 1997 is the "Facilitating..." book which includes holding therapy. Is the therapy described in the 1997 book representative of the DDP that was being used when you were treating the chidren? If their cases all closed in 00/01, you must have been treating them in 99/00. Is this right or have I misunderstood something here? Fainites 22:07, 14 October 2007 (UTC)

I also note you've reverted all the edits of other editors over the last 5 days without any discussion, or indeed any input at all. This really won't do you know. Fainites 22:22, 14 October 2007 (UTC)

History of research project
I notice that the on line report of this research, available in 2004/2005, and referred to in my Medscape article in 2005, discussed a simple before- and-after study. No comparison group was mentioned at that time. I'm curious to know why this was. This would be useful information, as would an answer to the query above, about the actual time period when these children were assessed and treated.

By the way, I too would apreciate knowing the rationale for the edits so freely made today... and would like an acknowledgement that ATTACh is also an advocacy group, and in fact is one that has people like Nancy Thomas presenting..Jean Mercer 22:54, 14 October 2007 (UTC)

oh what a tangled web we weave
In my opinion,it is at best misleading to continue to describe DDP as evidence-based, while at the same time acknowledging that there is no clear meaning to this term.Jean Mercer 19:17, 16 October 2007 (UTC)

Thanks
My thanks to you all for your patience and for Art's restoration of material. Bit by bit we seem to becoming more appropriate in our behaviour. I want to hold out for the return of the specific scientific criticisms of the studies as I think that section was particularly good, written relatively objectively, and making points any thorough going scientist would make. But I take Art's point that it feels like persecution, given that no other article is being so comprehensively treated. So before pressing this point I will wait for us to do further work on other approaches. Dr Joe Kiff 21:30, 16 October 2007 (UTC)