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Scientific Support, or Non-Scientific Foundations? This paper prekoova a draft prepared for presentation at a meeting of the International Working Group on Abuses in Child Psychotherapy, London, April 20, Scientific Support, or Non-scientific Foundations?
The Czech child psychotherapist, Jirina Prekopova, who practiced in Germany where she was called Prekop for some years, has returned to the Czech Republic and is promulgating her therapy method there and in other countries in Europe and Latin America see www.
In HT, parents hold young children ventre-a-ventre and restrain their movements during a period of an hour or more. The children resist, scream, and cry, and the parents speak to the child of their own negative and positive emotions about the child. The child is prekpova to reach a peak of resistance, then to calm, and to end the session with positive feelings on both sides.
Similar methods can be used with older children, but larger children lie supine while the parent usually the mother lies on top of them and restrains them prekoplva her body weight.
This practice is not the same as HT, but contains similar belief elements involving the power of physical contact and the possibility of recapitulation of early steps in development. Prekopova claims that autism and other behavioral problems are caused by separation of mothers and infants at birth and a consequent failure of bonding, which she defines as an emotional change in both members of the dyad.
Prekopova states that her approach has scientific support and that this is evidenced by the approval and encouragement of the co-winner of the Nobel Prize for Medicine, Nikolaas Tinbergen. The present paper is intended to examine the claim of scientific support for HT, first by considering the work of Tinbergen and of other ethologists, and second by looking at the small number of outcome studies that have assessed the effect of HT.
In addition, the paper will address nonscientific foundations for the theory and practice of HT. Both treatments and posited causes of autism will be considered. There are two ways to claim scientific support for an idea.
The first and most obvious is to report systematic investigations that provide supportive evidence. The second, easier, but less reliable technique is to show that the idea is plausible in terms of previous work.
Most of the cited publications are ethological in nature. Ethological Foundations of HT. Ethology is an observational approach to comparative psychology, the study of behavioral similarities and differences between species. Ethologists have generally used extensive observational study to determine common species-specific behaviors called fixed action patterns Eibl-Eibesfeldt, Using their understanding of fixed action patterns, ethologists have considered the roles of innate factors, of motivation, and of learning in the determination of behavior.
They examined the function of environmental triggers called releasers in the initiation of a fixed action pattern, and posited the existence of innate releasing mechanisms that responded to a releaser as a lock does to a key, permitting the fixed action pattern to be carried out. Although ethologists examined the behavior of mammals, including humans e. One ethological concept was of particular relevance to HT. This was the idea of imprinting, a particular type of learning that occurred very early in life and was difficult to undo once it had happened.
Imprinting did not create a fixed action pattern, but did determine exactly what releaser would call it out. For example, newly hatched ducklings were prepared to respond to any moving object as a releaser of their following response, but once they had followed a type of object, it became the only releaser of following, even though it was a model train or something else other than a mother duck. When the ducklings reached adulthood, they would then display mating behavior a set of fixed action patterns only toward an object similar to the one they had initially followed and were imprinted on.
In his early discussions of human emotional attachment, John Bowlby was influenced by ethological concepts and suggested that human infants, like ducklings, jirna monotropic and form an attachment to a single person. In addition to the idea of imprinting and its effect on fixed action patterns, ethologists were interested in behavioral responses to conflict situations, in which an individual might want both to approach and to escape from a situation.
An animal or person that was simultaneously frightened and attracted by something might respond with displacement behavior, in which a fixed action pattern that normally occurred in a different setting was enacted.
For example, birds that are in conflict about an object or situation may preen their feathers, which they ordinarily do for cleaning purposes; humans may yawn, which they usually do in response to sleepiness. Hutt and Hutt, who were frequently cited by Tinbergen, did not refer to HT as a possible treatment for autism.
Tinbergen and Tinbergen provided many examples of fixed action patterns and of imprinting in birds such as herring gulls, and referenced human fixed action patterns as discussed by Eibel-Eibesfeldt and others.
They argued jiria autism was caused by environmental events, as had been suggested by Kannerand that it might be possible for environmental factors to reverse the process and return an autistic child to more typical development. Tinbergen had proposed that an autistic child who avoided social contact might be attracted by a mask with unusually large eyes, which in ethological terms could function as a supernormal releaser, and could gradually move toward social contact with more usual releasers such as eye contact and facial expression.
The Tinbergens in their book put forward the views of Martha Welch, who attributed autism and other behavior problems to a failure of emotional connection between mother and child, and who proposed that intense face-to-face physical contact and emotional expression were required to correct a problem that had developed early in life.
The Tinbergen prekoplva later helped Welch in the publication of her own book, followed by a European book tour and meetings with the Tinbergens, Prekopova, and others. The ethological position provided a number of concepts that were useful for thinking about autism and even jirinna HT, but there were some serious problems with the view that ethology provides scientific evidence for Jiirina.
Ethology jriina is concerned with species differences and species-specific behavior; it does not assume preekopova fixed action patterns or other characteristics of a given species can necessarily be generalized to a different species, although it jirlna that mechanisms like displacement may be shown in different ways in different species. Ethological studies have shown that imprinting-like mechanisms occur in some but not all species.
Where genuine imprinting does occur, it is almost by definition extremely difficult to alter, as is seen in hand-reared captive birds who even if persuaded to mate may push their conspecific mates away if they see the human on peekopova they were accidentally prrkopova. In its discussion of imprinting, ethology also focuses on critical or sensitive periods, age ranges within which members of a species are ready to learn rapidly from certain experiences, and before or after which their learning of that type is limited.
The study of human attachment, with its strong ethological influences, jirinz considered a possible critical period for attachment in the second half of the first year and not at the time of birthbut current thinking stresses ongoing developmental changes in attachment as well as the ability of a child separated from attachment figures to form new attachments in a way quite different from imprinting.
These facts suggest that although Tinbergen himself was supportive of HT, ethological facts and principles did not actually provide a ptekopova for such support. The others, who made outstanding contributions to the study of jirona and behavior, were nevertheless not specifically relevant to treatment of autism or other behavior problems.
Whether or not a treatment for autism is scientifically plausible depends to some extent at what is known about autism at the time the treatment is proposed. Treatment plans often depend on assumptions about the cause of a disorder, so beliefs about treatments are also based on beliefs about causes.
Changing Beliefs About the Causes of Autism. An important reference point for Prekopova has been the work of George Victor He saw the development of autism as involving reactions of the child to unpredictability; self-stimulation, for jjrina, was seen as altering jiirna and further reducing the responsiveness of the child to social stimulation.
However, empirical work has indicated that this is not the case, that autistic children are as attached to caregivers as typically-developing children Gernsbacher et al. The present scientific position on autism accepts that environmental factors can influence both typical and atypical behavior. However, there are jiriba essential factors in current thinking preekopova take precedence over the environmental approach. The first is that there are many different types of autism rather than one general diagnosis that applies to all autistic individuals.
Beaudet suggested a division into two basic types. The first, a milder form, involves a higher intelligence quotient, no unusual prekopva features, an unknown rate of genetic problems, a mild transient increase in head size, a sex ratio of males to 1 female, regression as a common phenomenon, responsiveness to the environment, and a possibility of treatment or prevention by manipulation of environmental factors. The other form is more severe, involves physical dysmorphisms, features lower intelligence quotients, can include either microcephaly or extreme macrocephaly, has a sex ratio of boys to 1 girl, jirrina related to paternal age, rarely involves regression, involves both new and inherited mutations, and can probably not benefit from attempts at prevention or treatment.
Although no one would claim that these approaches have completely solved the puzzle of autism, it is clear that the current scientific position stresses genetic factors as causes of autism. Where environmental factors are emphasized as preventive or treatment measures, the genetic approaches considers them in terms of metabolic problems and dietary requirements.
Malý tyran by Jiřina Prekopová
Thinking of autism as a largely genetic problem does not imply that educational or other therapeutic methods cannot be helpful. Current thinking about autism does not focus on social interactions at the time of birth or even in the first year of life, as Prekopova does Prekop,and therefore does not assume that treatment needs to mimic some posited needed experience that occurs in early life.
Thus, HT is implausible in terms of what is presently understood about the causes of autism. These studies examine the effects of a specific treatment in ways that follow the rules established for evidence-based treatments Sackett et al. Because outcome studies for treatment of mental illness may be difficult to do in ideal ways, such studies are often considered in terms of levels of evidence, and may range from excellent studies using randomized controlled trials, to careful but nonrandomized controlled designs, down to simple descriptive work that employs no standard of comparison relative to the treatment outcome.
In addition, during the s, several German-language studies of HT were published. Prekopova herself published an account of 57 autistic children who were said to have become capable of trusting human interactions as a result of HT, but did not state how it was known that they had not trusted human interactions before treatment Prekop, Rohmann and Hartmann reported the use of a form of HT with a randomly chosen 7 out of 14 autistic children; all were reported to have shown significantly more positive than negative changes as compared to the no-treatment group, and when later given the treatment, the original comparison group also improved, according to the reports of parents.
Prekop and von Stosch n.
In all these studies, the outcome measurement was parent report, and in no case were the parents blinded as to the treatment they themselves administered. More recently, there have been some outcome studies of forms of HT, although none involving randomized controlled trials or assessments other than those of parents.
In one study concluding that HT was efficacious Lester,a simple before-and-after assessment of children by their parents was used, with reports of efficacy biased by unblinded parental evaluations and by the failure to control for normal rapid developmental change during childhood; the technique used was a method of HT other than that used by Prekopova. This paper was briefly listed as a RCT by a Cochrane review several years ago.
Wimmer, Vonk, and Bordnick carried out a similar study, but combined HT with so many other treatments that cause and effect were impossible to determine.
As parents provide the restraint in this method, there is again no possibility that they can be blinded to the treatment. Although these authors reported positive outcomes, they noted that a number of confounding variables, plus regression to the mean, could have had an effect on the results. They did not mention the effect of using unblinded parent reports rather than professional observations. Finally, a report by Sudbery, Shardlow, and Huntington described positive results of HT, but in fact was based on surveyed opinions of caregivers rather than on objective measures of child mood and behavior.
There appear to be neither randomized controlled trial studies, nor well-designed nonrandomized controlled studies, supporting the efficacy of HT. As a result, HT cannot be considered to be an evidence-based treatment, and should not be encouraged or paid for by organizations that claim they approve only evidence-based therapies.
Despite the approval of the Nobel Prize-winner Nikolaas Tinbergen for HT, and despite the many analogies that can be drawn between animal behavior and human behavior, HT does not appear to be based on a systematic scientific foundation.
What, then, are the sources of this treatment and the associated belief system? It may be easiest to divide these into relatively recent sources, say from on, and then to examine the earlier historical background. Sources from to Kanner argued for an environmental cause for autism, as did Bettelheim These views, with their emphasis on an environmental source for autism, were important background for the belief that HT could cure autism and other disorders.
Reich assumed a connection between body and mind such that physical states reflected mental states, and alterations caused in physical states could also create mental changes.
Reich believed that his treatment was responsible for the reduction of the Moro reflex in his infant son this reflex normally disappears gradually in the first months of life and presumably did so in this case as well.
Reich appears to be the major initial source for beliefs about the therapeutic effects of distressing physical treatment in the periodand thus is important to the background of HT.
The American hypnotherapist Milton Erickson advocated the use of restraint in treatment of oppositional children. He advised a mother to sit on her child for hours at a time and to restrict his diet to nonpreferred foods.
Erickson described the outcome of this treatment as greatly increased cooperation from the child, to the extent that he trembled when the mother spoke to him. Cline focused his work on adopted children who were unsatisfactory in their behavior and attributed their problems to the broken attachment between the child and the birth parent; treatment was to destroy their rage and permit them to form a new attachment see Stryker, Cline later surrendered his professional license after a disciplinary hearing by the state medical board.
The period was one in which intrusive psychotherapies, intimidation, and coercion of various kinds were often tolerated or even approved by mental health professionals.
In addition to the attitude of Erickson, mentioned earlier, this period in the United States saw the performances of Jacqui Schiffa Transactional Analyst whose work was associated with the scalding death of a schizophrenic patient Marlan, and John Rosen, a psychologist who was charged with having pushed prkopova patient down a flight of stairs Dolnick, ; Sidney Hammer et al.
Physical contact with patients, generally prohibited in earlier psychoanalytically-influenced treatments, was now accepted by a number of psychotherapists. Among these was an American practitioner, Daniel Casriel, who was later referenced by Prekopova.