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59 BEFORE THE BOARD of PSYCHOLOGIST EXAMINERS STATE OF OREGON IN THE MATTER OF: DEBRA (KALI) MILLER, Ph.D. ) Agency Case No.: ) ) FINAL ORDER HISTORY OF THE CASE On March 11, 2014, the Psychologist Examiners Board (Board) issued an Order of Emergency Suspension to Debra (Kali) Miller, Ph.D. (Dr. Miller or Licensee) based on a determination that Licensee s continued practice constitutes a serious danger to the public health or safety under ORS (2). On June 9, 2014, Dr. Miller requested a hearing. On June 12, 2014, the Board referred the hearing request to the Office of Administrative Hearings (OAH). 1 The OAH assigned Senior Administrative Law Judge (ALJ) Alison G. Webster to preside at hearing. ALJ Webster convened a prehearing conference on June 26, Senior Assistant Attorney General Warren Foote appeared for the Board, and Attorney Paul Cooney appeared for Licensee. During the prehearing conference, the hearing was set for August 11 through 14, The parties stipulated to waive the 30 day deadline for completing the hearing and closing the evidentiary record specified in OAR (3)(b). A hearing was held as scheduled on August 11, 12, 13 and 14, 2014 in Salem, Oregon. Senior Assistant Attorney General Warren Foote represented the Board and Attorney Paul Cooney represented Licensee. The following witnesses testified at the hearing: Dr. Miller; Debbie McGrath, RN; Christopher Brubaker, M.D.; Karen Berry, Board Investigator; Jennifer Bolsinger, DHS Case Worker; A.W., foster parent; Brian Allen, Ph.D., Board Consultant; Holly Crossen, Ph.D.; Ken Huey, LPC; Susan Scott; Arthur Becker-Weidman, Ph.D.; Myron Thurber, Ph.D.; Mark Coen, LCSW. At the close of the hearing, the parties stipulated to waive the 15 day deadline for issuance of the proposed order specified in OAR (3)(c). The parties established September 9, 2014 as the deadline for issuing the proposed order. The record closed on August 15, 2014, upon receipt of the parties written closing argument. /// 1 In the referral, the Board notified OAH that the parties had conferred and jointly requested that the hearing start on August 11 or 18, 2014, and be scheduled for four consecutive days. Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 1 of 33

60 ISSUES 1. Whether Licensee s acts and conduct with regard to Client A and Licensee s continued practice pose a serious danger to the public health or safety. ORS (2). 2. Whether circumstances at the time of the hearing justify confirmation, alteration or revocation of the Order of Emergency Suspension. EVIDENTIARY RULINGS The Board s Exhibits A1 through A37 and Dr. Miller s Exhibits R1 through R11 and R13 through R16 were admitted into the record without objection. The Board s objection to Exhibit R12 was sustained and the document was excluded. 2 FINDINGS OF FACT 1. Licensee holds an active license to practice psychology in the State of Oregon. For the past 18 years, she has had a private clinical practice under the name of Corinthia Counseling Center, Inc., located in Portland, Oregon. Licensee s practice focuses on children and adolescents with underlying trauma. About 80 percent of Licensee s clients have what she considers insecure attachment issues. Licensee has diagnosed about one third of these clients with Reactive Attachment Disorder (RAD). Most of these clients have, in her assessment, a disinhibited type of RAD, 3 as a result of early childhood trauma or neglect, and most are currently living in happy and stable homes. (Test. of Miller.) 2. Licensee considers herself to be an expert in the diagnosis and treatment of RAD. For the past few years, she has presented a program titled, Taming Tiny Tigers: Understanding and Treating Reactive Attachment Disorder (RAD) at conferences around the country. (Test. of Miller; Ex. A28.) 3. As part of her training, Licensee has attended seminars featuring Elizabeth Randolph, Ph.D., 4 creator of the Randolph Attachment Disorder Questionnaire (RADQ), and 2 The Board objected to Exhibit R12, an opinion letter from Louis Cozolino, Ph.D., on timeliness grounds and the lack of opportunity to review or cross-examine the author. The exhibit was marked and accepted as an offer of proof for excluded evidence pursuant to OAR (3). 3 As discussed in more detail infra, the 1994 Diagnostic and Statistical Manual of Mental Disorders, edition IV (DSM-IV) and the 2000 text revision (DSM-IV-TR) identified two categories of RAD, an emotionally withdrawn/inhibited subtype and an indiscriminately social/disinhibited subtype. In the 2013 DSM-V, these subtypes are defined as distinct disorders: RAD and Disinhibited Social Engagement Disorder. (Ex. A34; Test. of Allen.) 4 Dr. Randolph s license to practice psychology was revoked by the California Board of Psychology in She now practices as a pastoral counselor. (Ex. A15 at 9.) Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 2 of 33

61 Foster Cline, M.D., 5 co-author of the book, Parenting with Love And Logic, and other books on attachment disorders. In 2011, Licensee attended an intensive three day conference with Daniel Hughes, Ph.D., 6 on the treatment of children with RAD. (Ex. A12 at 3-5.) 4. Licensee also endorses, and uses in her practice, attachment therapies and methodologies recommended by author Nancy Thomas. 7 Several years ago, Licensee attended one of Ms. Thomas presentations on attachment disorders and was impressed by what she heard. Since that time, for the past seven or so years, Licensee has spent a week or more volunteering at Nancy Thomas Healing Hearts Camps in Oregon. The camps are designed to provide respite and training for children and families with attachment issues. (Test. of Miller; Ex. A28.) Licensee s Treatment of Client A: 5. In December 2011, the father and stepmother of Client A sought out Licensee for treatment for Client A and his two siblings. At that time, Client A was almost 10 years old; his older sister was 11 years old and his younger sister was 8 years old. (Ex. A2.) The parents were looking for a therapist who specialized in RAD. They had tried other therapists without success, and internet research led them to Licensee s practice. (Ex. A31 at 4-5.) 6. On December 16, 2011, Licensee s administrative assistant sent Client A s father and stepmother an information packet regarding Licensee s practice. The packet included an introductory letter and forms to be completed prior to Licensee s initial intake session. 8 The letter, addressed to the father and stepmother, stated in pertinent part, as follows: Since we keep Dr. Miller s schedule full, we work new clients in on cancellations so there may be one-three [sic] weeks between appointments. If you are uncomfortable with such scheduling or if you cannot afford co-pays with Dr. Miller, you might consider working with either of the Licensed Professional Counselors, Hannah Fischer, LPC, LHMC at and Sara Kohlenberger, LPC, LHMC, at They have trained under Dr. 5 Dr. Cline is no longer practicing. In 1995, he received a Letter of Admonition from the Colorado Department of Regulatory Authority. The admonition was based on a Stipulation and Final Order of the Colorado Board of Medical Examiners addressing his use of Rage Reduction Therapy on patients diagnosed with severe attachment disorders. (Ex. A15 at 10.) 6 Dr. Hughes, a clinical psychologist, is the founder of Dyadic Developmental Psychotherapy, an intervention for children with attachment issues. (Ex. R2 at 11). He is also associated with the Attachment Center at Evergreen, Colorado. (Ex. A15 at 10.) 7 Nancy Thomas has no academic or professional credentials. She is a self-proclaimed therapeutic parenting specialist and author of several books on attachment and parenting techniques. (Ex. A15 at 10; test. of Allen.) 8 The forms included a Client Information sheet; a Child s Intake Information form; a RADQ Answer Sheet (copyright 1988 from the Attachment Center Press); an Attachment Symptom Checklist For Children Over 5 developed by Daniel Hughes and the Attachment Center at Evergreen; and a Time-Out Checklist (copyright 1982). (Ex. A2 at 1-9.) Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 3 of 33

62 Miller and Nancy Thomas and continue to consult with them in the areas of trauma and attachment. * * * Dr. Miller, Ms. Fischer and Ms. Kohlenberger are all separate businesses and must be contacted individually. Our interns, Beth and Esther will be an excellent low cost option for those who do not have affordable insurance coverage or no insurance. Beth Duvall will be starting in January, 2012 as an intern. Her sessions will be $67 for the Intake and $50 for sessions with a sliding scale for those who qualify. In addition to her classes, she has taken specialized training and experience in working with RAD children and their families and Esther Prelog, MA, Registered Intern, at works both here and at The Four Rivers and is an excellent therapist for clients with no mental health insurance coverage. Until Ms. Prelog obtains her counseling license, insurance will not cover her sessions. Therefore, she charges on an income-based sliding scale beginning from $73 for intake and $65 for sessions down to $35 per session. Other interventions that Dr. Miller recommends are: Esther Prelog, MA, , is a licensed facilitator for Love and Logic Parenting classes in Portland. All our therapists highly recommend Love and Logic Parenting for attachment disorders. Ms. Fischer at provides a support group for parents of children diagnosed with Reactive Attachment Disorder at the Four Rivers. * * * * * NEURODEVELOPMENTAL EXERCISES: When Dr. Miller began to work with trauma and attachment disorders, she advised various exercise programs for her clients depending on the child s need. When she learned about neurodevelopmental (also called: neuro-re-organization) exercises which include creeping and crawling, she included this program in her advice. After about six months, she noted that about half of her clients were responding well to therapy and the rest were stuck. She realized that the responsive clients were the ones doing the neurodevelopmental exercises and she began to require that all her attachment disordered clients be doing this program. We refer you to three options: Susan Scott in Salem, OR at ; Emily Beard-Johnson who is available with appointment at or Nina Jonio who is 15 minutes away from our office in Gresham, OR at Dr. Miller advises parents to begin this program as soon as possible. If you cannot afford both the neurodevelopmental program and therapy at the same time, she advises doing the exercises first and then, starting therapy after two-three Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 4 of 33

63 months. If you [sic] child or schedule is challenging, you may choose to pay someone to help the child do exercises every day. Dr. Miller refers the parents of children with an [sic] trauma and/or attachment disorder and adults who have trauma and/or attachment issues to the seminars and classes produced by Drs. Ron and Nancy Rockey at In particular, she advises the class called The Passenger which is the first class in a series called The Journey and guides the individual through processing childhood experiences that are affecting the life of the adult. The Portland, OR contact for the classes is Audrey Woods at (Ex. A1.) In the letter, Dr. Miller offered the name of a respite provider, Kate Denny. She also recommended that the family attend a Family Challenge Camp, a behavior modification program designed by Nancy Thomas. (Id.) 7. On January 16 and 17, 2012, the father completed the intake information form and child behavior questionnaires for Client A. The father indicated, among other things, that Client A s mother used drugs, likely methamphetamine, and had extreme stress during her pregnancy with Client A. The father also indicated that, in the first two years of his life, Client A experienced separation from his mother, out of home care, neglect and parental stress, including his mother s depression. The father reported that Client A s mother had a history of depression, anxiety, manic-depression, suicide attempts and drug use. On the intake form, the father listed a prior mental health provider (Ali Burr-Harris). The father described Client A as unemotional, overly sensitive, needy, defiant, sad. (Ex. A2 at 3.) As to discipline methods for Client A, the father reported that Client A was subject to loss of privileges (no frequency noted), jumping jacks (on a daily basis) and extra chores (on a daily basis). The father reported a trauma history of verbal abuse and lack of connection with his birth mother. The father reported that Client A exhibited the following symptoms: anger (internalized); control problems; lack of motivation; low self-esteem; anxiety; defiance; lying; depression; and low impulse control. (Ex. A2 at 2-5.) 8. The RADQ Answer Sheet contains a list of 30 behaviors, and asks the person completing the questionnaire to rate how often the child at issue engages in the listed behavior. Client A s father marked that Client A usually (90 percent or more of the time) engaged in the following behaviors: acts overly cute and charms others to get them to do what he/she wants; acts overly friendly with strangers; acts amazingly innocent, or pretends that things aren t that bad when he/she is caught doing something wrong; doesn t seem to learn from his/her mistakes and misbehavior (no matter the consequences given, the child continues the behavior); doesn t do well in school as he/she could with even a little more effort. (Ex. A2 at 6-7.) The father also reported that Client A often (75 percent of the time) did the following: has trouble making eye contact; has a tremendous need to control everything becoming very upset if things don t go his/her way; deliberately breaks or ruins things; doesn t seem to feel age appropriate guilt for his/her actions (seems to lack a conscious for his/her actions); seems unable to stop him/herself from doing things impulsively; tries to get sympathy from others by telling them that he has been abused and/or neglected; is a pathological liar (lies even when it would be easier to tell the truth, or lies about obvious or ridiculous things). (Id.) Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 5 of 33

64 9. The Attachment Symptom Checklist for Children Over 5 lists 25 symptoms and asks the person completing the form to mark none, moderate or severe for each of the listed symptoms. For Client A, the father rated the following symptoms as severe : superficially engaging and charming, phony; lack of eye contact especially on parental terms; lying about the obvious, crazy lying; lack of cause and effect thinking; persistent nonsense questions; incessant chatter; inappropriately demanding and/or clingy; extreme attempts to control and/or manipulate; and habitual disassociation or habitual hypervigilance. The father rated the following symptoms as none : not affectionate on parental terms (not cuddly); destructive to self or others; destructive to material things; accident prone; cruelty to animals; preoccupation with fire, blood and gore. (Ex. A2 at 8.) 10. On or about January 18, 2012, Licensee met with the father and stepmother for an initial clinical intake. The father reported that Client A was in fourth grade and had an average IQ. The father added, If he tries he does really well. (Ex. A2 at 10.) During that intake session, Licensee made the following notes as the father and stepmother discussed Client A s symptoms: follow thru, admits does things to make [step-mother] mad, anger = stands rigid (will strong sit). Pass-agg, decreased motiv., sneaky, sev x/ day disobeys passively, I forgot. Neg self talk and decreased esteem, poor fine motor skills, anxiety = withdraw and quiet and won t talk about it, He ll say OK and do what he wants, Lies daily, moping, decreased interest in pos things. Decreased impulse control. Takes 30 minutes to fall asleep. (Ex. A2 at 10; Ex. A3 at 1.) The father and step-mother advised Licensee that Client A had not had any previous mental health treatment. 9 The father and step-mother also reported, among other things, that Client A had been subjected to verbal abuse by his mother and that he had witnessed domestic violence (including his mother striking his sister and the father). They also reported that Client A had an allergy to dairy milk. (Ex. A2 at 11; Ex. A3 at 1.) 11. On February 1, 2012, Licensee met with Client A. 10 During that session, Licensee diagnosed Client A with a generalized anxiety disorder, She noted that Client A was a self-proclaimed worrier with some OCD tendencies. (Ex. A2 at 12; Ex. A3 at 2.) At that time, Licensee identified the following treatment goals for Client A: 1. Increase attachment with father; 2. Decrease passive-aggressive and increase verbalizing, especially of feelings; 3. Process loss of bio-mother and new step-mother addition; and 4. Disclose and 9 This was inaccurate and inconsistent with what the father had indicated on the intake form. In the fall of 2011, the father and stepmother had sought counseling for Client A with Dr. Ally Burr-Harris at the Children s Program in Multnomah Village. (Ex. A31 at 3.) The father also did not, at the time, advise Licensee that Client A had been evaluated by Paul E. Guastadisegni, Ph.D. in September (Test. of Miller; Ex. A2 at ) 10 At the time of Licensee s first meeting with Client A, the parents had just put Client A s younger sister into a respite situation so she was no longer living with the family. (Ex. A12 at 13; test. of Miller.) Later in the year, the parents also sent Client A s older sister to live elsewhere. (Test. of Miller.) Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 6 of 33

65 process sister s violence and out of home placement. (Id.) Licensee further noted: Multiple traumas possibly RAD. She recommended treatment sessions once a week. (Id.) 12. On February 8, 2012, Licensee met with the father, stepmother and Client A. With Client A out of the room, they discussed the use of strong sitting as a disciplinary measure. 11 Father reported that Client A had been deliberately urinating all around the toilet, and had been taking too long to do his chores. With Client A in the room, they discussed, among other things, his fear that someone was always watching him through the window. Licensee suggested that Client A talk out his anger rather than pee it out. (Ex. A3 at 3.) 13. Licensee s initial treatment sessions with Client A focused on sleep interventions, to shorten the time it took for Client A to fall asleep at night. Licensee suggested that the father and stepmother firm up Client A s bedtime routine. She recommended that Client A shower or bathe two hours before bedtime, that the father or stepmother join him as he brushes his teeth to show him how to do it and to avoid arguments over whether he had done so. She also suggested that the father and/or stepmother read to him before bed. She also suggested that he have a flash light, or a night light, in his room for when woke and felt fearful in the dark. (Test. of Miller.) 14. At some point early on in the treatment, Licensee suggested putting an alarm or some type of monitor on Client A s door, so that the father and/or stepmother would know when Client A left his room at night. The father and stepmother thought this was a good idea because they did not want Client A going into the kitchen and eating food he should not be eating. Licensee thought this was a good idea to help assuage Client A s fears of an unknown and dangerous stranger coming into his room at night. Licensee also thought this a good idea for Client A s safety because the father had mentioned that Client A s older sister had on occasion been violent towards Client A. (Test. of Miller.) On February 15, 2012, Licensee wrote in her process notes, Zero alarm yet, but dad closes door and he is telling me he s sleeping good. (Ex. A35 at 32.) 15. Also on February 15, 2012, with Client A out of the room, the father and stepmother reported that Client A was not changing his bed sheets and that he was hiding his dirty clothes under clean clothes. They also complained that Client A was not growing academically, and expressed dismay that his school did not have consequences for students not doing homework. With Client A in the room, Licensee discussed the use of I statements. She taught Client A to use steel and spaghetti (her term for a deep breathing exercise) to calm himself. (Ex. A3 at 4.) She also encouraged Client A to do jumps, or jumping jacks, as neurological exercises. She told Client A that he could jump 25 times which would earn points to shop on the prize shelf in her office. (Ex. A12 at 14.) 16. On or about February 18, 2012, on the recommendation and referral by Licensee, the father and step-mother took Client A to Susan Scott for a functional neurological 11 Strong sitting involves the child sitting cross-legged with arms crossed and hands either on his or her shoulders or forming a hook up in front of the chest in a quiet space facing a wall. (Test. of Miller; Ex. A28 at 32.) The expectation is that the child will stay in this position for a few minutes (between 1 to 10 minutes depending on the child s age), until he or she is calm and regulated enough to process. (Id.) Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 7 of 33

66 evaluation. 12 (Test. of Scott.) Ms. Scott interviewed the father and step-mother regarding their current concerns with Client A s behavior. She questioned them about Client A s developmental history. She then asked Client A to perform certain tasks visual, tactile and motor tasks to assess his neurological function. Based on Client A s performance of those tasks, Ms. Scott determined that he had, among other things, difficulty with tactile perception, poor body awareness, restricted early mobility and incomplete development at certain areas of his brain. Based on her findings, she created a map of Client A s brain function, showing areas of deficit and incomplete development. Ms. Scott also developed a neurological reorganization program, an in-home exercise regimen for Client A to do each day. These exercises, which included army crawling and knee crawling (later described as tummy time ), were designed to emulate the developmental processes Client A may have missed due to stress or trauma as an infant. (Test. of Scott.) 17. Specifically, Ms. Scott recommended to the father and step-mother that Client A engage in approximately 50 minutes of physical activity each day, as follows: army crawling, twice a day for 10 minutes at a time; knee crawling, twice a day for 10 minutes at a time; vestibular stimulation, such as swinging, eight times a day for 15 seconds at a time; sensory stimulation, brief touching with different textures, 20 times a day for two to three seconds at a time; and patterning exercises, movement of the head and arms, for five minutes a day. Ms. Scott also recommended that Client A breathe into a paper sack 10 times a day for about a minute. She scheduled a follow up appointment to reassess Client A s neurological function for May 10, (Test. of Scott.) 18. Licensee endorses neurodevelopmental exercises for her clients. Licensee believes that the purpose of neurological reorganization is to evaluate the brain. She believes the exercises help with symptoms. (Ex. A13 at 2.) She was not concerned that the father and stepmother were using jumping jacks as a form of discipline for Client A. Licensee believes that for a child with processing or neurological issues, doing a set of jumping jacks will help get oxygen to the brain and help calm the child. Licensee also believes that this exercise is good for depression or anxiety. (Ex. A12 at 6.) 19. Between February 1, 2012 and March 28, 2013, Licensee had approximately 20 sessions with Client A and/or members of his family. 13 On February 29, 2012, the father and stepmother reported that Client A was having accidents in his pants; that he was taking candy from friends and lying about it; and that he was stealing items, such as vitamins, while visiting his grandmother s house. Licensee learned from the father and stepmother that when Client A came home from school, they expected him to go directly to his room, and remain in his room 12 Ms. Scott, who has no professional certifications or licensures, describes her practice as a non-medical, physically-based program to restore or develop brain function. (Test. of Scott.) 13 It is not evident from Licensee s charts and session notes which family member attended which treatment session, or whether or when Client A was in or out of the room. (Exs. A3 and A25.) Licensee recalls meeting alone with Client A on approximately five occasions. (Test. of Miller.) More often than not, Licensee met with the father, stepmother and Client A together, or with the father and Client A together when the stepmother chose not to participate. On occasion (in July and August 2012), Licensee s grandmother may also have attended the sessions. (Exs. A3 and A35; test. of Miller.) Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 8 of 33

67 until the father got home from work later in the evening. Licensee also learned that the stepmother did not want Client A to refer to her as mom. Licensee learned that the stepmother did not want to provide any type of nurturing to Client A or his siblings. During the February 29, 2012 session, Licensee documented the following statements from the stepmother about Client A and his siblings: They dominate our life... maybe that s what I m angry about, I need 100 percent for me, and I m sick and they re sick and they re sick is trumping [illegible]. Licensee suggested that the stepmother at least greet Client A at the door, ask him about his day, check in with him periodically and offer him a snack. The father and stepmother rejected this idea, noting that because Client A was stealing and eating foods to which he had sensitivities, this was not an option. (Ex. A3 at 4; Ex. A25; Ex. A16 at 22; test. of Miller.) In the exceptions, counsel for Licensee stated that it was Licensee s testimony that Client A s father agreed to leave snacks out for Client A upon his arrival from school and a fruit bowl would be available at all times. 20. During a session on March 14, 2012, the father reported that Client A was not doing chores he was expected to do and was lying about doing them. With Client A in the room, they discussed an interaction that had occurred between the stepmother and Client A, in which Client A became angry and hurt. They also discussed Client A s feelings towards his birthmother. (Ex. A3 at 4.) 21. During a session on March 22, 2012, Licensee learned that the stepmother had recently had a miscarriage and had been hospitalized. Licensee also learned that the father and stepmother had cleaned out Client A s room and had disposed of (thrown away) most, if not all, his toys because of his multiple thefts. (Ex A3 at 5.) 22. By this point, Licensee realized that the father and stepmother had impulsivity issues and could be very harsh on the children. She suggested to them that their punishment (throwing away all of Client A s toys) had exceeded his infraction. Licensee also recognized that the stepmother was very volatile and dysregulated. Licensee began to develop strategies to keep Client A and the stepmother away from each other. She suggested, for example, that they enroll Client A in an after school program so that he would get home later in the day. Licensee noted that the stepmother s presence increased Client A s anxiety, and that she had a way of ruining any positive or nurturing moments between the father and Client A. Licensee also saw that Client A would, at times, do things that he knew would provoke and/or agitate the stepmother. (Test. of Miller.) 23. In April 2012, Licensee had two sessions with the family. On April 6, 2012, they discussed, among other things, Client A s need to continue with his jumping jacks and neurological reorganization exercises. Licensee also recommended increased snuggle time. On April 17, 2014, Licensee s process notes state: 1 st x in 2 weeks saw RAD. It was a full RAD day. (Ex. A35.) On April 25, 2012, the father and stepmother reported that Client A s older sister had gone to a respite home, and that it was like a dark cloud had been lifted from all of us. (Ex. A3 at 5.) The father and stepmother also reported that, since his sister left the home, Client A s incessant chatter had increased. Licensee encouraged lots of interaction on the parents terms and contact every 5-10 minutes. She discussed I-statements and journaling with Client A. (Id.) Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 9 of 33

68 24. After providing treatment to Client A for a few months, Licensee recommended to the father that Client A undergo a neuropsychological evaluation. Licensee did so because she thought that Client A was doing the best that he could do in such a dysfunctional family situation. The father eventually provided Licensee with a copy of Dr. Guastadisegni s September 2011 evaluation report. When he handed the report to Licensee, the father expressed his dissatisfaction with it and stated that Dr. Guastadisegni did not understand RAD. Licensee made a note to that effect on the first page of the report. (Test. of Miller; Ex. A13 at 1.) 25. In the neuropsychological evaluation report, Dr. Guastadisegni assessed Client A as having the following Axis I diagnoses: Anxiety Disorder Not Otherwise Specified; Attention Deficit Hyperactivity Disorder, Inattentive Type; Depression Not Otherwise Specified; Post Traumatic Stress traits; and Parent Child relation problem (mother-son). Dr. Guastadisegni had the following recommendations for Client A, among others: [Client A] has difficulty in assimilating new information when problem solving (i.e., shifting sets]. He needs to be educated about inhibiting responses when feedback tells him that a particular strategy does not work. It is important for parents and teachers to note that processing information for [Client A] is different than what they would expect from a typical child/student. He may have difficulty in processing past an event or action that just happened. Adults should make an attempt to be able to identify subtle clues about [Client A s] frustration and takes these cues to intervene (e.g., ask him what is going on) or allow him more time to process. [Client A] needs structure and guidance when completing tasks, especially multi-step tasks. * * * He needs direction and assistance in learning to stop and examine his surroundings before proceeding with a task. He needs to develop an understanding as to how things relate to each other. He needs practice and reinforcement with this approach. I would encourage that some of his therapeutic involvement focus on how to implement social skills. It is likely that he already knows social skills and could easily verbalize appropriate behavior. Educating his parents about his brain functioning and ADHD is needed. [Client A] does have a problem and this interferes with his ability to smoothly transition and handle a typical amount of work for his age. * * * Provide immediate rewards and consequences for complying with instructions. Have the most demanding schedule in the morning. Schedule boring or repetitive tasks early in the morning. If possible, have him take all academic courses in the morning. Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 10 of 33

69 Give frequent feedback, and use incentives rather than punishment. Avoid lengthy discussions with him. People working with him should act rather than talk. [Client A] will respond better to action, and have less patience to listen to long drawn out, (but often logical) explanations. (Ex. A2 at ) 26. At some point in May 2012, Licensee diagnosed Client A with RAD (inhibited type) and Oppositional Defiant Disorder (ODD) in addition to Generalized Anxiety Disorder. 14 (Test. of Miller; Ex. A2 at 12.) Licensee s RAD diagnosis was based on Client A s history of early childhood trauma and neglect, as reported by the father and stepmother; his current behaviors, as reported by the father and stepmother (including issues with taking and/or asking others for food, lying, withdrawing from family situations, having few, if any, friends, and inconsistent responses to physical contact); feedback from other sources regarding Client A and his family 15 ; and behaviors that Licensee observed during her treatment sessions. These included behaviors included Client A s infrequent eye contact with his father and stepmother; occasional baby talking; choosing to play with baby toys, i.e., toys that were appropriate for much younger children in her waiting room; appearing inhibited, hypervigilant and occasionally exhibiting frozen watchfulness ; asking irrelevant and hypervigilant questions; exhibiting inappropriate affect at times; and exhibiting ambivalent and contradictory responses to nurturing from his father and stepmother. (Test. of Miller; Ex. A16 at 6-9.) 27. In a May 9, 2012 letter to the father, Licensee wrote as follows: I am writing regarding [the three children], ages 8, 10 and 11 respectively, who I began seeing in January All three children have Reactive Attachment Disorder (RAD) which is caused by neglect, abuse and/or trauma in the first two years. All three also exhibit symptoms of Post-Traumatic Stress Disorder (PTSD). For these children to heal, they need continued high structure in their daily lives, regular therapy, stability and no ongoing trauma. In short, the adults in your children s lives need to exemplify stability and honesty. As you know, these children need to be parented constantly with 14 The exact date that Licensee confirmed these additional diagnoses is not documented in Client A s chart. Licensee also did not document in her chart notes the bases for her diagnoses of RAD and ODD, though she explained her reasoning and determination to the Board in her Response to the Board s allegations, in her interview with the Board and in her testimony at hearing. (Exs. A12, A13 and A16; test. of Miller.) 15 In her response to the Board s allegations, Licensee A stated as follows: (Ex. A16 at 5.) Over time, prior to making these additional diagnosis, I interfaced with [Client A s] paternal grandmother, staff at [Client A s] school, multiple DHS caseworkers involved with the family, several respite care providers and both of [Client A s] sister s therapists. Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 11 of 33

70 specialized parenting tools which address their specific needs and behaviors developed in a response to their early experiences. I applaud your continued efforts as you provide such an environment. (Ex. A2 at 25.) Licensee wrote this letter on the father s request. The father had heard from the court that the children s biological mother wanted to spend the summer with the children, and he did not want that to happen. (Ex. A13 at 5.) 28. On May 18, 2012, Client A s father reported that it had been a rough week with Client A. Licensee learned that Client A had been eating food he should not be eating, which was causing him to cough and wheeze. The father and stepmother also reported that Client A had been asking his classmates at school for food. (Ex. A3 at 6.) According to the school s principal, Client A was never mean about asking, he was just very persistent. He would ask his classmates for snacks during the morning, he would ask for food during lunch and would also, at times, ask a friend after school to bring him something specific the next day. Sometimes he would eat the food he had procured and other times he tossed the food in the trash. Licensee learned that Client A s classmates were advised that Client A had allergies and some family things he was working on and it was best if they did not give him their food. (Ex. A2 at 18; test. of Miller.) 29. On May 23, 2012, Licensee s process notes indicate that either the father or stepmother reported, Everything has fallen apart. They also reported that Client A had lied to his grandmother about his exercise program. He told her that he did not have to do his exercises on Saturday because it was his day of rest, and because she did not check, she did not have him do his exercises. Licensee s process notes indicate as follows: To teach them a lesson and elicit sympathy I got parents thinking errors handouts and with [Client A] used wrong versus right thinking. (Ex. A3 at 7.) 30. On May 28, 2012, the stepmother contacted Licensee and asked that she provide information about Client A to Trillium Family Services, a provider of mental and behavioral healthcare for children and families. The father and stepmother wanted to place Client A in the day treatment program. (Ex. A2 at ) 31. At some point (the date or therapy session is not evident from Licensee s process notes), Licensee recommended that the father and Client A engage in activities and/or exercises designed to promote attachment between father and son. Licensee went through a list of activities with the family, most of which the father and/or stepmother or Client A rejected. One of the recommended exercises that both the father and Client A were willing to try (and the stepmother did not appear to oppose) was bottle feeding. Licensee suggested that while the father and Client A were snuggling, the father take Client A in his lap, feed him warm chocolate milk from a baby bottle and look at him in a tender manner. Licensee also suggested that the father and Client A go to the store together so that Client A could pick out the baby bottle of his choice. (Test. of Miller; Ex. A13 at 2.) 32. Baby-birding was another exercise that Licensee recommended to make the interactions between Client A and his parents more positive. Licensee suggested that the father Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 12 of 33

71 or stepmother place a sweet treat, such as a jellybean or small piece of chocolate, in Client A s mouth at random times when Client A was calm and behaving appropriately. (Test. of Miller; Ex. A16 at 25.) Ordinarily, Licensee would have recommended that the father and Client A hug twelve times per day rather than engage in baby birding, but because the father reported that Client A was often resistant to hugs, she did not recommend a hugging intervention. Licensee was also aware of the stepmother s desire not to hug Client A. (Ex. A16 at 26.) 33. Licensee had a session with the family on June 20, The father and stepmother came in with a detailed schedule for Client A s activities and tasks at home. They mentioned that when the father got called out of town for work, Client A failed to comply with the schedule. They expressed dismay at Client A s inability to do what he was supposed to do. They also reported that Client A was playing all kinds of games since he got home... constant challenge, constant manipulations. They discussed the stepmother s frustrations in dealing with Client A and the fact that Client A was going to be staying at his grandmother s for a while. Licensee recommended that the father and stepmother stay neutral [with Client A] but give as much affirmation as possible. (Ex. A3 at 7; Ex. A13 at 6-7.) 34. After that, from late June until some point in September or October 2012, Client A lived with his grandmother. In Licensee s opinion, Client A was making good progress while living with his grandmother. (Ex. A13 at 5.) Licensee s process notes from a session on July 10, 2012 indicate that Client A was still at respite with grandmother because the father was not having [stepmother] watch them at all. (Ex. A3 at 8.) During that session, Client A reported that when he sees Dad cuddling [stepmother] he feels Dad loves her more. (Id.) Licensee s notes also reflect that Client A appeared nervous, so she had him on the father s lap looking in the father s eyes. Client A indicated that he felt sad when his father dropped him off at his grandmother s house because you are tired of me and you want to be by myselves [sic]. The father advised Client A that he was staying at his grandmother s because his older sister had returned to the home, and Client A could not live with his sister until she got healthier. The father also advised Client A that the stepmother was too sick to care for him. (Ex. A35 at 23; Ex. A3 at 9.) 35. On July 19, 2012, Client A s grandmother advised Licensee that she had no concerns with Client A s behavior at her home, and that Client A always excels when he s the focus of attention. (Ex. A35 at 22; Ex A3 at 9.) Licensee noted that other children having attention makes Client A nervous, lonesome and mad. (Id.) During this session, Client A discussed his past experiences with, and feelings toward, his birth mother. Licensee reviewed breathing exercises, journaling and rump relaxers as techniques to help calm Client A s anxieties. (Id.) 36. Licensee had sessions with Client A and his father and/or grandmother on July 27, July 31, August 10, August 24 and September 5, During these sessions, Licensee learned that Client A was doing his neurodevelopmental exercises, jumping jacks and strong sits. The grandmother reported that Client A had a good attitude, that he was falling asleep quickly and beginning his schedule by himself in the morning. Client A reported, among other things, that he was missing his siblings. Licensee reviewed I statements, journaling, and relaxation techniques with Client A. (Ex. A35 at 19-21; Ex. A3 at 9-11.) Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 13 of 33

72 37. When Client A returned to the father and stepmother s home in September or October 2012, Licensee realized that she had no leverage over this family. (Test. of Miller.) Her treatment recommendations were not working and she was no longer comfortable continuing to treat this family on her own. She suggested to the father that he look to the Department of Human Services (DHS) for family services, such as proctor homes for Client A s sisters, which could provide some relief for their situation. Thereafter, Licensee began working with DHS as a consultant, primarily for reasons related to Client A s sisters. (Id.) 38. Licensee s process notes reflect that she had a brief check in with Client A s father on December 19, The father described the situation as un-normal, and advised that Client A was in school and after school care. The father noted that Client A had confessed that he had asked for food at school. Licensee recommended that they give Client A snacks for school. The father also reported that Client A s older sister told Client A he was a weak ugly little boy and would never have a girlfriend. (Ex. A35 at 15; Ex. A3 at 12.) 39. During a session with Client A s father on January 23, 2013, the father reported that Client A was struggling... we worked for two and a half days to get him to empty the trash. (Ex. A35 at 14.) The father also reported that Client A broke two ceramic planters outside the house on his way to school one day. (Id.) Licensee s process notes indicate that Dad hugged in bathroom sporadically. (Id.) Licensee discussed journaling. She advised the father not to push Client A on academics but to focus on attachments. (Id.) 40. During a telephone session with the father and stepmother on January 30, 2013, they reported that Client A is a lot more physically destructive than we thought and that he freaks out and denies everything. (Ex. A35 at 13.) Licensee suggested that Client A was scared and can consequence before he admits. (Id.) The parents reported that Client A gets to sit until he is honest with it. Licensee suggested that they do experiments with letting Client A try screaming into a pillow, hitting a punching bag, tearing a phone book. She suggested they discuss little, just acknowledge he had a big feeling. (Id.) She also suggested that they have Client A continue to journal his feelings. (Id.) 41. On February 24, 2013, Licensee had a half hour session with Client A and his father. They discussed, among other things, Client A s relationship with, and feelings about, his older sister. Client A noted that he was nervous around her because if he did not do things exactly the way she wanted she would hurt him or break one of his things. He added that she sometimes slapped him across the face. They discussed Client A s mother telling the police and others, including Client A, that his father was a child molester. They discussed Client A s reaction to that claim, that he knew it wasn t true. (Ex. A35 at 11-12; Ex. A3 at 14.) With Client A out of the room, the father advised Licensee that it s all consuming trying to help Client A. The father also noted that Client A had spontaneously apologized to his stepmother for the first time ever and that he took responsibility for something he did... it s a sliver. (Id.) 42. On March 28, 2013, Licensee met with Client A and his father. The father reported that Client A was still really struggling. (Ex. A35 at 11; Ex. A3 at 14.) He added that things were going downhill and Client A was still destroying things. (Id.) The father Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 14 of 33

73 mentioned that Client A was not doing his daily tasks and chores, such as taking a shower and making his bed. He added that he could not afford respite now, so they were trying in-home respite. The father also reported, among other things, that Client A refused showers for three weeks and it took four days of sitting in spare time for Client A to admit he had kicked the outdoor pots until they broke. (Ex. A35 at 10; Ex. A3 at 14.) During the session, Licensee made recommendations to address Client A s reported destruction and reluctance to do his exercises. They discussed the strong sit and journaling. On this point, Licensee s process notes document the following: Dad questioned who s idea to strong sit. U guys I said me and explained several things. I encouraged journal to me if mad. Said no journal because they said I m writing for an audience I said no problem. I m audience and I don t care if he believes what he writes explained why it s important to have him [illegible]. (Ex. A35 at 9.) 43. In a March 28, 2013 letter to the father, Licensee wrote as follows: I am writing concerning [the three children]. At this time, I recommend that each child have separate placements away from home. Due to the trauma and neglect they suffered when young, they have developed coping skills that have been and are hurtful to their relationships with each other. Currently we are focusing on developing and strengthening their attachment to you as their primary caregiver. Until they have secure attachment with you, they will not feel safe dealing with their past injuries from others and/or between themselves. Therefore, please continue to keep each child in a separate placement and focus on developing that essential trust and attachment with yourself. I look forward to the children being able to visit each other. This will depend on their acknowledging if they have physically or emotionally harmed each other and if they are strong enough to share emotions if they become frightened or angered by a sibling s behavior. (Ex. A2 at 34.) This letter was written at the father s request, in response to DHS attempts to bring all three children home at the same time. The father did not want all three children in the home together because he had occasional travel out of town for work and the stepmother was not willing or able to be a caretaker to the children. (Ex. A13 at 9.) 44. On April 11, 2013, Licensee met with Client A s father without Client A. The father reported that it was still pretty much the same with Client A. He advised that Client A did his laundry and took a shower then put his sheets where he knew they don t go, though he had previously been doing this correctly for months. (Ex. A35 at 8; Ex. A3 a 15.) The father reported that Client A was being passive aggressive. (Id.) Licensee asked how their attachment was going, and the father reported, Not well. (Id.) Licensee documented that the father hasn t been snuggling and baby birding. (Id.) Licensee also documented that she gave Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 15 of 33

74 ideas regarding cuddle time, rare sugar, talk about baby things (how named, first time saw, etc.). (Id.) The father also reported that Client A had gotten mad and scratched himself because he did not like what had been offered for dinner, and that he was wearing dirty clothes instead of clean ones. (Id.) During this session, Licensee recommended that Client A come in for regular treatment. The father expressed concern about the cost of treatment. (Ex. A16 at 16.) 45. On April 16, 2013, the father asked Licensee for approval to send Client A to a respite home. In an to Licensee s assistant, the father wrote: We had a complete meltdown with [Client A] last week and needed to take him to a motivational respite provider. She only takes kids that the therapist is on board with this type of program. Her name is Beth Hudson and her and Dr. Miller know each other so I did not think it would be a problem. Would it be possible to get a quick letter [sic] her know that Dr. Miller approves of the placement? It can be sent to me or directly to her if you have her address. Thank you so much. (Ex A2 at 23.) Licensee subsequently left a message for the father advising that she did not recognize the name of this respite provider. (Id.) 46. On May 2, 2013, Licensee again met with the father alone. The father reported that Client A had been in motivational respite with Beth for the past two weeks. The father reported that Beth saw no authenticity in Client A, and that he had pooped into a bucket instead of in the toilet on two occasions. The father also reported that Client A had done about $1, 000 in damage to the respite provider s house. The father told Licensee that he was trying to give [Client A] a shot. (Ex. A35 at 7; Ex. A3 at 16.) The father discussed spending time with his younger daughter, the stepmother s reluctance to have the younger daughter in the home, and issues involved with having Client A and his sister together for visits. (Id.) 47. On May 8, 2013, Licensee had another session with just the father. The father reported that Client A had been doing well with his neurological reorganization exercises while in respite, but not since his return home. The father reported that Client A loves showering, and he asked whether it was okay to say no to showers if Client A refuses to do a job. Licensee advised not generally maybe one time every two weeks if he s doing something important. (Ex. A35 at 6; Ex. A3 at 16.) Licensee also documented the following in her process notes: Taught babybirding. Bottle time daily! (Id.) The father reported a huge breakthrough with Client A s behavior toward the stepmother when they picked him up from respite. Licensee recommended that the father and stepmother help pattern. Licensee encouraged having the stepmother bring Client A a bottle and say I hope it s ok I added a little extra. (Id.) She recommended that the stepmother join the father and Client A during bottle feeding time and that she put lotion on Client A s feet, pat his leg, etc. and judge his reaction. The father also advised Licensee that Client A had damaged his bedroom door, so the father took it off. The father said that Client A denied damaging the door, but he was positive Client A did it. The father also reported that he had gone over his room with a fine tooth comb. (Id.) Final Order - In the Matter of Debra (Kali) Miller, Ph.D. Page 16 of 33

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