Concerned About Unconventional Mental Health Interventions?

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

Friday, July 22, 2016

Nancy Thomas' Inaccurate Statements About Children and Mental Health

Usually I avoid looking at Nancy Thomas’ website, www.attachment.org, but I was reminded of it the other day and had a look—several looks. And of course, having looked, I want to point out a few of the flaws therein.

Let’s start by looking at Thomas’ comments about Attachment Therapy (www.attachment.org/what-is-attachment-therapy/), which, she says, consists of eye contact, touch, smiles, and the “sharing of sugar between the mother and child”. Yes, folks, it appears that Thomas is still committed to the idea she put forward in the 2000 book edited by Terry Levy (and published, to its shame, by Academic Press). She suggested there that attachment can be created by hand-feeding caramels to a child. Logical? You bet, if you can accept Thomas’ premises. These are 1) that attachment normally occurs soon after birth, 2) that breastfeeding contributes to attachment, 3) that because human milk is slightly sweeter than cow’s milk, milk sugars play a role in attachment, 4) that caramels, which contain milk and sugar, are analogous to human milk, 5) that when a woman hand-feeds caramels to a child, the effect on the child is like that of being breastfed. Of course, attachment does not begin shortly after birth, nor is it especially related to breastfeeding. Although it’s true that human milk is sweeter than cow’s milk, there is no reason to think that its sweetness has more to do with an emotional effect on the child than its protein or calcium contents or the individual flavors that come from what the mother has eaten (and anyway, as I just said, there is no particular connection between breastfeeding and attachment). In fact, this whole argument is simply based on sympathetic magic mixed with the assumption that a mother’s early positive feelings toward her infant are immediately mirrored by similar feelings on the part of the infant.

Attachment Therapy, as discussed by Thomas, requires, in addition to sugar, a “release of rage” over a period of several hours. Thomas’ hero Foster Cline supposed that children in this kind of treatment are angry because of the loss of the birthmother and that their rage blocks the development of a new attachment. He used a hydraulic analogy to suggest that when the children express rage, they then become able to form an attachment. This belief unfortunately contradicts research evidence that expression of anger actually intensifies the anger rather than diminishing it. In addition, the belief that a newborn separated from the birthmother will be angry is in contradiction to everything known about early cognitive and emotional development. On this topic, of course, we need to ask how the “release of rage” would be brought about, and the most likely guess is that it is to be done by physical restraint, shouting, and terrifying the child, as per the rage-reduction therapy of the ‘90s. Although Thomas does not define Attachment Therapy directly in this way, she provides enough cues to convey what she is actually talking about, and allows us to guess what she does in her camps when she takes a child aside for a “tune-up”.

The same page reveals two other incorrect assumptions--  unstated, as presumably the wished-for reader already agrees with them. One is that unwanted behavior of children is of necessity associated with difficulties of attachment--  difficulties that, we are told, can be fixed with caramels and other equally likely methods. The second is that the diagnosis Reactive Attachment Disorder  means that a child is manipulative, aggressive, untruthful, exploitative, and so on. Neither of these positions is correct. Certainly children who show risky behavior may have had few opportunities for attachment, but the same kinds of behavior can appear in children with a good attachment history and clear attachment behavior in earlier life. Also, certainly there are children who are manipulative, etc. etc., and they may have at one time also shown symptoms of Reactive Attachment Disorder (although there is no clear method for diagnosing that disorder in school-age children), but the various undesirable behaviors named are not symptoms of Reactive Attachment Disorder.   
Thomas also repeats a claim that was common among members of Cline’s group in Evergreen in years gone by. She proposes that “traditional therapies” are not only ineffective but actually harmful in cases of undesirable child behavior. On another page, www.attachment.org/therapy-goals/ , Thomas states that “Non-directive play therapy, traditional talk therapy, and sand tray therapy have been proven to either be ineffective with children with RAD or make them sicker.” This is, of course, completely untrue with respect to any usual use of the term “proven”. In order for such proof to exist, someone needs to have systematically compared the outcomes of Attachment Therapy with those of the methods Thomas references, and I can assure you that this has not been done. Indeed, there has never been a systematic study of the outcomes of Attachment Therapy alone. Thomas’ argument is not based on the existence of systematic research, but instead on her belief that if a possible mechanism for an effect can be named, this is as good as having found evidence that the effect occurs. She states on both pages the unsupported belief that being alone with a therapist enables a child to become more manipulative, etc., and thus “sicker”, and that the presence of the mother is essential to prevent this. These assumptions are put forward as evidence that the claimed outcomes occur.

It’s a bit mind-boggling to try to unravel the logical and factual mess presented on www.attachment.org. Unfortunately for their children, those who can’t bear a bit of mind-boggling may fall for the claims of this purveyor of snake oil. And just as regrettably for all of us, reporters who hastily copy Thomas’ claims can and do spread these misconceptions and give free advertising to Attachment Therapists.
   
  



Missouri and Wyoming Take the Wrong Path on Fostering and Adoption

Twenty years ago, the state of Utah opened a can of worms by hiring trainers for adoption caseworkers from a Colorado group who advocated Attachment Therapy (AT) in its “rage reduction” form. Caseworkers were trained to teach adoptive parents that any resistance or disobedience in the children had to be met with physical force in the form of lying with the adult’s whole weight on the supine child. In the case of  Don. L. Tibbets’ adopted  preschool daughter, the child stopped breathing briefly under this treatment, and although Don reported this to the caseworker, he was told that he and his wife had to continue the restraint practice--  on pain of having the adoption stopped. Don (a registered nurse) did as he was told, but when the child stopped breathing again, she could not be resuscitated. Don was sentenced to six years in prison for his role in the death, but as I am sure you can guess, the caseworkers were not punished. 

The Colorado trainers hired by Utah left behind them the seeds of a number of catastrophes, child deaths, and injuries later caused by AT. Efforts at legislation prohibiting this type of treatment for children were successfully fought by “parents’ rights” groups and by AT therapists and clinics that had sprung up. Nevertheless,  the national furor among professional psychologists and social workers, culminating in a task force report strongly rejecting AT in the journal Child Maltreatment in 2006, helped to limit some of the more egregious AT practices in Utah and elsewhere.

But how soon they forget, right? Wyoming has recently arranged for social services training by the Institute for Attachment and Child Development of Evergreen, CO, home of at least one practitioner with AT roots going way back. The IACD website includes a requirement for parents sending their children to this residential treatment center: if the child has ever accused an adult of abusive treatment, a document to this effect must be provided, so that law enforcement and others will know how to respond to claims a child may make while at IACD.   This precaution must cut out a lot of problems like having to investigate whether a child was actually abused while at IACD, and may have appealed to Wyoming social services bureaucrats. As far as can be told from the website and from reports of personal experiences. IACD does not use any evidence-based treatments, so other than convenience and shared philosophies, reasons for choosing IACD training are difficult to find.


According to the article linked here (thanks to Linda Rosa!),

Missouri is now spending public money to send adoptive parents to an ATTACh conference, where they will receive instruction in a range of beliefs advocated by that organization. Although ATTACh, a parent/professional organization that taught AT concepts years ago, has apparently retreated from the belief in physical restraint as an appropriate way to create attachment, nevertheless the organization continues to teach that behavior problems in foster and adopted children are largely based on a failure of attachment, resulting in Reactive Attachment Disorder. Treatment of disruptive behavior, according to ATTACh, requires “fixing” a child’s attachment to an adult caregiver, even though the child in question is years beyond the developmental stage which is the focus of evidence-based therapies that nurture relationships between adults and children. These views are strongly opposed to positions taken by conventional psychologists and certainly do not provide the evidentiary basis that should be required before public funds are expended. Like Wyoming, Missouri is making a big mistake; people in both states have been conned by AT proponents.


I want to comment on one other aspect of the St. Louis Post-Dispatch article. In addition to reporting that parents will be treated to attendance at the ATTACh conference, the piece refers to a program called Extreme Recruitment, which is said to aim at adoption within 12 to 20 weeks for difficult-to-place children, including older and special needs children. Given that it is very hard on children to be unsure of their position in a family, or even where they will be sleeping the next day, and that frequent changes of foster care are to be avoided if at all possible, this rapid path to adoption nevertheless seems to be an invitation to trouble and disruption. Can either parents or children rationally know that they want to proceed to adoption after such a short period? Especially in the case of special needs children, can parents during that time period learn what they should know about a child’s medical, psychological, or educational needs?  Much as a caseworker or a parent may want to close a file, they need to consider the number of cases in which parents say that the child “came home”, all was well, then suddenly the honeymoon was over and the parents complain that no one gave them all the information they needed. Hastening to reach adoption decisions seems like a way to guarantee those kinds of difficulties, with possible dissolution of adoptions, or in the worst cases the informal Internet “rehoming” that has had such ill effects for children. When people are convinced that all problems of fostered or adopted children are attachment problems, and when they believe that they can “fix” attachment and therefore all the other troubles as well, it is easy for them to fall for the idea that speedy adoption will have positive results.  Extreme Recruitment is associated with the Carleen Goddard-Mazur Training Institute, which on its website offers no evidence of any evaluation of the outcomes of this practice, although it uses the word “replication” which would suggest to professionals that some outcome studies have been done--  but in fact seems to mean only that this approach is being tried in several places. Someone in Missouri needs to examine this program under a strong light. 

Wednesday, July 13, 2016

Did Anne of Green Gables Have Reactive Attachment Disorder/

Looking at various on line discussions of Reactive Attachment Disorder, we see multiple claims that every orphaned, mistreated, or medically fragile child is likely to have RAD (a disorder incorrectly claimed to cause anger and aggressive behavior). Made-for-TV movies like “Child of Rage” echo these claims. But… people have not always thought that orphans as a group were overtly or covertly hostile to other people. This is a fairly recent idea, and one without real support.

Let’s look at how people used to think about orphans in the 19th and 20th centuries. Literary depictions of children give us some information about how people thought, because readers would not have accepted stories that went against their own beliefs about orphans.

Should Anne of Green Gables have been diagnosed with RAD? She was described by L.M. Montgomery as having come from an orphanage to her adoptive home on Prince Edward Island, so she had experienced the separation from her birth mother that is supposed to be a major factor in RAD. She was taken in by people who did not really want her; they had asked to be sent an orphan, a boy, who would be helpful on their farm and grow up strong to work for them. Anne’s adoptive mother wanted her to be sent back to the orphanage and exchanged for the right kind of child, but Anne had winning, though exasperating, ways (hmm, psychopathic charm maybe?) and the adults decided to keep her. As she grew up, Anne was a bit impulsive, but affectionate to her caregivers, and friendly to her teacher and other children. In later books, she was shown as falling in love and marrying, while maintaining loving relations with her former caregivers. The author  clearly did not think of Anne as emotionally handicapped or depict her as having more risk-taking behavior than went with her red hair (an assumption of the time). Orphans were all right as far as L.M. Montgomery was concerned.

Did Oliver Twist have Reactive Attachment Disorder? Born to a poverty-stricken mother who soon died in the workhouse, and not knowing his father, Oliver spent his first years “on the parish” with minimal food or care. When big enough to be useful, he was sold to an undertaker as an apprentice, but escaped only to be taken in by the criminal Fagin and forced to learn to pick pockets by his terrifying mentor. All the elements of abandonment and mistreatment are here, even Oliver’s presence at a murder. Nevertheless, Oliver grows up as a kind and engaging person who is willing to give half of his small inheritance to someone else. Orphans were all right as far as Charles Dickens was concerned.

How about Dondi, if anyone else remembers him? Dondi was a comic strip character following World War II. He had a lot of black hair, pale skin, and huge dark eyes. His ethnicity was far from clear, but he was a war orphan of some kind, and was adopted by a very rich lady with a lorgnette and an immense bosom. She was always drawn from a child’s-eye perspective, so the bosom was much in evidence. Despite his experiences of separation and trauma, Dondi was not only not angry, but was depicted as wholly good. His reliable moral compass made him an ethical adviser to Mrs. Van Bosom and her friends. Orphans were not only all right, but purified by suffering, in the opinion of the artist.

And then, what about Huey, Louie, and Dewey, or Ferdie and Mortie? These Disney characters of the Depression, fostered by their uncles, the cranky and indifferent Donald Duck and the somewhat more socially engaged Mickey Mouse, were depicted as mischievous, but no more so than non-orphaned children. Their independence was admired rather than being interpreted as high-risk behavior.

My point here is that beliefs, expectations, and stories about influences on children change historically and are not necessarily good guides to decision-making about individual children. When narratives tell us that orphanhood is a psychologically healthy status, we tend to believe that, and when we believe it, authors tend to tell us that  orphans do very well even under very difficult circumstances. When narratives like “Child of Rage” tell us that orphans are not only dangerous but capable of hiding their threat from us, we may believe it, especially if the stories are repeated. And when we believe, there are many reasons why more such narratives may be presented to us.

What’s the moral of this discussion? It’s not a good idea to depend on stories for our understanding of children’s mental health. Stories are always more interesting when they exaggerate reality, and when they repeat for us what we already think. They cannot tell us about diagnosis and treatment of emotional disorders as systematic research can do.


It can be hard for people to resist the appeal of “Child of Rage” and more recent examples of the type – but just think: would you expect to learn the real facts about sharks from “Jaws”?  About human physiology from “Fantastic Voyage”? If not, just keep in mind that stories about childhood mental illness were not written as sources of fact, and we should not try to use them that way.

Tuesday, July 12, 2016

How to Deceive the Public About Reactive Attachment Disorder for Fun and Profit

In a recent essay in the newsletter of the Society of Clinical Child and Adolescent Psychology, Eric Youngstrom described the “hyper-abundance of information on the Internet” as including “a wild mix of good information with opinion, direct-to-consumer marketing, and snake oil sales pitches, all clamoring for attention”. The latter two commercial approaches are all too easily absorbed by naïve print reporters, repeated as accurate in print, and then doubled down back on the Internet as statements of fact. Deception of an unwary public is multiplied during this process.

A fashionable topic for intentional or unintentional public deception is Reactive Attachment Disorder. As presented by representatives of the Snake Oil Manufacturers Educational Association (SOMEAss), this is a juicy topic, including serial killing just like in the movies, hypersexuality, and failure to be grateful to one’s mother—all to be treated by a strict regimen of authoritarian and intrusive parenting. (In reality, RAD is a diagnosis that describes young children’s difficulty in feeling comfortable with or staying close to adult caregivers; the term does not describe feelings or behaviors of school-age children or older individuals.)
Mistaken articles about RAD appear every other day, but my friend and colleague Linda Rosa has put me onto a beaut out of Oklahoma City: kfor.com/2016/07/11/camp-for-families-with-children-dealing-with-rare-mental-disorder/. This article makes mistaken claim after mistaken claim and does not allow for the public comment that might correct these mistakes.

The piece begins with a remark that alerts all knowledgeable readers: “Bonding with your baby is one of the most precious moments in a parent and a child’s life.” What’s wrong here? Don’t I think that happy moments with a baby are precious? Yes, of course I do. But “bonding” is a term that describes a parent’s sense of engagement with and commitment to a baby—“falling in love” with the baby is what we are talking about. The parent’s deep involvement leads to a cascade of positive events for the baby, but “bonding” is not in itself part of a child’s life. You have to be grown-up to  “bond” in this way. Babies will later develop attachment to a consistent, sensitive, and responsive caregiver, but this is not “bonding” and it is not the matter of a moment, precious or otherwise, but takes months and continues to change form for many years. Parents’ “bonding”, too, may or may not be a quick process; although some parents feel smitten by their babies the first time they hold them, many others feel a bit worried that they don’t “feel more”, but some weeks later will realize that now they are intensely engaged with the baby. The Oklahoma article is deceptive in its statement that both parent and baby go through a rapid and permanent emotional change, and that their feelings about each other are similar. This is not just a problem of a little detail about child development, because it wrongly suggests to readers that young children have adult-like feelings that are established at a very early age--  and would take severe methods to change later on. 

The Oklahoma article goes on to state that Reactive Attachment Disorder is a rare condition, and that is quite true. So what is deceptive? It’s the slightly later description of children with RAD as “lacking a conscience”, being aggressive, lying, stealing, and having fits of rage. None of these characteristics have anything to do with RAD as the term is conventionally used. The behaviors listed are in fact far from rare, and are related to conduct disorders, oppositional defiant disorder, obsessive-compulsive disorder, PTSD, even autism or early-onset schizophrenia. These disorders are not associated with attachment issues but are certainly more common among children who have been mistreated and who end up in foster care or placed for adoption. The basic cause is the mistreatment, and although developing good relationships with caregivers may be very helpful to the children, after early childhood this is no longer an issue of attachment.

One more--  extremely important—point from the Oklahoma article: an interviewee is quoted as saying that “traditional therapy can have the opposite effects for a child with Reactive Attachment Disorder.” While the man may not have known and may have had the best intentions in saying what he did, the fact is that this statement is a bald-faced lie. Pseudoscientific approaches to childhood mental and behavioral problems have been making this claim since the early 1990s, when Foster Cline appears to have been an early adopter of this mistaken view. His protégée Nancy Thomas (of whom I will have more to say) has followed up and repeated the idea frequently. In fact, there are several conventional evidence-based therapies well-known to be effective in treating children with the problems mentioned earlier; these include Sheila Eyberg’s Parent-Child Interaction Therapy and Mary Dozier’s Attachment and Biobehavioral Catch-up. There has never been a randomized controlled study of the effects of the therapy proposed by Cline, Thomas, etc. , much less a study comparing their treatment with conventional methods.

The Oklahoma article proposes a “RAD camp” to treat the problems they have defined (incorrectly) as Reactive Attachment Disorder. Click on the “learn more” link and what do we see? Yes, it is a Nancy Thomas camp, which will, by the way, cost $895 for each family member over 3 years old, an expenditure of almost $3000 for a couple with one child, and not, I can almost assure you, covered in any part by health insurance. This woman, a former dog trainer, has re-issued herself as a Therapeutic Parenting Specialist (UClc, for impressiveness, but unassociated with any actual certification or licensure). The Oklahoma reporter has been most cooperative in providing free advertising for Thomas as part of what Youngstrom called the “wild mix” including “snake oil sales pitches” and what I call deception of the public. 

What actually happens at these camps is not clear, so I will refrain from suggesting that it includes the holding therapy known to have caused child deaths and injuries. In other material about the camps, however, Thomas has said that she takes recalcitrant children away for “tune-ups”, and I think we can make some educated guesses about what she does. 
  
We can hardly expect Thomas and her ilk to become more straightforward, but we can demand that journalists consider their sources. Deception of the public should not be their goal, however much such deception may benefit snake oil merchants and thus help a reporter's career.

Wednesday, July 6, 2016

Early Developmental Milestones: The Two-Month Shift

I received the following query, but somehow it did not get published here on childmyths, so I am posting and answering it here. This message brings up a topic that I’ve been meaning to mention, as well as some other issues.

GOOD EVENING Madam

I love to read your posts in your blog.Thos e are really helpful.I am a mum of 5 week's child.He hardly gazes at me while breastfeeding or while craddling.I am worried unless that he is a very active child and doctor told me.he is doing well.So.please tell me.the milestons in the following months.It will be so grateful if you lwt me know..Thank you in advance..
Send from my vivo smart phone________________________________________


 Thanks for your question! These points you mention are concerns for many young parents who expect to spend a lot of time in mutual gaze with their baby. But in fact young babies (in the first few months) do not gaze at people for very long at a time. They are interested in faces, but they don’t look for a long period of time, the way we look at them. They also have trouble looking at things that are not brightly lit, so if you are cradling the baby and your face is in shadow, the baby may not be able to see you as well as you can see him.

Breastfeeding is an especially difficult situation with respect to a young baby’s ability to look at a person. For one thing, young babies are ravenous when they are hungry, and they are interested in nothing but getting that milk. They usually close their eyes tightly and their faces turn red with the effort of sucking, then they fall asleep when full, or let go of the nipple only to be changed to the other  breast. For a second thing, breastfed babies take the nipple right into the center of their mouths, and this means that they turn the face toward the breast and cannot see much other than the breast even if they open their eyes. A bottle-fed baby (a little older) may turn to look and keep the artificial nipple in the corner of the mouth, but a breastfed baby cannot suck if he does that, just because of the way the mother’s nipple works.

A breastfed baby of 7 or 8 months may let go of the nipple to look up at the mother, or may just hold the nipple loosely in his mouth while looking around, then may go back to sucking. He may also put his hand up to explore his mother’s face and put a finger in her mouth or (sometimes painfully!) up her nose. Mother and baby may look at each other at those times, but don’t forget, nursing mothers may be doing other things at the same time as breastfeeding—drinking a cup of tea, talking on the phone, or reading to an older child. Breastfeeding is a lovely experience, but it is not always the exclusive focus of the mother and baby.

There are a lot of developmental milestones ahead of you, and you can look these up easily if you have Internet access. I just want to point out to you a developmental step that is coming along soon. At about two months of age, most babies become much more easily interested in other people and the world in general. This change has been called the “two-months shift”. Before it happens, it is quite hard to get a baby’s attention. Occasionally the baby may look at you and even smile, but at other times he or she seems to look everywhere else. The baby smiles “at the angels” sometimes, at you other times, and sometimes not at all, even when you do all the baby-pleasing tricks like opening your mouth and eyes very wide. Years ago, before the diagnosis of autism was created, people used to call this a period of normal developmental autism; the baby was focused almost completely on herself or himself, which is what “autism”means.   


Please keep in mind that like other developmental milestones, the two-months shift does not occur on a specific day of life, but just somewhere around the age of two months. For some babies, the change is abrupt and noticeable. For others, it is gradual and may not appear in the same way from one day to the next. However, generally speaking, from around the age of two months you will see that the baby looks at you more, smiles at you more, is more likely to get quiet and listen to your footsteps approaching, and so on. You will get much more of a feeling of successful communication about things other than feeding. Just like an adult, though, the baby will not always look at or listen to you or smile when you smile—but these things will happen often enough that you will feel your relationship developing.

Tuesday, July 5, 2016

Premature Babies and Corrected Age

Michael and Ian are both 12 years old. Their birthdays are only a day apart. They are in the same class in school and play on the same soccer team. Both are reluctant to show any interest in girls or romance. Neither has begun a rapid growth spurt and both are still sopranos. Their parents and teachers think of them as a lot alike.

But… let’s go back about 12 years. Michael was born on just the day he was predicted for, about 40 weeks from the first day of his mother’s last menstrual period before she became pregnant (depending on the mother’s cycle, this puts the birth about 38 weeks after conception). Ian, however, was born about 35 weeks after the first day of his mother’s last menstrual period  (about  33 weeks after conception). Michael was a full term (or just “term” baby), while Ian was what most people call “premature”, a preterm baby. They were quite a lot different at that time, because they were at different gestational ages—40 weeks for Michael and 35 weeks for Ian..

The most obvious difference between them was their length and weight at the time of birth. At 7 pounds 15 ounces, Michael was similar to many babies at 40  weeks of gestational age. He was average in weight for his gestational age. Ian was also average for his gestational age of 35 weeks, but because he had not been developing as long, that average weight was not as great as  Michael’s. The average weight at 35 weeks gestational age is only about 5 and ½ pounds, and Ian weighed 5 pounds 7 ounces. Michael was at the average age for birth, counting from his conception, and he was similar in weight to most babies born at that gestational age. Ian, even though he was much lighter in weight than Michael, was about the same as most babies born at the same gestational age as himself.

There were some other differences between the newborn Michael and the newborn Ian. One was that Ian had a good deal more of the creamy skin coating called vernix; Michael had had time to lose this and just showed a bit in skin creases. Ian still had a lot of the head hair called lanugo, but Michael had only a little. When Ian was lying on his back, an examiner could take the baby’s left hand and pull it to the right quite a way across his chest and neck. Michael, lying in the same position, would resist the pull and the arm could not be pulled very far. Again, when they were lying on their backs, Ian’s foot could be brought up close to his ear, but Michael’s could not. (There were many other differences, and you can see more about them at www.ballardscore.com.)

But—very confusingly—Michael and Ian were about the same chronological age! The same amount of time had passed since they were born. Ian spent a little extra time in the hospital, but even a while after he came home in good condition, his father, Sam, was worried. “I looked in the book,” Sam said. “It says right here that a baby who is two months old can look at people and even smiles at them sometimes. Our friends’ baby Michael does that all the time, but Ian is still just looking around a little bit, just like Michael did a month ago. I don’t know what’s going on. I know they say not to compare babies, but I just don’t see how two babies almost the same age can be so different unless something’s wrong somewhere.”

What Sam missed was that even though they were born only a day apart, the babies Michael and Ian were not really the same age. Two months after their birth, Michael had been developing for the 38 weeks between his conception and his birth, plus two months—about 46 weeks. Ian had been developing for the 35 weeks between his conception and his birth, plus two months—about 41 weeks.  This does not seem like a big difference, but it means that at two months Michael was almost 10% older than Ian, developmentally speaking. (But of course as time passed the percentage difference became less and less, and by the time the boys were 12 the percentage difference was a very tiny one.)

It’s much less confusing to understand preterm babies if when they are very young we think of them by their corrected age—the gestational age plus the chronological age. If Sam had done that, he would have realized that when he compared Ian’s behavior to Michael’s from a month before, he was exactly right because Ian was developmentally at about the point where Michael had been a month earlier.


There are risks for preterm babies, and their development can be affected by their too-early birth. Also, whatever the reason for the early birth, that reason could also contain risks for the babies. It would be a mistake to think that all differences between all preterm and term babies just have to do with corrections for gestational age. But, all other things being equal, the biggest differences will be present simply because of gestational age differences, and understanding that  fact can save a lot of worry for parents of young babies.       

Monday, June 13, 2016

Taking Turns is Hard to Do

Parents of toddlers, preschoolers, even school-age children sometimes feel there is no end to the task of getting children to share and take turns. It seems to be especially difficult—and embarrassing for parents—when the child is at a party or with “rivals” of their own age. The child’s own birthday party can be the worst, as he or she sulks, pouts, and makes every effort to prevent the party guests from touching any of the presents.

I suppose I needn’t point out how hard sharing and turn-taking is for us adults? We can’t see why there should such a fuss about a toy train, but we would not care for other people to expect to sleep in our beds or “take a turn” with our spouses. A whole lot of maturation and learning has gone into our adult capacity for sharing, such as it is. Yet, somehow we believe that it’s possible for a preschooler to have such a wonderful personality and such character that he or she will cheerfully share and take turns with the most precious toys in the toybox.

Well, guess what: it’s not possible. Whoever knows how to share, has learned to do it, with help and support from older people. It did not just happen, and what’s more, it did not happen in the moments of violent jealousy that are so conspicuous, but in various quiet events that took place along the way.
Looking through some papers the other day, I came across my notes from a lecture by Lisa Poelle, the author of the excellent book Chronic biting extinguished. Among other things, Lisa was considering the situations in which toddlers bite people, and thinking about ways we might make those situations less fraught and the children less easily frustrated. She had a number of suggestions about how we can prepare children for situations where we expect them to share or take turns.

One of Lisa Poelle’s suggestions was to find everyday situations where we can model taking turns by doing it ourselves and/or talking about how it’s being done, and by offering another person a turn doing what we have been doing. So, to take some of her examples:

  1. “I’ve been stirring the batter for a long time. Would you like a turn?”
  2. “Let’s play ball. My turn to roll it…  your turn to roll it… my turn.”
  3. “Let’s put the puzzle together. I’ll do this piece… okay, your turn to do one. “
  4. “You can have a turn with the truck after Sam has it for three more minutes” (N.B. one of those three-minute egg timers can be a big help on this one).
  5. “I’m tying your sister’s shoes now. Next it will be your turn.”

A second suggestion is about helping the child know when a turn begins and ends. For example:

  1.  “You put the doll down; that was the end of your turn. Jessica picked it up for her turn. When she puts it down it will be your turn again. “
  2. Pointing out situations where characters in books or in videos take turns can also be helpful.
A third suggestion is to point out how often adults as well as children have to wait for their turn. For example:

  1. “Let’s take a number at this counter. When the man is ready to wait on us he’ll call our number. We can look at these pictures while we wait.”
  2.  “ All the cars are lined up to cross the bridge and each one gets a turn. We’ll wait for our turn before we go.”
  3. “We’ll wait for the traffic light to change before we walk across the street. When we see the little green man on the sign, that means it’s our turn to go.”

One problem preschoolers have about waiting for their turn is that they don’t have a very good idea of time. When we tell them “wait just a minute”, we might mean a real minute, or five minutes, or we might forget all about what we said--  so they don’t get much of an idea about how long they have to wait. Again, an egg timer may help with the waiting, at least by providing some distraction. Distraction may also be helpful if the waiting child can be helped to find something else to do until her turn comes around.

Can we expect children not only to share and take turns, but to be cheerful about it? Eventually we get to be skilled at these social “white lies”, where we thank people for presents we hate, or smile cheerfully as someone takes the last two chocolates instead of one or spills red wine on our cream-colored carpet. But that takes time and practice, and perhaps some adult experience with how we feel when other people are grouchy about problems. There’s no harm in trying to work with a preschooler on how to be polite when cross, but we need to remember that their basic tendency at this age is to become incensed and flounce around in a towering huff, several times a day. There is no taker of umbrage like a four-year-old! Our job, perhaps, is to avoid having our own anger triggered by  the child’s ire—and to be sure that we do not respond angrily just because we are embarrassed in front of other adults. There’s more to model for the child than just turn-taking, and being calm when someone else is mad is something we should display to children if we can manage it.


Should an Eighteen-Month-Old Be Seen by an Autism Specialist? Yellow Flags

As we all know, various Internet sites proclaim “red flags”, or behaviors of young children that may be associated with a later diagnosis of autism. Unfortunately, these “red flag” sites usually neglect to explain the considerable overlap between typical and atypical behavior, or the fact that behaviors very typical of infants can closely resemble the behavior of older children diagnosed with autism. Worried young parents see one “red flag” behavior that is characteristic of their [usually quite young] infant and convince themselves that they must find treatment at once.

But in fact, for children under the age of two or three years, atypical behaviors are only “yellow flags “, or “caution” signs, and even that only if several of them are seen. A small group of “yellow flags” in a toddler simply suggests that the child should be observed and his or her development should be watched more carefully than might usually be needed. These “yellow flags” act as a screening device that helps to focus on a small number of children of whom some are going to need special help.

                        Quite a few years ago, the British psychologist Simon Baron-Cohen (yes, brother of you-know-who!) developed a checklist to help pediatricians screen for toddlers who should be seen by an autism expert. Now, let me point out once again that these children are EIGHTEEN months old or older when screened with this checklist. They are not 12 months or 6 months, and they certainly are not 4 weeks old!  Let me also point out that one or two or even three atypical responses does not mean a diagnosis of autism; this whole thing is about finding the small number of children whose diagnosis needs a highly specialized professional examination that can rule out this particular problem for many of the kids.

So, given all that, here are some questions that might be asked a parent of an 18-month-old:

Does your child enjoy being swung, bounced on your knee, etc.?

                        Does your child like climbing upstairs or up on other things?

                        Does your child enjoy peek-a-boo and hide-and-seek?

                        Does your child ever PRETEND? (Baron-Cohen uses the Brit example of pouring                         and drinking tea, but other examples might be stirring a spoon in an empty                                                    pot, or using an electric cord as a “stethoscope” after visiting the doctor.)

                        Does your child ever point a finger to ASK for something?

                        Does your child ever point a finger to show INTEREST in something?

Can your child play with objects by rolling a toy car or building with blocks, rather than just mouthing or dropping them?

Does your child ever bring objects to you to SHOW them to you?

Notice, by the way, that some of these questions ask whether the child EVER does certain things. The fact that he or she does not do them all the time is not important, but if they are never done, that may be important.

Baron-Cohen’s list then goes on to questions for the pediatrician and what he or she has observed about the child:

During the appointment, has the child ever made eye contact with you?

If you get the child’s attention and then say “oh look!” as you point at an interesting object, does the child look where you are pointing?

If you get the child’s attention and then give him or her an object that could be used to pretend (the teacup again--  but any toy can be used ), and ask if he or she can drink the tea, stir the pot, etc., does the child do so?

If you ask the child to show you a light or other object, does the child look up at your face and then POINT?

Can the child build a tower of two or more blocks?

Once again, the issue is whether the child does most of these things a lot of the time. If he or she does, the possibility of a later diagnosis of autism is remote. If the child does not do most of the things mentioned, there may still be reasons other than autism for the problem, but it would be a good idea to see a specialist who can make sense of what is going on. Whatever the trouble may be, it may be time to seek treatment and help to move the child along developmentally as much as possible.

That was EIGHTEEN months, remember! And those flags are yellow.  
   


   

Webinar for Parents Of Children with Disruptive Behaviors 6/17/2016


Hello everybody-- I want to call your attention to a webinar for parents that will be held by the National Center on Birth Defects and Developmental Disabilities on Friday, June 17, 2016, 1-2:30 PM Eastern time. To register, go to htpps://goto.webcasts.com/starthere.jsp?ei=1105300. There is no charge for participation.

This webinar is about learning to do a parent version of behavior therapy for children whose behavior is disruptive, perhaps because of ADHD.

According to the announcement I received:


During the webinar, parents and families will learn about:
·        What is behavior therapy for young children and why it is delivered by parents; the parents’ role in fostering a healthy and positive environment for their children;
·        What parent training in behavior therapy looks like (including what programs and interventions are effective for young children with ADHD and other disruptive behaviors);
·        What they can expect when being trained in behavior therapy (setting, number of sessions, activities during sessions, homework, time to see progress, types of skills addressed in the training);
·        When medication is recommended for children with ADHD;
·        Questions to ask their primary care physician or referring clinician;
·        Questions to ask a potential parent training provider before beginning training in behavior therapy;
·        How to monitor treatment progress to decide whether or not a provider and/or treatment is a good fit for your child’s needs.

This promises to be a very helpful experience for parents who are concerned about children's disruptive behavior!

Monday, June 6, 2016

Maltreated Toddlers in Foster Care: What Can We Do for Them?

A week or so ago I had an email from a CASA (court-appointed special advocate) working in Washington State. She asked a very reasonable question: So, you say not to send young foster children for Attachment Therapy. Well, what are our options? What should we do to help them?

In reply, I sent her a journal article and suggested that she read about the Attachment and Biobehavioral Catch-up  (ABC) program directed by Dr. Mary Dozier of the University of Delaware. Dr. Dozier has spent 22 years developing this program and has reported four randomized controlled trials showing its benefits to children who have experienced serious adversity. ABC is now being implemented in 15 states and is wanted in others, but Dr. Dozier is concerned about maintaining high fidelity to the original program and must thus move more slowly than we might like.

ABC is a 10-session program, done in the home by trained coaches, which targets key child issues resulting from experiences of adversity. The focus is on parenting behavior, not on underlying attitudes or motives, and the parents may be neglecting birth parents, foster parent of toddlers, or parents who have adopted internationally. Randomized controlled trials have supported the effectiveness of ABC as done by certified coaches, with long-term positive effects for children’s development. The coach does not interact with the children, but watches and comments on the parent’s behavior.

ABC teaches and increases three basic parenting behaviors: 1) nurturance, 2) following the child’s lead, and 3) non-frightening behavior. These behaviors are not all carried out at the same time, so a challenge for a parent is deciding which kind of behavior is suitable at a given time.

Nurturance, or comforting or helping when the child needs this, is especially important for children who have experienced early adversity. Their high rate of disorganized attachment behavior shows that they have no consistent strategy for deciding whether to approach or avoid an adult caregiver, so caregivers need to be able to recognize situations and subtle communications showing a need for nurturance. When toddlers are avoidant or resistant to nurturance, caregivers tend to respond “in kind” – to feel rejected and to avoid trying to comfort the child. To increase nurturance, ABC-trained coaches actively comment in the moment by making, once a minute, positive comments on a caregiver’s nurturing behavior, like going to a child who has fallen down or picking up a child who approaches the caregiver.

Increasing parents’ nurturing behavior helps to decrease the non-nurturing behaviors that are too easily resorted to when toddlers are perceived as avoiding caregivers. These behaviors include making fun of the child, acting on unrealistic expectations of the child, deliberately letting a child get into difficulty “so he will learn”, telling the child “you’re okay, you’re not hurt” or “you’re too big to cry”, ignoring the child, or distracting the hurt child by pointing to something interesting. These actions all tell the child that the parent is saying “you don’t need me”, whereas the fact is that the child does need a nurturing caregiver and needs to identify a specific adult as actually being such a person.

Nurturing behavior involves responding to the distressed child’s needs with minimum--  or perhaps, no—signals from the child.  This behavior is different from  following the child’s lead, in which the parent responds to a child’s interest signaled by speech, gaze direction, movement, or toy play. For example, if a toddler is banging two blocks together, a caregiver might follow his lead by banging two other blocks or by putting one block forward to join in the banging, or jut by saying “bang!” each time. A caregiver is not following the child’s lead if he or she takes one of the blocks and asks the child to say what the letter on it is, or takes the blocks and starts to build a tower with them.  These parent activities have their place, but ABC tries to increase the adult’s success in identifying the child’s interest and making use of it for pleasurable communication. 

Parent behavior that does not follow the child’s lead can be “teach-y” under the wrong circumstances, bossy, intrusive, or ignoring. Of course, there are many times when a caregiver appropriately does not follow a child’s lead, especially when limits need to be set or boundaries established. The ABC goal is to increase the caregiver’s ability to follow the child’s lead when doing so is appropriate--  not when the child’s lead will take the child or others into danger.

ABC-trained parents also learn to avoid frightening behavior that makes it more difficult for a young child to stay calm and regulated. This includes intrusive behavior like grabbing or tickling. For a child who has experienced severe adversity, typical “normal” parent-toddler games like “I’m gonna get you”, the threatened tickle with a finger that goes around and around near the child’s belly, or exciting chasing and hiding, may all be inappropriately frightening. The child who still struggles with knowing whether to approach or avoid a caregiver may interpret even play at frightening behavior as a signal that this adult should be avoided if possible.   
The ultimate goal of ABC is to improve the ability of the child to stay calm and regulated in the everyday circumstances of the home. This improved regulation allows the child to learn and communicate more effectively and to have more inhibitory control. One of the ABC outcomes is that children of ABC-coached parents later have more success than controls in a laboratory test where they are shown some fascinating toys and told not to touch them by an adult who then leaves the room.


When Internet sites for foster and adoptive parents tell parents that conventional treatment “just makes a child worse”, or when they advocate highly authoritarian, intrusive, managing methods that are supposed to make maltreated children “attached” and therefore obedient, they are badly mistaken (to put it politely). Evidence-based treatments like ABC and PCIT (Parent-child Interaction Therapy) can make enormous positive differences to the lives of children and families. I hope my CASA correspondent will pass along what I told her to others and help them understand this.