Monday, April 21, 2014

You Can't Go Home Again, Or Regress to Infancy Either

The idea of psychological regression keeps pushing its way to the front of the discussion, and I suppose I shouldn’t be surprised, because current na├»ve beliefs about psychology almost always assume that someone can go back to early childhood, back to the womb--   even back to previous lives. Still, when this matter comes up again, I feel like taking up the fight on the side of reason.

In a recent blog post, I referred to  Kathy Brous, who says she accidentally regressed herself back to infancy. (I really must get her book and see how she did it, and I do think she should warn us all of the kind of accident that might have this effect.) Then, a few days ago, I received a flyer advertising a class in qigong (the Chinese exercise/meditation routine) for autistic children. The class instructs parents how to do what they call qigong sensory training, which they are then to do with their autistic children every night. What does that have to do with regression, you ask? Well, here’s what the flyer says: “The routine is designed to normalize your child’s difficulties with touch & sensory sensitivities so they can essentially ‘go back’ and begin to reclaim the key developmental milestones that were missed in the first years of life.” In other words, the qigong presenter (who is someone I know and had respected up to this point) claims that the treatment can cause regression to an earlier psychological stage, followed by rapid recapitulation of previously-missed developmental steps.

The idea of regression has become so embedded in American thought that it is hardly even discussable--  it’s an a priori assumption, an agreed-upon given, even one of dear Mr. Rumsfeld’s known knowns. But let’s just think about it for a bit.
The idea of regression came out of the neurological studies of John Hughlings Jackson in the late 19th century. Hughlings Jackson was interested in seizure disorders (his wife had died from one) and other aspects of brain damage, and in the course of his work he concluded that the nervous system was organized in a hierarchical fashion. This meant that higher-level brain areas acted to inhibit the more primitive parts of the brain, but if the higher areas were damaged, primitive movement patterns would reappear, showing that the lower areas were now “in charge”. Hughlings Jackson’s view of regression was of great interest to Sigmund Freud, whose biological view of personality used the metaphor of regression, comparing psychological changes to neurological events. Freud’s second important metaphor, the idea that human motives and needs acted in a hydraulic manner and could be blocked in their normal flow by disturbing events, worked together with the regression idea, suggesting that if a patient could regress to and remember an event that caused emotional blockage, that blockage would disappear.

Freud’s ideas about regression really involved events after the first year of life or so, and in some of the cases he mentioned, patients had been young adults when the problem incident occurred. However, some of Freud’s students and colleagues, like Otto Rank, suggested that emotional difficulties required regression to the time of birth, and some later authors moved the problem period to prenatal life--  or even, as Scientologists claim, to conception.

So, how do we examine these ideas? It’s certainly true that sometimes people act childish, and if they are children they may show problem behaviors characteristic of earlier ages, things we thought they had “outgrown”. Under hypnosis or other forms of suggestion, people may act as if they are babies, or at least act the way they think babies act. Have any of these people really regressed? The first issue, that of showing less mature behavior, is easily explained as a reaction to stress; it’s not necessary to posit regression in order to explain it. For the second, it’s important to realize that with suggestion people can also act as if they are much older than they are, or at least they can act the way they think a much older person acts. If we are going to accept regression on the grounds of a person being able to act like a baby under hypnosis, it seems that we should also accept “progression” to a later stage of life--  and I can’t believe that even the most devout regressionist would be willing to do that.

It seems, then, that we don’t have evidence that people do regress in the common sense of the term. And according to the usual rules of logic, the burden of proof is on those who claim regression happens, as it is not possible to prove that something never occurs.

Obviously, the most important question about regression has to do with whether there is evidence to support its occurrence. But in the absence of such evidence we can also proceed to consider the plausibility of regression. An important concept that argues against psychological regression is epigenesis. This term refers to the fact that in the course of development, innate biological factors interact with experiences to shape the individual. At every stage of development, new experiences act on a person who has already moved along a developmental pathway determined by biological characteristics added to previous experiences. Thus, the individual who has had Experience A at an early stage may respond very differently to an event than the way someone who has had Experience B responds to the identical event. In the course of development, people really change, and the results of past events may or may not be able to be undone later—but in any case are not undone by repeating early experiences.

To take a biological example, a child who has been badly malnourished may be brought back onto a normal developmental path if given an improved diet at age 18 months, but if the better diet does not appear until age 5, stunting of growth and of brain development will not be corrected no matter how good the food is---  and incidentally, to improve the five-year-old’s diet does not mean to give him 6 months of milk alone and then start him on pureed foods, which would be the appropriate analogy to many psychological regression methods. Similarly, a person who has lost speech due to a stroke is not treated by exposure to infant-directed talk of the kind he originally needed for good speech development.

Erik Erikson’ psychosocial theory of development made good use of the idea of epigenesis. Erikson saw the individual as working through a series of challenges in which he or she needed to find a balance between two aspects of the self and of the world. At each stage, the person brought to the new challenge characteristics that came from previous development, which helped to determine how a balance might be found.  Regression was not an option--  but did that mean that a problem from the past could never be resolved? No, in Erikson’s view, every problem of personality development (like a balance of trust and mistrust) was to some extent re-worked at every developmental stage, in the context of new events and new abilities. Each stage had a focal problem, but other issues were also malleable, so, for example, a person who had in early life had reason to be distrustful could during childhood, adolescence, or later, have new experiences with people that would enable a more positive balance of trust and mistrust.

The idea of epigenesis is that people are influenced by experiences but that they keep on developing and become different persons over time. The idea of regression is that some aspect of an individual remains identical in spite of maturation and experience, but carries with it “buckets” of experiences that can be dumped and replenished with better contents through a regression procedure. This seems to suggest that according to the regressionist view, the personality is somehow independent of the usual rules of time, space, and developmental change.

But, you say, let’s go back to the qigong. What if the regression claim is irrelevant? Isn’t the important thing whether it works? And it turns out that there are claims that it works, but it’s all a bit sticky. For example, in one study (Silva, L., Schalock, M., & Gabrielsen,K. (2011). Early intervention for autism with a parent-delivered qigong massage program: A randomized controlled trial. American Journal of Occupational Therapy), the authors concluded that qigong was effective. Having invited parents to join the trial, and presumably explained that some would receive treatment and others be wait-listed, they compared a group of children whose parents were given 3 hours of training , plus 30 minutes a week for 7 weeks of coaching while the parents performed the procedure in the presence of a trainer, to another group who were not described as receiving any attention except for being told they were wait-listed. So, as so often happens, we have people who are told they’re getting a good treatment, get a lot of attention from enthusiastic trainers, get together with the trainer and the child periodically, and spend more time in direct interaction with the child than usual, and they’re compared to people who don’t get any of that. Not surprisingly, it turns out that families with kids with handicapping conditions do better when they get supportive attention, and the kids then do better too; we don’t have to turn to Chinese medicine for an explanation here. The authors of that study should have had a comparison group with sham qigong  using different movements than the real thing, and they did not have that, so I’m afraid they don’t get to conclude that the treatment is effective.  


Monday, April 14, 2014

Disorderly Thinking About Developmental Trauma Disorders

Sunday Koffron Taylor [sorry, I gave the wrong name before] kindly posted for a Facebook group the following piece:, the work of one Kathy Brous, who is said to be a technical writer and advertises her own book with the statement that she accidentally regressed herself back to infancy. (How’d she get back again? That’s what I want to know.)

I was floored by Brous’s statements about the posited Developmental Trauma Disorder, proposed by Bessel van der Kolk to the editors of  DSM-5 and rejected by them on the grounds that there have been no published accounts of cases that are appropriate for this diagnosis and not for other existing diagnoses. Brous appears to quote van der Kolk and Allan Schore correctly, however, so I don’t think the whole problem can be blamed on her.

Let me offer a few quotations from Brous’s article, with rejoinders to each.

First, I note that Brous refers to Allan Schore as the “father of attachment theory in the U.S.” This is an absurd statement and indicates that Brous is in fact ignorant of the actual history of attachment theory as understood by psychologists, rather than by journalists. If one had to choose “fathers” for attachment theory in the U.S., Alan Sroufe and Everett Waters come to mind as the major candidates. Schore’s contribution, if such it can be called, is something he calls “regulation theory” or “modern attachment theory”. As I was preparing an article about attachment theory for the journal Theory and Psychology several years ago, a reviewer asked me to include Schore’s ideas, which I did, looking especially at his attempts to bring material about brain injuries and about behaviors of other species into the discussion. Here is part of what I said: “.. A.N. Schore’s speculation about right-brain functioning is on shaky ground. Passing over the well-known fact of the holistic functioning of an intact brain, we can note that a careful parsing of Schore’s sources (J.R. Schore & A,N, Schore, 2008) suggests a lack of due attention to some important points. In addition to a number of references to Schore’s own publications as evidence for specialized right-hemisphere attachment functioning, Schore and Schore cited about 10 sources as indicating empirical evidence for the postulated connection. Of these, two… involved work on rodents, which was presented as supporting evidence without any textual reference to the use of data from non-humans. One paper… described hemispheric differences in processing upper and lower parts of a facial display, and concluded that lower facial displays are preferentially processed by the left hemisphere and upper facial displays by the right hemisphere; Schore and Schore mentioned only the right-hemisphere data. A fourth paper… discussed facial processing deficits in persons  for whom a cataract in early infancy had prevented stimulation of the right visual cortex; Schore and Schore cited this paper as evidence for the right-brain hypothesis without noting that the teratogenic or genetic event that caused the cataract might also have caused atypical brain development…” (Mercer,J. [2011]. Attachment theory and its vicissitudes: Toward an updated theory. Theory & Psychology, 21, 25-45). Et cetera, et cetera, all to the point that Schore’s “modern” theory is based on a stroll through the cherry orchard. Read the background material, and you see at once that Schore’s part of this belief system is largely notional.

All right, let’s soldier on to more of Brous’s remarks. How about this one? “Developmental trauma starts in utero when there’s not much more than a brain stem and goes on during the pre-conscious years… until 36 months, when the thinking brain… comes on line. It’s 45 months [apparently beginning at conception, to make the numbers right. JM] ranging from general anxiety to non-stop terror.”

Where to begin? How about psychological trauma in utero? What events are emotionally disturbing to a fetus? Are we talking about emotion-related hormonal changes in the mother, which could certainly shape aspects of brain development but would have to be related to intense and continued distress in order to do so?  Is this a theory that actually could apply only to children of mothers held in concentration camps or caught in civil wars, or is there some attempt to think about more typical developmental events? My guess is that Brous, at least, is not talking about any of these things, but instead is committed to the idea of trauma at the time of conception, a la Scientology. My crystal ball suggests that behind Brous’s references lies a belief in “cellular consciousness”-- posited learning that does not require a nervous system--  and that this is also concealed in van der Kolk’s claims about the body keeping score.

All right, and when are these “preconscious years”? Is Brous claiming that children of almost three years are not thinking in the usual meaning of the term? Are these the same children who are known as toddlers to be able to figure out whether to believe a person who has acted “nice” rather than one who has not? Are they the same ones who tell and listen to stories and express intense likes and dislikes, or who reason about their own behavior (I’ll quote one two-year –old of my acquaintance: “I like chickens, but I never kiss them, because they have beaks and no lips.”) If Brous wants to say that cognitive development is very much in progress during the first three years, or even that most people have few or no memories from that period, that’s fine--  but to say young children are “preconscious” is inaccurate and without purpose except to allow for an extravagant emphasis on their experiences of fear, even constant terror.

Let’s jump ahead a bit. Now we see that van der Kolk calls “insecure attachment and attachment disorders” the causes of the posited Developmental Trauma Disorder. But, hold the phone a moment. It’s well known that infant-parent attachment does not develop until at least 6 months after birth. Methods for measuring insecure attachment are directed at children of 12 months or older, so there’s no way anyone could reliably identify this in a child between 6 and 12 months, much less in earlier life. As for “attachment disorders”, these are not the same thing as insecure attachment (see previous post for more about this). How can it be that attachment “problems” cause DTD, but DTD is caused by events as early as conception--  as much as 15 months before attachment even begins? Like a problematic form of attachment behavior, this reasoning is disorganized/disoriented.

Just one more bit here, as I’m sure we’re all getting tired (goodness knows I am; reading this stuff is wearing). Van der Kolk has a treatment for the disorder he proposes. It’s somatosensory healing, which turns out to mean doing theater, yoga, and martial arts in order to “get them inter-personally attuned.” Folks, it’s as easy as that! These children have lived in terror from conception and had their brains skewed as a result, but children’s theater will fix it! Their bodies will change that scoreboard to say “game on”. The National Endowment for the Humanities will take over from NIMH, and the Santa Barbara Graduate Institute will be accredited by acclaim, and Alice Miller will be canonized, and I will become a hermit.

Saturday, April 12, 2014

Insecurity Is Not Pathology (cf. Linus and Woody Allen)

 For a very long time, before attachment became a religion, Americans have been worried about “insecurity”. People who value independence and individualism can get nervous about insecurity, with its suggestions of emotional dependence and social engagement. I remember overhearing a conversation years ago, about a child who had a “security blanket”. “How come he carries that blanket around all the time?” “I guess he’s insecure.” “Oh. Well, I guess then we’d better take it away from him.” (Here we have not only the belief that everyone must at least behave as if they are independent, but a common error of logic--  if A causes B, then removing B must also remove A!) Like many other somewhat frightening things, insecurity has been a topic of humor from Linus right on to Woody Allen.

Today, we see the concern with insecurity reflected in journalism and discussions that equate  insecure attachment, as measured by methods like the Strange Situation, with “attachment disorders”. Insecure attachment, originally defined as a pattern or quality of attachment, may now be touted as an emotional disorder (e.g.,
According to a number of studies, among children with normal family experiences, about 65% are evaluated as securely attached. About 30% are insecurely attached in one or another of the possible categories, and a small percentage are assessed as disorganized in their attachment behavior. Disorganized attachment is associated with early maltreatment and also with later externalizing problems (e.g., aggressive behavior). Insecure attachment is not ideal, but on the other hand is not particularly associated with serious psychopathology.

If insecure attachment does not cause serious problems, how did it come about that people are so concerned with it--  indeed, that they are concerned about it at all? How did “security” come into the study of attachment? There is a history here.

It’s easy to assume that secure and insecure attachment behaviors are so different that they jumped right out at Mary Salter Ainsworth as she observed young children. Actually, though, Ainsworth went looking for them and developed the Strange Situation as an instrument that would differentiate them. She has told part of the story herself (

Ainsworth was a student of William Blatz of the University of Toronto in the 1930s. Blatz developed a “security theory” that was a welcome alternative to Freudian theory in an anti-psychoanalytic intellectual environment. Blatz did not publish widely or sponsor a great deal of research on security theory, and Ainsworth’s recollections and comments are probably the most accessible source of his ideas. As Ainsworth noted about Blatz, “He was a brilliant hypothesizer, but I believe he did not think of research so much as a way of testing hypotheses as a way of reformulating old hypotheses and discovering new ones. He did not attempt to spin a theory to encompass all of personality and its development. He did, however, think that the concept of security could guide the exploration of this rich and confusing field.”

What was security, from Blatz’s viewpoint? According to Ainsworth, it was “feeling confident or effective, even though one’s feeling of efficacy might stem from reliance on something or someone other than oneself.”
Blatz felt that people want to be comfortable and secure, but they were also motivated by an “appetite for change”, which in itself can create insecurity. When very young, they experienced an “immature dependent security”, in which they needed to be able to retreat to a protective parent when frightened by the consequences of their exploration. Subsequently, as children became more knowledgeable, they could achieve an “independent security” that allowed them to explore without constantly checking back with adults. In fact, Ainsworth noted, Blatz thought that by the time they reached maturity, “they should be fully emancipated from parents and not dependent on them any more… any substantial continuation of ‘immature dependent security’ was to be viewed as undesirable”--   a far cry from the current preoccupation with maintaining early attachment behavior through the teens! Having achieved independence, however, the individual was now ready to enter into a partnership of “mature independent security”, in which each partner provided support and protection for the other as needed.

If steps in the development of security did not progress properly, Blatz considered, a variety of processes like intolerance of disagreement and blaming of others might come into the picture as ways to achieve a sense of comfort and effectiveness. However, as Ainsworth pointed out, “Blatz arrived at his list [of processes] in a purely ad hoc fashion in the course of his clinical experience, and never claimed it was complete.”
Ainsworth’s early research involved attempts to evaluate the security of adults. In pursuing this work, and in her later efforts to assess children’s attachment, she followed an important concept contributed by Blatz. As she wrote, “Blatz’s theory does not hold with a simplistic dichotomy between secure and insecure. The degree to which children are secure can be assessed through an examination of their confidence in others, especially parents, to provide comfort, reassurance, and protection when needed, and [my italics—JM] their confidence in being able to cope with the world on the basis of their own skills and knowledge… One cannot arrive at a single security/insecurity score, but should instead consider the patterning in a comprehensive assessment.” Such patterns, of course, are what Ainsworth and her colleagues attempted to assess by means of the Strange Situation, and that much-valued measurement seems unfortunately to have encouraged not only a dichotomy of secure vs. insecure, but an overvaluing of the former and a pathologizing of the latter. (Not all students of attachment agree with the typology of secure and insecure attachment, and some authors have proposed that attachment security actually lies on a continuum.)

As you can see, Blatz’s view of security seems to have been a major factor causing Ainsworth to look for “secure” and insecure” patterns in young children’s attachment behavior. She did not first look for patterns, and then label them as secure or insecure. (Disorganized/disoriented attachment behavior, on the other hand, was first noticed as a pattern and later named.) Ainsworth continued, very appropriately, to focus on patterns of attachment behavior, but unfortunately popular and journalistic views have come to identify secure attachment as a good category and all other types of attachment behavior--  insecure patterns, disorganized/disoriented attachment, even Reactive Attachment Disorder--  as belonging to an equally bad category. This is comparable to assuming that there is only one acceptable pattern of early language development or of pubescence, and that all others --  not just the truly problematic---are to be deplored or subjected to treatment.

It is a curious pursuit, the examination of the journalistic theory of attachment. In some cases, like the one just discussed, the media have re-worked earlier views in order to achieve a simple way of defining the good and the bad, and in order to abandon the complicating idea of developmental change in attachment.  In other cases, some of Bowlby’s old tenets, now long abandoned, are maintained. For example, the statement that “you don’t attach in a group home” ( may well be a result of assuming that Bowlby’s original monotropy theory (attachment to a single caregiver only) still holds, although in fact this idea was abandoned long ago, and it is clear that a young child may be attached to several adults, not all necessarily with equal security.

Wednesday, April 2, 2014

Autism Awareness versus Autism Anxiety

Today, April 2, has been designated as Autism Awareness Day, and I think this is a wonderful idea--  provided that what people are made aware of involves accurate information about autism. To be anxious about autism—an increasingly frequent condition of parents--  is not the same thing as actually being aware of the facts. Here are some of the factual issues that can create a lot of anxiety if not understood.

  1. Diagnosing autism
I receive almost daily inquiries from young parents who are terrified that their infants of a few weeks old are autistic, because the babies don’t gaze into their eyes, or sometimes because the babies are rather placid. These very worried people are not aware that babies do not become very socially interactive until they are three or four months old. In fact, in the old days before autistic disorders had been described, this normal stage was often referred to as “autistic” or self-absorbed.  The anthropologist Ashley Montagu spoke of human beings as having a period of “exterogestation” in which babies developed for a few months as if they were still in the womb, and it’s during the months of  “exterogestation” that autistic self-involvement and inattentiveness to stimulation are evident.

Someone asked me yesterday how babies acted at two months of age when they were going to be diagnosed as autistic later on. This is an excellent question (as we all say when we don’t have an answer), but think what would have to be done in order to know this. We would have to have careful descriptions of the behavior of thousands of two-month-olds, follow them until age 2 or 3 years, and find out which ones were diagnosed as autistic--  then look to see whether there had been differences at two months between those who were later said to be autistic, and those who were not. This research has never been done, and given our current fiscal austerity, I don’t suppose such expensive work will be done in my lifetime, although perhaps it will eventually take place.

The bottom line is that it is not possible to tell babies who will be autistic apart from those who will not, when they are very young. I know this is disturbing in light of the constant emphasis on early intervention, but it’s a fact nevertheless. It’s also a fact that when babies are diagnosed as being autistic during the first year or so of life, there are many false positives--  children who are categorized as autistic, but who then proceed along a typical developmental trajectory. Even  toddlers and preschoolers may be incorrectly diagnosed. One of the problems is that some behaviors often associated with autism, like toe-walking and hand-flapping, are also often seen in younger typically-developing children.

  1. That epidemic
One concern that naturally makes parents anxious about autism is the constant reference to an epidemic of autism, with numbers of diagnosed children increasing so rapidly that if we keep on at this rate everyone will be autistic and the concern will be about those unfortunate neurotypical kids, growing up in a world they don’t understand!

Is there really an epidemic of autism? Or do these increasing numbers have something to do with the way we diagnose and count cases of autism? There’s no question that criteria for the autism diagnosis have changed over the years, and of course there will be more or fewer diagnosed cases if we broaden or narrow the standards for making the diagnosis. The anthropologist Roy Grinker (grandson of the famous name, if anyone remembers him) has looked at editions of the “Diagnostic and Statistical Manual of Mental Disorders” (DSM) back to the first edition in 1952. Autism was originally conceived of as a type of schizophrenia, later as possibly a cause of mental retardation, still later thought to be related to attachment, and in the most recent edition is connected with communicative disorders and includes the problems that used to be called Asperger’s syndrome. There are likely to be big differences between numbers of children diagnosed as autistic when the criteria are those for a form of schizophrenia, and the numbers diagnosed when an “autistic spectrum” includes mild social disabilities. This is not to say that there is or is not an actual increase in cases of autism, but the facts warn us to be careful about conclusions that may be based on apples only, apples and oranges together, or all the fruit in the produce aisle.

A relevant piece of information is that state autism rates are correlated with the average adult educational level of the state. That is, in states where adults tend to be highly educated, there are high rates of autism diagnoses. Does this mean that we’re back to the old idea of the over-intellectual refrigerator mother who causes autism? No, what it probably means is that when parents are well-educated and know that autism is a possibility, they are more likely to seek that diagnosis and the treatment that can go with it. Less educated parents may assume that their possibly-autistic child is “just peculiar” or perhaps mentally retarded, and never seek diagnosis or treatment. (And by the way, if they happened to choose homeschooling, who else would there be to suggest a diagnosis?)

  1. What causes autism?
At the risk of repeating myself and many other people, I want to say that It Is Not About Vaccines, with or without thimerosal, or whether on the recommended schedule or some other schedule. Andrew Wakefield’s study pointing to vaccination as a cause of autism was fraudulent, and this has been known for quite a while.
An excellent article by Sam Wang, “How to think about the risk of autism”, appeared in the Review section of the New York Times on March 30. A graphic showed a list of possible causes of autism and the risks associated with each one. (For those who are worried about the effect of older fathers [over 60], fewer than 3% of the children of such fathers are expected to develop autism.) The effect if being premature by 9 or more weeks is much greater, but still, fewer than 3% are later diagnosed as autistic.

The huge cause of autism is a genetic one; when one identical twin is autistic, the chances are between 36% and 95% that the co-twin will also receive this diagnosis.(However, because there seem to be many genes and gene interactions at work in autism, there is no genetic test available.) For fraternal twins, who are not genetically identical, the chances are up to about 30% that if one twin is diagnosed as autistic, the other will also be diagnosed. The other leading cause of autism, a non-genetic factor, is damage to the cerebellum at the time of birth, which is rarely mentioned by the mass media.

  1. Are there good treatments for autism?
I wish I could answer this question more positively than I can. The best established treatment for autism, Applied Behavior Analysis (ABA), was originally reported to be highly effective and to enable a large proportion of autistic children to attend mainstream classes without any special help. But a more recent randomized controlled trial suggests that the size of the effect of ABA is not nearly as large as had been thought. ABA is often recommended by school child study teams and is often paid for by health insurance.

Another treatment that has been put forward as useful for autistic children is DIR/Floortime ™, a procedure that encourages the development of communication at levels from the simplest to the most complex. Unfortunately, there has been little research giving supportive evidence for the effectiveness of DIR. A randomized controlled trial has been said to be ongoing, but I have not been able to find that it has been published.

Both ABA and DIR are plausible in terms of established information about child development and learning.

I am sorry to say, however, that there is a list of implausible, non-evidence-based psychological treatments that are sold to concerned parents and that make unreasonable claims both about causes of autism and about their own effectiveness.  (These are in addition to physical treatments like chelation or diet restriction.) I will describe a few of these.

Holding Therapies, methods that involve physical restraint of children accompanied by demands for emotional expression, were suggested for treatment of autism in the 1960s. These treatments are painful and frightening for children and have largely been rejected in the United States, in spite of the support given to them some years ago by Temple Grandin and Bernard Rimland.  They continue to be used in Germany and in the Czech Republic, in spite of  the protests of psychologists in those countries. There is no evidence that Holding Therapies are effective in treating autism. Jirina Prekopova, the leading Czech proponent of the treatments, has in fact shifted her claims to a religious/spiritual benefit and re-named her method a “lifestyle”.

A treatment that shares some concepts with Holding Therapies is le packing. This French method combines restraint through wrapping in cold, wet sheets with a psychoanalytic approach, and is based on the belief that autism results from a poor mother-child relationship. It has been stated that a randomized controlled trial of le packing is underway, but I have found no published report.

Son Rise ® is a method advertised in the United States. It proposes that  autism is caused by a lack of bonding. Treatment involves adult efforts to encourage eye contact by wearing big glasses and holding interesting objects near their eyes to attract the child’s attention; adults also practices “joining” (a method derived from dance and movement therapy) by imitating the child’s self-stimulating movements. There is no acceptable evidence supporting Son Rise®, but it seems to be attractive to parents desperate for help.

HANDLE (Holistic Approach to NeuroDevelopmental and Learning Efficiency) is a method which assumes that autism is an extreme anxiety disorder, although it is not clear how HANDLE techniques would impact anxiety. HANDLE uses a variety of exercises such as the wearing of red and blue “3D” glasses and sucking on “crazy straws”; these are said to increase eye coordination and stimulate the cranial nerves by causing rhythmic stimulation of the brain hemispheres. HANDLE therapists also practice face-tapping by tapping with their fingers along the lines of the trigeminal nerve, to the rhythm of “Twinkle, twinkle, little star.” The CAM practice of Reflexology is referenced as the rationale for the tapping. Needless to say, there is no systematic evidence that HANDLE is effective as a treatment for autism.

I hope that some real awareness about autism, the facts about the “epidemic” and the actual causes of the disorder, can reduce a bit of the anxiety about autism that is tormenting many parents. I also hope that some understanding of the implausible treatment methods on offer will help guide parents of autistic children to ABA and DIR, the methods that are plausible, even though their evidence basis may not be what we would like to see.

Tuesday, March 25, 2014

Institutions versus Foster Homes for Parentless Children: Rich and Healthy, or Poor and Sick?

When I was a teenager, we used to think it very funny to ask people their opinions: “Is it better to be rich and healthy, or poor and sick?” This “joke” comes back to me nowadays when I think about discussion of the advantages and disadvantages for abandoned children’s development of being cared for in an institutional setting or in high quality foster homes.

Most discussion of this issue is based on the findings of the Bucharest Early Intervention Project (BEIP), a randomized controlled trial of the two care settings carried out almost ten years ago by Charles Zeanah and colleagues. Further publications and recommendations based on the BEIP finding that foster care had beneficial effects are appearing every day, and proposed legislation in the U.S., the Children in Families First Act (CHIFF) is based primarily on the BEIP reports.

A few months ago, the publication Zero to Three published an article, “A Matter of Timing” (Fox, N.A., Zeanah, C.H., & Nelson, C.A., Vol. 34 (3), pp. 4-9). The article repeated many of the conclusions of earlier reports of the BEIP, as well as focusing on alterations in brain development possibly associated with institutional care in the early years.

I responded to the article with a letter which was kindly published by the ZTT editor, Stefanie Powers, along with a response from Fox, Zeanah, and Nelson. In my letter, I expressed concern with possible biases from lack of blinding of evaluators--  an almost insurmountable problem of this type of research, but one that requires cautious interpretation of findings. I also queried the comparison between the “poor and sick” institution and the “rich and healthy” foster homes, and particularly the apparent blanket conclusion that all foster homes were superior to all institutions, a conclusion that appears to evade the fact that this randomized controlled trial did not in fact isolate or hold constant some relevant variables. In closing, I expressed concern about the emphasis on the BEIP in the proposed CHIFF legislation, and the fact that the practical outcomes of inappropriate interpretation of these research outcomes could be very serious indeed.

Fox, Nelson, and Zeanah  kindly replied to my comments in the  March 2014 issue of Zero to Three (pp. 4-5).They summarized some of the statements of the earlier article, and very reasonably emphasized the findings of the brain measurements as unbiased by expectations of researchers. They went on to note that every nonrandomized earlier study of institutional versus home care had the same findings—that home care was superior—which is hardly surprising because in those nonrandomized  studies selection biases would certainly have been at work. (And surely the BEIP, with all its difficulties and expense, would never have taken place if the nonrandomized studies had had different outcomes.)

In responding to my comment that comparisons of high-quality institutions to foster homes had not been done, Fox, Nelson, and Zeanah referred particularly to a 1975 publication by Tizard and Rees, comparing children in  high-quality institutions to a contrast group of which the children had been full-term, healthy babies, both parents were white, the father was employed and working-class, the mother was not employed outside the home, and there was no slightly older child in the home. The institutions studied by Tizard and Rees were certainly of very high quality compared to the Romanian orphanage of the BEIP, but there were some serious problems by today’s highest standards of care for infants and toddlers. Tizard and Rees noted that “Although staffing was generous, many different nurses handled the children. The average number of staff who had worked for at least a week with each child in the past 2 yr was 25.8, range 4-45. The major turnover was in untrained assistants and student nurses, but in all except two institutions the trained nurse in charge of the child’s group had changes at least once in the past 2 yr.” (p. 64). In addition, a number of the children had parents who visited from time to time. These institutions, although of high quality in various ways, did not meet the criterion of having assigned caregivers that I stated in my letter, nor the criterion of having low staff turnover that is usually considered developmentally important. The Tizard and Rees study thus did not do much to supply data comparing an excellent institution to foster care, as the institutions did not meet important criteria, and the contrast group were not in foster homes.

In their response to my letter, Fox, Nelson, and Zeanah concluded, “Our research provides the most definitive evidence to date that foster care is a more effective alternative than institutional care for abandoned infants and young children”. And, yes, I must agree with this, that it is “the most definitive evidence”. However, this does not mean that it is actually definitive, and it is regrettable that the CHIFF legislation confuses “most definitive… to date” with “definitive”.

Relevantly, the March-April 2014 issue of Infant Mental Health Journal contains several articles that contribute to this discussion. One of these “Psychopathology in young children in two types of foster care following institutional rearing” (Tibu, F., Humphreys, K.L., Fox, N.A., Nelson, C.A., & Zeanah, C., IMHJ, 35, 123-131), compared children from the BEIP who had been assigned to high-quality foster homes to a group that remained in institutional care for a time, then were placed in government-sponsored foster care (some of this group had already been adopted or returned to biological parents; the comparison group here were those who had not had those placements). The groups had thus spent different amounts of time in foster care. Information about the two groups also differed in  sources of bias, as there could have been biological or behavioral reasons why some were adopted or returned, and others not. Children in the high-quality foster homes had significantly fewer reports of ADHD. Girls in the high-quality group had significantly fewer internalizing problems--  an unusual finding, as girls are usually seen to be less sensitive to environmental factors than boys are. The authors pointed out the need for high-quality foster care to support good development.  (This comparison may have been one of “rich and healthy” care to “poor and healthy” care, rather than to the “poor and sick” care of the  low-quality institution.)

A second useful article from this issue of IMHJ  is by Victor Groza and Kelly Bunkers (“Adoption policy and evidence-based adoption practice: A comparison of Romania, Ukraine, India, Guatemala, and Ethiopia”, INHJ, 35, 160-171). This is a complex article reviewing a number of issues about adoption practices and needed policy, and I am going to choose a few comments from it that may be of particular interest to readers. (I don’t think I am “cherry-picking”, but no doubt someone will call me on it if I am.) Groza and Bunkers note that there is already a comprehensive legal framework on these issues, derived from the United Nations Convention on the Rights of the Child and emphasizing that decisions about adoption or other placements are always to be made with the goal of achieving the best interests of the child rather than furthering adult concerns of other kinds. They point out the need for careful record-keeping about domestic adoptions (a point well applied to intercountry adoption as well), and the difficulty of having a good evidence base without this—relevantly, they refer to traditions of secrecy about adoption that can interfere with the collection of information.

Groza and Bunkers looked at efforts to encourage domestic adoption in countries that were once much involved in intercountry adoption. These have generally been successful, but in the case of Ukraine a public relations campaign that emphasized how difficult it was for children to grow up in institutions may have stigmatized the children and alienated institution staff. Groza and Bunkers noted that it was not clear how these efforts had progressed after a change in government in 2010, and of course the current unrest in Ukraine in March 2014 makes it hard to predict what will happen next--  reminding us that there are many factors in any nation’s life that influence the number of abandoned children and the ways available to care for them.

An interesting point made by Groza and Bunkers compared situations in countries with many resources to those in the low-resource countries examined in this article. They commented, “Regardless of the [low-resource] country reviewed in this article, the main reason children entered the child protective system was abandonment.  The second reason was that a parent, usually the birth mother, relinquished the child, most often immediately or soon after birth. In contrast, most children in high-resource countries enter the child protection system because of a combination of neglect and abuse within their biological family. Often, parental rights are terminated involuntarily through the judicial system” (p. 167).  

Obviously, systematic investigation is revealing more and more about characteristics of abandoned children and their developmental outcomes in different settings. What is “most definitive… to date” may not be so at a later date. In any case, extreme care must be taken about generalization from events in low-resource countries to those in high-resource countries, and vice-versa. Research on the needs of parentless children is not yet ready to be depended on by legislation. If such legislation is baldly stated to be based on values or a priori assumptions, well and good; if it is claimed to be  based on the “scientifically proven”, that is a mistake. 

Tuesday, March 18, 2014

Psychozoology in the Courtroom: Dodo Birds, Woozles, Heffalumps, and Parenting

Extinct or imaginary creatures seem to make good shorthand for referring to issues in the field of psychology. Psychologists who talk about Dodo Birds are usually concerned with the claim that all forms of psychotherapy are equally effective--  as in the statement by the Dodo Bird in Alice that “all have won, and all shall have prizes”.

I have recently become acquainted with a new and important analogy-animal, thanks to Dr. Linda Nielsen of Wake Forest University, who kindly sent me her article, “Woozles: Their role in custody law reform, parenting plans, and family court.” (Psychology, Public Policy, and Law, 2014). Readers who have, or have been, children, may recognize the word “woozle” from A.A. Milne’s Winnie-the-Pooh stories (sorry, Disney, you may have gotten your hands on them, but you didn’t write ‘em!). The woozles who concerned Pooh and Piglet were fearsome imaginary animals, the evidence of whose existence was the many tracks Pooh and Piglet had left in the snow as they walked around and around looking for woozles. As Nielsen uses the term with respect to psychology, “a woozle is a belief or claim that is not supported – or is only partially or tentatively supported—by the empirical evidence. But because the claim has been repeatedly cited and presented in misleading ways, the public and policymakers come to believe it.” Nielsen applies the woozle concept to beliefs and assumptions about the potential harm of overnight visits for infants and toddlers to an estranged parent. To quote another bit of Lewis Carroll, she is concerned that “what I tell you three times” is taken to be true.

Nielsen kindly sent me a synopsis of the paper, which I give immediately below. She also says that people who would like a copy of the complete paper may contact her at

“What’s a woozle? And what role does it play in child custody decisions and custody law reform?
If you remember Winnie the Pooh, he and his friends become obsessed with the idea that they
are being stalked by a frightening beast they called a woozle. In fact, they are being deceived by
their own footprints as they walk around in circles. In social science a woozle is a belief or a
claim based on inaccurate, partial, or flawed data – data that have been repeatedly
misrepresented, misinterpreted or “woozled” in ways that end up influencing public opinion,
individuals’ decision making, and public policy.
This paper illustrates the woozling process that has contributed to the creation of a powerful
and damaging child custody woozle: After parents’ separate, infants and toddlers who spend
even one night a week in their father’s care are more irritable, distressed, inattentive, vigilant and
anxious with their mothers, and physically stressed. In short, up until the age of four children
should live exclusively, or nearly exclusively, with their mothers. The one study that has
frequently been proffered as evidence that overnighting has a “deleterious impact” on infants and
toddlers is an Australian study commissioned by the attorney general’s office (McIntosh, Smyth,
Kelelar & Wells, 2010, Post separation parenting plans: Outcomes for infants and children).
By examining the discrepancies between the actual data and the woozles that have arisen
from the study, this paper deconstructs the mythical woozles. For example, the “wheezing
woozle” claims that infant wheezing is a valid and reliable measure of stress – stress that is
caused by spending more than 3 nights a month in the father’s care. In reality, wheezing is
caused by many factors having nothing to do with stress – including mold, pets, cigarette smoke,
and carpet in the house. Moreover, the toddlers who frequently overnighted wheezed less than
those who rarely overnighted. Likewise, the “whining woozle” claims that overnighting causes
infants to be more irritable and to exhibit “severely distressed” behavior towards their mothers.
The woozle conveniently ignores the fact that the frequently overnighting infants had exactly the
same mean score on the irritability scale as the infants in intact families – and that infants who
frequently overnighted were no more irritable than infants who never overnighted. As for the
“severely distressed behavior” woozle, the overnighters’ scores on the behavioral problems test
were well within normal range – and 50% of the mothers in the nationwide survey reported these
same types of problems with their two to three year-olds: sometimes refusing to eat or gagging
on food, clinging to her when she tries to leave, getting angry with her, or hitting and biting her.
More disturbing still, the “anxiety/insecurity woozle” was based on three questions taken from
the Communication and Symbolic Behavior Scale which is designed to assess infants’ readiness
to begin talking. This novel “scale” was created solely for this study and had no established
validity or reliability as a measure of anxiety, stress, attachment or insecurity. Because the
overnighting infants tried to get their mother’s attention and gazed at her more often – which on
the Communication and Symbolic Behavior Scales is a positive sign of readiness to learn
language – these researchers concluded that the infants were more “watchful and wary” about
their mom’s whereabouts, indicating more anxiety and insecurity in their relationship with her.
How are woozles born and raised? And how can they be used to dupe judges, parents, and
policy makers into opposing shared overnight parenting plans for children under the age of four?
Woozling is a process where many factors work in conjunction to distort the data. Among these
woozling techniques are exaggerating, misrepresenting, and frequently reporting only the data
that support the woozles, while ignoring and failing to report the data that undermine them.
Another is downplaying or completely overlooking the limitations of the study – especially those
that make it in appropriate to generalize the findings to the general population. Discussions and
presentations about the Australian study seldom, if ever, mention its many limitations –
especially in reports to the media and presentations or articles that reach large audiences of
professionals involved in custody decisions. Among the limitations were that: 90% of the
infants’ parents had never been married to each other and many had never lived together; no
more than 20 infants were in the rarely overnighting group, and no reliability or validity was
reported for four of the six instruments. Then too, this study was predicated on a theory that is no
longer widely held by attachment theorists: the belief (woozle) that infants form a “primary”
attachment to only one parent – the one who provides most of their daily care - and that spending
time overnight away from this primary parent jeopardizes the security of their attachment. In
fact, however, empirical studies have shown that infants form attachments to both parents at
about the same time, and that one attachment is not more important than the other. When we peel
back the layers of the woozles based on this Australian study, the highly publicized and alarming
warnings against overnighting are unwarranted and grossly exaggerated. In short, the study is ill
suited for making any recommendations for or against overnighting for children under the age of
Unfortunately the woozles arising from this particular study have been repeated frequently in
the media, in academic journals, and at conferences – woozling judges, lawyers, legislators,
custody mediators and other professionals involved in custody decisions. And as is the case with
woozles, those studies that have found no ill effects and some positive effects for infants and
toddlers who overnight in their father’s care have been overlooked. How do we corral these
damaging woozles once they are on the loose? First, share the woozles article with people who
are involved in making custody decisions – especially with parents who are in the process of
designing parenting plans for their very young children. Second, make the media aware of how
this particular study has been woozled in ways that are depriving many infants and toddlers of
loving, attentive care from both parents. “  

Nielsen has a specific serious purpose in circulating this discussion of woozling as it may be influencing judicial decisions about child custody and shared parenting.  There is an additional, overarching serious purpose to alerting the public and policymakers to the woozling use of psychological ideas in all kinds of decision-making. But this article has made me think: have we identified all the analogy-animals that can interfere with appropriate use of psychological concepts ?

Woozles do not seem to be the exact animals at work in problem areas like the overuse of attachment concepts (and, recently, of the idea of trauma). Woozling convinces people that events exist, when the evidence does not support this idea. But there really is attachment, with thousands of well-done studies about its phenomena, and there really is trauma too. What animal analogy is at work when the focus is too strongly on attachment or on trauma, when other factors are ignored, and when the power of an event is much exaggerated? Going back to Pooh, I offer the term “heffalump” to describe this. The heffalump seen with such trepidation by Piglet was simply his friend Pooh with his head stuck in a honey pot--  a real creature, but not the fearful heffible horralump Piglet fled. Similarly, attachment (for example) is simply one of a number of factors that determine human developmental outcomes, and giving it the heffalump treatment leads people to ignore other important considerations. Curiously, this analogy even holds at the level of “heffalump traps”,  as we see measures of attachment used in an effort to grab the exaggerated factor and use it in custody decisions as it was never meant to be used (see, for example, an article by Isaacs et al., Journal of Child Custody, 2009).

The heffalumps may not seem to be on the same topic as Nielsen’s woozles/overnights paper, but I would speculate that these two imaginary animals may be  cooperating when there are conflicts about shared parenting. Why are some parents and some authors so adamant that overnights must be prohibited until a late age? Why are others seeking overnights so enthusiastically? No doubt some of this conflict is simply left over from a dysfunctional marriage, but…  what do these people believe about attachment? Is one parent convinced that the child will lose attachment to him/her if not put to bed by him/her? Does he or she believe that attachment is time-limited, and that less than ideal attachment conditions in early life would mean that the whole relationship would be ruined and never recover? What beliefs do judges and attorneys bring to these disagreements? My bet is that the heffalumps have been romping with the woozles to create an unnecessarily increased tension about attachment, between parents who are already in many cases beyond rational decision-making.

And, let’s not forget that increased tension can lead to some wealth and fame for some of those who manipulate it. Both the woozles and the heffalumps can be lucrative for those who herd them, while they trample the financial and emotional resources of families.

Tuesday, March 11, 2014

More on Overnights, Infants, and Toddlers

A few days ago, at, I commented on a recent article that had been sent to me by Dr. Richard Warshak. (The complete citation for the article is given in that post.) In that paper, Dr. Warshak had examined research that is relevant to the issue of having infants and toddlers pay overnight visits to the estranged parent with whom they do not live most of the time. “Overnights” are a hot-button issue for many divorcing parents with very young children, and for a variety of reasons such visits have become a contentious part of the development of post-divorce parenting plans. Although some psychologists have argued that it is unwise to permit overnight visits for infants, toddlers, and even preschoolers, Dr.Warshak states that the available research evidence does not support that position--  and he is supported in his claim by a great many “famous names” in developmental psychology.

Dr.Warshak would like to establish a general guideline for courts, stating that there is no evidence that young children in most divorcing families will suffer from overnight visits to a parent who does not live with them. In this preference, he opposes the several-decades-old principle of the “best interests of the child” as recommended by the authors Joseph Goldstein , Anna Freud, and Albert Solnit; one aspect of this principle includes the idea that a custodial parent should in fact have all the decision-making power about shared parenting and all other aspects of child care.

For myself, I am uneasy about the formation of a general rule in an area where there are so many individual and family differences. But I concede two points. One is that whether or not a general rule is formulated in an “official” way, courts will employ their own general rules, and past experience with “best interests of the child” suggests that these court-determined general rules may wander far from the information on which they purport to be based. The second point is that if there is going to be a general rule, it had better be based on research evidence rather than on values or traditions or other a priori assumptions.

Without yet being in a position to say what general rule about overnights I would like to see in place, I can point to some considerations that I think should be included in any thinking about this subject:

  1. Burden of proof.  In discourse that tries to apply rules of logic to an argument, it is considered that one who states that something exists must demonstrate that evidence supports that claim; he or she cannot challenge an opponent to show that it does not exist, and in fact it would be impossible to show this about anything. The burden of proof concept means, in the case of overnights, that those who argue that such visits are potentially harmful to young children have the burden of demonstrating that  harm has resulted in the past. So far, there has been no clear demonstration of harm.
  2. Generalizability. The search for research evidence for or against overnight visits is bound to be a frustrating one, because this kind of research is so difficult and the existing work is so weak in comparison to studies that can control variables. No one can be made to divorce for research purposes, so all studies of post-divorce events are full of the confounded variables related to personality, situational, economic, and other factors that played some part in causing the divorce which the couple “chose” for themselves. These factors also influence children’s developmental outcomes and their effects may be impossible to differentiate from the effects of divorce itself, of overnight visits, or of any other factor. In order to generalize from the results of research to the “real life” of individual families, we need to know that the families closely resemble the group from whom the  research evidence was collected--  but because there are so many variables involved, this may be quite difficult to determine.
      It’s especially important not to assume that research on middle-class, well-educated           divorcing couples can necessarily be generalized to high-risk families, ill-educated and      living in poverty--  or vice-versa. This reality can lead to problems because it is often    much easier to get middle-class people to participate in research than is the case for poor    people, who may feel threatened by the apparent nosiness or imagined disapproval of the             researcher. When a study looks at a group of parents of whom a high percentage are          under restraining orders (cf. Solomon & George, 1999), or who have some other unusual       characteristics, it is questionable whether the results of the study should be generalized to the rest of the population.
      In considering generalizability, it’s also critical to see what comparisons were made in       the research being considered. Do these comparisons reflect the differences we might be   interested in understanding? For example, Dr. Warshak’s paper examines with care the     famous study by Solomon and George which has been used to suggest that overnight  visits were problematic for toddlers. Solomon and George compared young children who were having overnight visits with a combined group who were either in an intact family    or were with a mother alone, but not having overnight visits. But surely the important      question for generalizing to the guidance of parenting plans is the difference between children of separated parents who were having overnight visits, and those who were not.

  1. Issues about attachment. One of the serious problems related to creating general guidelines about overnights for young children is the extreme popular focus on attachment and the assumption that attachment quality determines everything from childhood obedience to school performance to later success in marriage. Other motivations and developmental factors of childhood, such as exploration, are generally ignored outside developmental psychology. There are also some common misunderstandings about attachment that have become woven into thinking about parenting plans.
  1. Monotropy. The original theory of attachment formulated by John Bowlby made the assumption, based on studies of animal behavior, that infants’ and toddlers’ emotional attachment was to a single caregiver at a time (monotropy). As it became clear that this was not the case, there was a tendency to make only a slight change in the monotropy assumption by designating primary and secondary attachment figures.
      However, it seems clear now that several attachment figures can (and usually do) exist for young children, and attachment to one does not alter attachment to others, although a child may show preferences for one over another in certain circumstances. The obvious example is the maintenance of attachment to a parent in spite of many hours a week spent with a day care provider who is also an attachment figure. A reasonable conclusion is that overnight visits to a parent, if they facilitate attachment to that person, do not also destroy attachment to the live-in parent.

  1. Time limits. The original view of attachment was that there was a sensitive period during which attachment relationships had to develop, or else they would not be possible. As Everett Waters pointed out in his interview with Jennifer McIntosh in the 2011 Family Court Review issue, this does not appear to be the case. Attachment is a developing, changing aspect of motivation and personality, and does not have the time limits once assumed to hold. Understanding of this point can suggest, as Waters did, that early overnight visits are not required for eventual attachment to a nonresident parent, but on the other hand it does not particularly suggest that such visits will be beneficial.
  2. Security and order. Some discussions of parenting plans focus on security of attachment. However, insecure attachments are by no means outside the normal range or associated with psychopathology. Presumably it is not the purpose of a parenting plan to create the ideal of psychological development, but instead its purpose is to balance the needs of family members in a way that provides for “good enough” development of a child. “Insecurity” sounds unpleasant, and in popular thought is associated with neurotic behavior, but in fact insecure attachment is an orderly and adequate strategy for dealing with attachment and exploratory needs.
Much more serious outcomes are associated with disorganized/disordered attachment, a way of responding to caregivers in which young children may “freeze” on seeing the adult, or may use unusual approaches like backing up to the person or approaching while averting the eyes. Solomon and George’s 1999 paper reported that such behavior was more common among the children having overnight visits, and of course this is concerning. However, work like that of Mary Dozier has shown that this behavior is associated with the caregiver’s behaving in a frightened or frightening manner toward the child, and interventions like Dozier’s Attachment and Biobehavioral Catch-up can change the adult behavior and make the child’s attachment strategies more ordered and less disorganized. Unless it can be shown that indeed overnight visits cause adults to behave in frightened or frightening ways (which is not impossible), it is hard to see how shared parenting is directly causal for the child’s disorganized attachment quality.

  1. Results now, or later? As has been noted (e.g. by van IJzendoorn et al, 2005), immediate changes in disorganized attachment behavior can be considered a good measure of the effect of events on a young child. However, it is equally or more important to look at long-term outcomes before concluding that an overnight visit is harmful, or an intervention is helpful. Only a well-designed longitudinal study can show the real impact of overnight visits on development. Infants and toddlers, from about 8 to about 24 months, are well-known for their negative response to changes of any kind. Developing autonomy (“No!”) and neophobia are enough to cause young children to resist change and to display stress reactions when more than a minimum number of changes occurs; even ordinary transitions like getting dressed to go outdoors can be fraught with emotion. It would be surprising if children in this age group did not respond negatively to visit experiences, especially if they pick up cues from the adults that anyone is worried or frightened about what is happening. The question is, how do these experiences alter the trajectory of development and lead to more, or to less, desirable outcomes--  if indeed they do?    
  1. Gender differences. As this post is getting very long, I am going to be brief on a point that may be of interest. As it happens, girls are more likely than boys to be assessed as securely attached during the toddler period, and girls may be less vulnerable to developmental disruption due to environmental stress.
Men and women may also bring different relevant characteristics to shared parenting. Women with perinatal mood disorders are more likely to have children whose development is problematic, and it is conceivable that mood disorders can disturb a marital relationship to the point of divorce.

Men, on the other hand, may be more likely to bring antisocial behavior into the picture. In  a study that is only indirectly related to the issue of overnight visits (Jaffee, S.R.Moffitt, T.E.,  Caspi, A., & Taylor, A. [2003]. Life with [or without] father: The benefits of living with two biological parents depend on the father’s antisocial behavior. Child Development, 74, 109-126), the authors showed that the children they studied experienced what they called a “double whammy” of behavioral problems when they received both the father’s genetic material and experienced living with him; children with the genetic tendency to antisocial behavior did better when they did not live with antisocial fathers. Antisocial behavior on the father’s part may also disturb the marriage and lead to divorce; the issue may then be to what extent any contact with an antisocial father is beneficial.

All I have done here is to bring up various factors and research issues that I speculate may be related to the effects of overnight visits for infants and toddlers (although they are probably much less relevant for preschool children). These points make me hesitate to think in terms of any general guidelines about overnights--  although I am well aware that some guidelines will be applied in most cases, however questionable they may be. I would like to suggest that rather than offering guidelines for parenting plans, it would be more constructive to develop a protocol for assessing how well a given plan is going for a child, and for fine-tuning plans that are proving problematic--  for example, a plan for visits that is frequently disrupted by scheduling changes or by the influences of non-parent adults.