Concerned About Unconventional Mental Health Interventions?

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

Friday, November 20, 2015

Does Trauma Stop Development?

When you explore some of the beliefs of unconventional, “alternative” therapists like Nancy Thomas, one idea that often emerges is that development stops when a child experiences psychological trauma.  This idea serves as justification for treatment methods involving ritualistic re-enactment of normal early-childhood experiences, based on the assumption that recapitulation of early experiences will cause development to “start over” and follow a desirable pathway. That assumption would be remotely plausible only if it were true that trauma stopped development--  and even if it were plausible, such treatments would have to be supported by systematic evidence in order to be truly acceptable.

But let’s look at the idea that development stops after trauma. Presumably this view of development—which is actually speaking of cognitive and emotional development, especially the latter—is based on analogies to specific aspects of development and specific types of trauma. It’s clear that serious traumatic brain injury can stop some aspects of development and slow others. For example, a child who receives radiation therapy for brain cancer can end up with such serious brain damage that she is never conscious again, although her life may continue for some time. She grows, but slowly, and unless she receives careful physical treatment her limbs become distorted into a “fetal” position. Much of her development has slowed, and some has stopped, but as long as she is alive she will continue to change in some ways over time—and that is what development is: changes with age.

Now let’s consider less drastic physical trauma. Suppose, for example, a child is nutritionally deprived in early life. The result will be slowed growth, but also some much more subtle problems. The bones will ossify (become hardened by absorbing calcium into their structure), but they will not do so in the order typical of well-nourished children. Development does not stop, but continues in a way that is distorted or “detoured”  rather than following a typical developmental pattern.

The effects of trauma and deprivation also depend on “critical periods” of development. A young baby who loses half of the brain through injury will develop largely normal cognitive and emotional abilities; an older child will be permanently handicapped by such a loss, sustained when  neuroplasticity is less. A malnourished infant or toddler may have slowed brain growth and development; he will “catch up” developmentally if nutrition is corrected by about age 4, but not after that, no matter how excellent the later diet may be. It’s a mistake to assume that an event that may be traumatic at one age--  abrupt separation from familiar people at age three, for instance--  is also traumatic at other ages; separation at birth does not in itself  cause emotional trauma (although learning about that separation years later may be distressing).

The effects of any kind of trauma or deprivation are also determined in part by a range of factors other than the one that seems most important. Babies exposed to lead in the environment develop better when their diets and general health are good, while lead exposure has a more serious impact on those who are poorly nourished. Similarly, infants and young children who are exposed to terrifying or painful events do better when competent parents and good family relationships serve to buffer the effects of the trauma. Events that influence development all work together, so an apparent trauma cannot be considered as having a predictable outcome all by itself.  

Research by famous names like Michael Rutter suggests that children who have suffered from trauma and deprivation in poor care settings will in most cases develop normal cognitive and emotional abilities. Better recovery is likely to occur for those who move to family care or to enriched institutional care when they are still infants or toddlers. This situation seems analogous to what we see in children who are brain-injured or nutritionally deprived—“catch up” growth is possible up to a limited age. Because emotional and cognitive life depend on brain functions, it is plausible that emotional and cognitive development follow the same rules as brain development and allow for recovery from trauma or deprivation by intervention fairly early in life.

Finally, it’s important to realize that there are individual differences in children’s vulnerability, or its mirror image, resilience. For reasons of genetic or other factors in early development, some children “rise above” traumatic experiences relatively easily, while others have lasting and potentially serious effects.

Whatever roles all these factors may play in a child’s response to trauma, the result of traumatic experiences is a matter of distortion of development or changes in developmental trajectory, not of “stopped development”. Brain-injured children, for example, continue to grow and develop along the lines permitted by their injury; they do not simply stop and remain exactly as they were, without learning or emotional maturation proceeding at all. Treatment of trauma works by fostering positive change in areas where the child is not doing well, and exactly how that can be done depends on the child’s age and environment. Part of this process is recognition of the behavior problems that have emerged from trauma (like anxiety and anger about certain situations) as well as of those that occur for different reasons. 

It’s clear that one size of trauma does not fit all, and neither does one size of treatment help guide distorted development back onto a desirable trajectory.

Wednesday, November 11, 2015

"Faux-RAD" and the ABC 20/20 Video: Some Progress

There has been some interesting progress with respect to the letter to 20/20 I included in a post two days ago. I received a phone call from Miguel Sancho, a 20/20 producer, and another from his assistant Lynn Redmond. They plan to modify the video that caused so much concern, and to do this with the help of Dr. Anne Marie Albano of Columbia University, a clinical psychologist and one of the signers of the letter.

In talking to Sancho and Redmond, I realized how easy it is for people to assume that if an approach to childhood mental illness or problem behavior does not use holding therapy, it must be all right. Naturally I am pleased when the dangerous and physically-intrusive techniques of holding therapy are abandoned, but I continue to be concerned about the use of related methods without evidentiary foundations. There are a number of these methods that were historically associated with holding therapy and have persisted on their own as holding therapy has diminished. These methods include demands for “strong sitting”, assertion of adult authority by requiring children to ask an adult for permission to do anything they need (including toilet use), making sure that a child is within the line of sight of an adult at all times, and the assumption that physical contact between child and adult has a therapeutic value of its own.  These methods are not likely to do direct harm to the child, but they add to what Michael Linden has called the emotional burden of therapy, and because they are ineffective may cause indirect harm by keeping the child out of effective treatment.

I have been trying for years to find a term that will describe not only these methods, but the related diagnostic efforts, and the unconventional theory that supports the whole can of worms. I recently encountered the expression “faux-RAD”, which I think conveys the disparity between these beliefs and practices and those of the conventional, evidence-based practice of psychotherapy. Michael Shermer years ago referred to the suffocation of Candace Newmaker  by her therapists as “death by theory”, and I consider that insight to be essential to the understanding of faux-RAD. It is faux-RAD theory that allows the replacement of one harmful or ineffective treatment with another that is based on the same assumptions.

To deal with the faux-RAD problem, as exemplified by the 20/20 video, we need to understand the tenets of the theory. I am going to state them here in simple form:

  1. Emotional attachment normally begins before birth and is present in basic form in newborn babies.
  2. Children separated from their biological mothers are filled with rage and grief even if the separation is immediately after birth.
  3. Rage and grief prevent development of attachment to new caregivers, as do later experiences of abuse and neglect.
  4. Normally, in non-separated children, attachment advances in two stages during the first and second years.
  5. In the first year, attachment to caregivers progresses because the child comes to recognize that the caregiver is the source of all satisfactions of needs. The repeated experience of need followed by satisfaction given by a parent (called an “attachment cycle”) establishes the authority of the caregiver.
  6.  In the second year, the caregiver sets limits on the child’s behavior, further establishing authority and therefore attachment.
  7. Children are obedient, compliant, and grateful when parental authority has been established in these two ways, and they are said to be attached.
  8. Children who are disobedient, noncompliant, and ungrateful are not attached but have attachment disorders, and they do not recognize parental authority. This situation may occur because of persisting rage and grief, and/or because of the absence of the attachment cycle.
  9. To make children obedient, compliant, and grateful, they must express their rage and grief and achieve catharsis; then, they must experience re-enactments of the attachment cycle which involve complete dependence on adults for food, drink, etc. This treatment causes obedience by establishing attachment.
  10. Because infants need touch experiences, children in treatment also must experience re-enactment of frequent adult touch; this must be given at the decision of the adult and not at the request of the child, and indeed may be against the child’s wishes.
  11. Children who are not attached (have attachment disorder) by faux-RAD criteria are filled with hatred and the desire for violence; if treated by conventional psychotherapies, they will get worse; if untreated, they will grow up to be serial killers or prostitutes.

The tenets of faux-RAD described here are at odds with everything known about attachment, about parent-child relationships, about sources of violent behavior, and about effective psychotherapy, as well as with established definitions of Reactive Attachment Disorder. The confusion of attachment and authority is especially noxious, as it opens the door for practices that are distressing and potentially harmful to children.

Regrettably, a look at doctoral and master’s theses written in U.S. social work schools in recent years reveals that faux-RAD ideas are sometimes taught and accepted. This  fact, together with the state-sponsored faux-RAD trainings of adoption workers in Georgia and Utah some years ago, means that the undercurrent of these potentially harmful beliefs is still very real and may have been exacerbated by the 20/20 video. However, I look forward to correction by ABC and to increased awareness of the issues on the part of psychologists, social workers, parents, and teachers.

Monday, November 9, 2015

Letter to ABC About Their Inaccurate Portrayal of Reactive Attachment Disorder

Some readers may have watched an ABC 20/20 program in late October that dealt with a very disturbing adoption story from Arkansas. While the program itself was passable, a video trailer posted as a "teaser" for the program was not. A number of psychologists and social workers have written to David Sloan at ABC and to the ABC ombudsman, outlining our concerns and asking that ABC make some positive move to undo the harm done by the trailer's misinformation.

Here is the text of that letter:

David Sloan, Senior Executive Editor, ABC                                              Nov. 5, 2015

Dear Mr. Sloan:
As psychology and social work professionals concerned about public understanding of childhood mental health, we are deeply disturbed by the video clip The material in this clip conveys to the public a view of Reactive Attachment Disorder (RAD)  that belongs to “fringe” therapists and is not shared by professionals with serious training in psychology. In addition, this view has been used to support the use of potentially harmful interventions with children and to argue that abused children have somehow forced their caregivers to harm them.

The opening scenes of the clip appear to show a method called “holding therapy” or “attachment therapy”, which was strongly rejected in 2006 by a joint task force of the American Psychological Association (APA) and the American Professional Society on Abuse of Children (APSAC). This method has been associated with child deaths and injuries.

A later part of the clip features women stating that their children a) had RAD, and b) were dangerous to other people and to animals, as has been suggested by “fringe” therapists. The implication was that the disorder itself is characterized by aggressive and oppositional behavior. This is not the case, as can be seen by consulting the Diagnostic and statistical manual of mental disorders of the American Psychiatric Association, 5th edition (DSM-5). Sadness and social disengagement are in fact the leading features of RAD. In addition, it has been recommended that RAD be diagnosed in young children and not in the teenagers some of the women mentioned.

Our concerns are not simply that there was some inaccuracy in the clip, or that the discussion of RAD was insufficiently nuanced. The problem is that the content of this video supports a common misunderstanding that, among other things, can cause people to fear and reject children who have histories of abuse or abandonment, or can lead the children’s caregivers to seek “fringe” treatments that may cause real harm. In addition, this content can be used to support the “RAD defense” in abuse cases--  the argument that children who have been mistreated are so dangerous because of RAD that their caregivers were forced to hurt them.

Now that the inaccurate clip is on the Internet, it will be available for a long time. Taking it down from the ABC website will not get rid of it. For that reason, we would like to ask you to create an additional, accurate video about RAD, with our help, and to post it with a message that it is to correct the previous clip in a responsible fashion.

We hope that you will understand the reality of our concerns and respond positively to our request.

[signed by 19 professionals in psychology and social work]

Readers who are concerned about the 20/20 presentation may also want to express concerns to ABC.

Thursday, October 22, 2015

A Personal Account of Attachment Therapy/Holding Therapy

The following is an account of one adopted girl's experience of attachment therapy in 1995-1997. The author, "Ann Onymous", would like readers to understand what this was like from the child's point of view. As she suggests, treatments of this type are still happening in the U.S. and other countries today.

If readers recognize what "Ann" is describing and know that they had similar experiences, I would appreciate it if they would comment or get in touch. One of the difficulties of the fight against these fringe treatments has been that victims have grown up isolated from social networks and sometimes with little education, and as a result only a few have come forward.

My thanks go to "Ann" for preparing this account:

  " My first experience with Attachment Therapy happened when I was 12 years old. These two women came to my house and my Mother called me downstairs to meet them. I walked in the living room and one of the women immediately ordered me to do jumping jacks “fast and snappy and right the first time”. I laughed and then did a few jumping jacks. She then told me that I had done the jumping jacks wrong and that I needed to clap when my hands were above my head. Because I did them wrong the first time, I was assigned 150 jumping jacks. After doing the jumping jacks, I was assigned 80 pushups, and I was made to complete them before I was allowed to go back upstairs. On my way upstairs, I overheard one of the women tell my Mother that I definitely had Attachment Disorder as evidenced by my failure to look into her eyes. My parents thought there was something wrong with me because I lied and snuck out of the house and hid food and nothing they did made much change in my behavior. After seeking support from many counselors my mother did not agree with, they sought out Attachment Therapists.

            It was after this first meeting that everything changed in my home. The same night, my parents came in my room and installed an alarm on my door. If I tried to open the door, the alarm would go off. The alarm was about the volume of a house alarm, and I think they are normally used to keep dementia patients from escaping. Also, after this meeting, my mother started keeping me out of school for long intervals and locked in my room. I was only allowed to come out to go to the bathroom or when my mother said I could. Sometimes I was allowed to eat with the family and sometimes I ate in my room. This went on for several months.

            Several months after the change, my Father came into my room one morning with a duffle bag and told me to pack it. He told me that I was going to go and stay with someone else for a while. I was not told anything other than that limited information. We got in the car and drove for two hours. During that trip I was excited. I thought living with someone else would be better and that maybe this person wanted me. I was so wrong. I was made to get out of the car, wait on the curb, and not do anything until the lady came out to get me. When she came out, I was shocked. She was an older mean looking lady and she had two other kids with her. Though her name was Mary Harless,she told me to call her “Mom Mary”. We then drove another hour to her home. During the drive she introduced the other two kids. I will call them S and D. I was very interested in S and D and so I began to talk with them. Mary then told me that she expected complete silence in the car. On the way home, Mary stopped at the grocery store and told us to remain seated and silent when she went in the store. While she was gone, S and D and I talked. When Mary returned, she said that we were all in trouble because we had not remained silent. I later found a recording device in her car while I was cleaning it.

            Life with Mary was one of unending horrible. Each day, we were woken up very early and made to go outside and run laps. She would assign laps each morning based on our “behavior” the day before. I never actually knew whether I would have many laps or only a few. Sometimes it took over an hour to run all the laps. We then had to wait in silence outside the front door for her to let us back in the house. We were not to open the door or enter the house ourselves. Mary would then let us in and assign morning work that had to be completed before we were allowed to eat breakfast. The chores included weeding the garden, washing the van, sanding a piano (more on that later). Sometimes those chores could take two to three hours and if they were not done right (which could be something as minor as leaving one weed in the flower bed) we had to either get the thing dirty and clean it again or just do another chore of equal time consumption.

            Once chores were completed, we were given a bowl of plain oatmeal (no milk, no butter, no sugar). After breakfast, we were assigned morning chores. Morning chores were similar to the before breakfast chores except that they were harder or took longer to complete. These chores had to be complete before our lunch of a piece of bread with peanut butter on it and maybe a carrot.

            My chore that I had for several weeks was to sand a piano. This was an upright piano that had been painted green. Mary found this piano and brought it home just for me to sand as my chore. I had to sand the entire piano with small pieces of sand paper. In order for it to be done, there had to be no green left on the piano. Morning, noon, and night, I would sit and sand this piano. Like I said, it took several weeks.

            There were punishments if we did something wrong. Something wrong would be anything but complete and total compliance and completing tasks fast and snappy and right the first time. For a minor infraction, we would be assigned exercise like 300 jumping jacks, 100 push ups, or 150 squats. For major infractions we had to do wall sitting, which is where we would sit cross legged in front of a wall with our hands at our sides and our nose touching the wall. We would sit there for hours, and sometimes even days. My longest time of wall sitting was two weeks. If I was given food, I was allowed to relax my position only long enough to eat. If I relaxed my position or my nose wasn’t on the wall, Mary would come up behind me and grab the back of my neck and squeeze hard until I straightened back to position. The other form of sitting we did was called cookie sheet sitting. We would sit facing the wall with our legs outstretched and feet flat against the wall. Mary would place the cookie sheet upright against our ankles, and we were to sit holding the cookie sheet up with the tips of our fingers. This would also be for hours or days depending on how much trouble we were in. This one was particularly painful for me because I am not flexible and I dreaded it.

            Another particularly tough punishment was to have cold showers. We were told to get into the bathtub with our clothing on, and then she would turn on the cold water. We were not allowed to get out of the shower. We would stand there in the water for a while, then she would turn the water off so we had to stand in our wet clothes. Then she would come back in and turn on the cold water etc… The longest I saw a kid in the shower was S, and she was in the bathtub for a week. She was made to sleep in the tub. At the end of the week S was very ill, but was not taken to receive medical care.

            The most brutal punishment was food deprivation. If we were in minor trouble, we missed two meals and were only given oatmeal once, and if we were in major trouble, we did not eat. The longest I went with no food was either three or four days. The longest I went with oatmeal only once per day was three months. One week, I stole pickles. I was so very hungry and I saw the pickles and I took the bottle and hid it behind my bed. When was caught, I was made to eat the entire jar and then went without food for two days. Another time I stole food, I stole marshmellows from an open bag on the counter. When Mary found out, I was made to eat an entire large bag in one sitting and then did wall sitting for the next week. I stole the food because I was hungry, but soon learned that stealing food caused me to be even hungrier. 

            After a while of living with Mary, we began “homeschooling”. Homeschooling consisted of writing sentences in a notebook. These were done in the afternoon between chores and usually consisted of something awful about ourselves. I once had to write “I hate myself” 5,000 times.

            After living with Mary for a few months, maybe three or four, we moved to Evergreen Colorado. S and D were sent to residential treatment facilities and I was the only foster kid to actually move with her. When we arrived in Colorado, we were greeted by a woman named Connell Watkins. Connell was a therapist that Mary travelled to Colorado to work with. Once again, I held onto hope that things would get better in Colorado and that Connell would be nicer, but not so.

            I started therapy twice a week with Mary, Connell, and sometimes another lady named Deborah Hage. Therapy was bizarre. I was wrapped from head to toe and blankets, and then all three women (who were not small) would sit on top of me and I had to get out of the blanket. It was horrible and sometimes I couldn’t breathe. They would make fun of me as I struggled. They called me a quitter. They said I must not want to be born or live. They told me I should just give up because that is what I always did. Sometimes during therapy, they would hold me across their laps. I would have one arm behind Connell’s back and be laying across two or three laps. They would ask me questions (usually shaming questions about me) and if I answered wrong they would put their faces really close to mine and yell at me. If I answered right, I had to yell the thing I had just said over and over. It was usually something bad about myself. If I was not compliant, they would make me lie down on the couch and kick my legs for long periods of time, and sometimes they would wrap me completely in a blanket and lay there for long periods of time. I would get really hot and sweaty and I felt like I couldn’t breathe. There was a lot of yelling and anger involved with therapy, and in order to do a good job, I had to be angry. They were always looking for anger. If I did not get angry, they would dig their fingers into my ribs until I screamed. They called this hassling.

            During the time I lived in Colorado, I had two very severe punishments. The first punishment happened because I started giving Mary and Connell sassy looks. They bought me a pair of sunglasses, and for several weeks, unless it was therapy time, I had to wear the glasses because they said that other people shouldn’t have to look at me. Once, I took the glasses off. Mary came up behind me and grabbed the back of my neck and led me to the mirror. She made me stand for hours in front of it until I had shouted out all the horrible things I could think of about what I saw when I looked at myself in the mirror. She then explained that all those things were why no one else should have to look at me. I didn’t remove the glasses again.

            For the other extreme punishment, I was locked in my room for three months. I got to come out of my room to go to therapy and that was it. I was given plain oatmeal once a day unless I tried to escape, and if I did that, I was not fed. The room was stripped of everything but the mattress, a bucket for me to urinate in, and a journal and pen. Mostly, I wrote about how I wanted to get out.

            I lived with Mary Harless for a year and a half from the ages of 12 to 14 years old. I spent a Christmas and two birthdays there. I was Connell Watkins client for a year. The abuse I suffered was extreme and horrible. I actually did have some attachment insecurity growing up due to foster care and a negative adoption experience. When I was a child, I lied and snuck around and got bad grades. My Mother (adoptive) and I did not get along. I was absolutely sure she was disappointed over having adopted me at all, and I behaved accordingly. If I was already a disappointment, I figured I could just do what I wanted. I was also angry because I didn’t get a family I “fit” with. Even with all my behaviors, I did not deserve abuse. My Mother took me to several different counselors when I was a child, but each time, as soon as the counselor suggested any changes to her behavior, she would get angry and we would never go back. My Mother wanted to believe that she had just received a defective child and she didn’t want to shoulder responsibility in fixing me. When these women came and told her what she wanted to hear (I was defective and it must be so hard for her), she latched on. It is, for me, the biggest rejection of my life. Not only did she not want me, she paid someone to openly and blatantly abuse me. If parents are still doing this to adoptive children, it needs to stop."

Please, readers, if you have other information like this and are ready to join the fight against this type of treatment--  which is certainly still in existence--  please get in touch!

Once again, my thanks to "Ann" for coming forward--  JM

Wednesday, October 14, 2015

Orphanages, Foster Families, and Culture Wars

A struggle over the right way to care for unparented children has been shaping for a number of years now. The difficulties of doing good outcome research on this issue are such that evidence tends to be overborne by values, opening the door to confirmation biases. The current arguments in Russia about orphanages, and the encouragement by some parties of a movement toward foster-family care for all unparented children, are examples of a confusion between systematic evidence and values as reasons for making practical decisions.

Child-care institutions have existed in some form back to at least the Middle Ages, when monasteries accepted children as oblates, cared for them, educated them, and reared them to be part of the monastic group. Often, but not always, orphanages were run by religious or other charitable groups. During the Great Depression in the United States, institutional care was common, not only for genuine orphans, but for children whose parents could not afford to care for them at home. Although some institutions involved cruel experiences for the children, others did excellent jobs and were remembered with pleasure by their graduates. During the 1994 Congressional upheaval in the U.S., Newt Gingrich (I never thought I’d be quoting him!) referred to those successful orphanages and suggested that they might do a better job than foster families do.

But today we have people in a range of countries speaking loudly against institutional care for children and advocating family care systems. How did this shift come about? The initial push came from the revelations about the horrible Ceausescu-era Romanian orphanages. This information became public in 1996, following the death of Ceausescu, when news sources published extremely disturbing photographs of malnourished young children tied to cribs and groups of older children naked.  The term “orphanage” quickly took on a powerful negative coloring when people identified highly inappropriate practices as equivalent to all institutional care for children.

A few years after the Romanian revelations, several researchers became interested in the outcomes for children who were adopted from Romanian orphanages. The English-Romanian Adoptees project, directed in part by Michael Rutter , followed these children into young adulthood and found that on the whole their development was quite satisfactory. An American research group, the Bucharest Early Intervention Project, headed by Charles Zeanah, began in about 2000 to conduct an investigation that would compare young children randomly assigned to remain in the orphanage to others randomly assigned to foster families. Zeanah and the rest of the BEIP group reported later that the fostered children showed better development than those who stayed in the orphanage, and that therefore family care had a better effect on development than institutional care did. This conclusion, repeated in several professional journals, in the magazine Science, and in the publication Zero to Three, as well as in popular news sources, has had a strong influence and has been used to support the argument that foster care or adoption are demonstrably better methods for unparented children than institutional care.

However, as I have pointed out in this blog and in letters published in Science and Zero to Three, the design of the BEIP studies does not permit the conclusion that has been publicized. The Romanian foster families received special training and funding, as well as access to frequent consultation with child development experts. The orphanage staff received none of these, nor were they helped to provide more consistent staff assignments that would allow infants and toddlers to be with a few familiar caregivers. The comparison was thus between the best possible foster care and poor institutional care, so the outcome was not surprising. Indeed, it would be interesting to know what would have happened if the institutional staff had been specially trained, paid more, and had consultants available to them, while the foster families were left to get along as best as they could--  that would have been a meaningful test of the advantages of foster care per se over institutional care.

As I have also pointed out on this blog, there is important research that contradicts the BEIP conclusions. That work, by Kathryn Whetten, was a nonrandomized study of children in low- and middle-income countries that compared development of fostered children with that of children in institutions and did not find an advantage for foster care. Whetten’s work has received much less attention than the BEIP work, presumably because her design was nonrandomized, whereas the BEIP involved random assignment to groups—but the fact is that randomization is used to attempt to isolate a variable, and the remainder of the BEIP design did not successfully isolate the variable of type of care, instead conflating type of care with availability of training and resources. In my opinion, the two studies are about equal in appropriateness of design and outcome validity.

A new study in which Whetten was involved is also relevant to the comparison of institutional and family care. This study (and my thanks to Yulia Massino for calling my attention to it!) is by Christine Gray et al., “Prevalence and incidence of traumatic experiences among orphans in institutional and family-based settings in 5 low- and middle-income countries: A longitudinal study” ( The researchers looked at physical and sexual abuse experiences among children in institutions and in foster care, and found no more such experiences in institution-reared children than in those cared for by foster families.

Gray et al. concluded that “understanding the specific context, and elements contributing to potential harm and benefits in both family-based and institutional care, are essential to promoting the best interest of the child.” This comment should be related to recent ideas in clinical psychology, where professionals are beginning to recognize that there are adverse events in psychology just as there are in medicine, and that these should be investigated, recognized, and reported along with  demonstrated benefits.

Decisions about best practice need to take unwanted events into account as well as considering the level of evidence supporting a practice. Yet, as we see in the Russian disagreements about orphanages and about adoption, as well as in the American movement from reuniting families at all costs some years ago, to the current concern about putting child safety first, many such decisions are driven by value considerations other than the best interest of the child, and adverse events are not mentioned. An egregious example would be the push for multiple adoptions by fundamentalist Christians in the U.S., as described by Kathryn Joyce in The child catchers.

As Gray and her co-authors imply, one size does not fit all unparented children. When anyone suggests that there is a single best care approach, we should ask what value considerations are guiding this claim. Culture wars are not a way to provide the best outcomes for children, who are likely to experience “collateral damage”.


Tuesday, October 13, 2015

Very Early Diagnosis of Autism Is Still Not an Option

It’s so sad to see the number of queries that come to this blog from terrified young mothers who have become addicted to Googling about autism and want to know whether the (usually) typical infant behaviors they see mean that their children will be autistic. Other than cursing these insufficiently-informative “red flag” sites, there’s not much I can do except to tell them that they will just have to wait to get a definitive answer, because their babies are too young for anyone to tell whether there is an autism diagnosis in their future.
I recently came across two articles in the very helpful Brown University  Child and Adolescent Behavior Letter (CABL) that I would like to summarize--  not because they tell how to diagnose autism early, but because they underline the problems of trying to do so.

The first of these articles, by Stephen Sheinkopf, is titled “Autism in infancy: Advances and implications for clinical practice” (CABL, March 2013, pp. 1.4-5). Sheinkopf notes that “the presentation of autism in infancy is subtle, with more obvious signs and symptoms emerging over the first two to three years of life… these early developmental differences are difficult to detect, making it a challenge to screen for the risk of autism in early infancy. The gradual emergence of autism symptoms during development also makes diagnosis challenging in later infancy and toddlerhood.” Even when symptoms like poor communication development become evident, it may be far from clear whether there are hearing difficulties, specific speech and language disorders, or even mental retardation at work. Sheinkopf goes on to say that there are “few reliable findings reported in infants younger than 12 months of age”, even when children studied are known to be at risk for autism because they have autistic siblings--  and as Sheinkopf point out, it may not even be possible to generalize from those at-risk children to the rest of the population.

Even when toddlers are diagnosed with autism, a longitudinal follow-up is needed to be sure that diagnosis was correct. Sheinkopf describes two composite cases (in other words, these are not specific real children, but a narrative based on several similar cases). One case involved a 30-month-old boy who had been born at less than 30 weeks’ gestation, had been in intensive care for some time, and had normal motor development, no cerebral palsy, and no hearing or vision impairment. He was quite delayed in language and had some cognitive delays as well. He also showed behaviors  that can be symptoms of autism—repetitive movements, little eye contact, poor communicative abilities, and he received a tentative diagnosis of autism. However, following early intervention services he improved in language skills, performed fewer repetitive movements, and became more social and playful with adults as well as becoming more interested in other children than he had been. Although he continued to have some delays, by the time he was 40 months old, the autism diagnosis was ruled out.

In Sheinkopf’s second case, a 20-month-old boy had one older brother with autism, another with language delays, and a member of the extended family for whom autism was a possibility. He did not speak at all and did not vocalize much. He could solve problems that required no verbal ability but did not respond to verbal instructions.  He was affectionate and playful with his parents and showed some interest in other children. He flapped his hands when excited, but not in ways different from typical children of his age [I hope readers will notice the fact that hand-flapping  is common in toddlers]. It was not clear at this point whether his diagnosis should be autism or language delay. Ten months later, after early intervention services were received, it was seen that although his language had improved it was repetitive and not necessarily directed to other people. His social pragmatic skills had worsened compared to where he was at 20 months. He had an increase in repetitive and stereotyped actions and had begun to examine objects intensely in a way that interfered with play or social activities. By his third birthday, the diagnosis of autism given at 30 months continued to seem appropriate.

Notice that in both these cases the children were seen to have factors that put them at risk for autism, but that even well past the first birthday it was not clear whether their abilities and behaviors were indicators of autism—it was simply seen that autism was one of the possibilities. The first child became less “autistic-like” over time, but the autism diagnosis was not ruled out until he was well over three years old. The second child improved in language, but showed increasing evidence of autism and was finally diagnosed at age 2 ½. The child diagnosed with autism became more different from typically-developing children with age--  the differences were not clear-cut earlier in his life.

In a second relevant piece in CABL, Alison Knopf (“Brief observation not adequate to detect autism risk in young children”, March 2015, pp. 3-4) described a study by Gabrielsen, Farley, Speer, et al., (in Pediatrics, 2025, Jan. 12). Knopf notes that “autism spectrum disorder doesn’t manifest itself suddenly; symptoms appear over time, with gaps between typical and atypical development widening as the child gets older. Children have both typical and atypical behaviors [a most important point—JM] but little is known about what the ratio of these behaviors is during the 10-minute timespan of an average primary care visit.” In the study by Gabrielsen et al., clinicians were asked to see whether they could identify autism in children 15 to 33 months old, by watching two 10-minute video clips of each child.  Children who were previously identified as autistic were missed in 39% of the cases, suggesting that longer observations and more information than most pediatricians get are needed for more accurate diagnosis.

In the Gabrielsen study, a very important point concerned the fact that both typically-developing and autistic children had some typical behaviors and some atypical behaviors. The autistic children showed typical behaviors 89% of the time and atypical behaviors only 11%, while the typically-developing children showed atypical behaviors only 2% of the time. All the children were prompted to respond to their names at least once, and 50% of the children in the typical group failed to respond once or more, while 59% of children in an additional language-delay group did not respond on one or more occasions. Of the children in the autism group, 58% responded  to their name at least once, while 80% of the typically-developing children responded at least once.

Making eye contact, responding to their name, hand-flapping, repetitive behaviors—all of these are found in both autistic and typically-developing toddlers. There is no single symptom or list of symptoms that is a certain indication of autism even in children this old, and much less can such a symptom be found for infants in the first year.

Although specialized early intervention services can be helpful for toddlers and preschoolers, the best thing parents of infants can do is to encourage good development by sensitive, responsive care, by plentiful and playful social interaction that follows the child’s lead, and by minimizing the screen use that so easily keeps parents from these first two development-supporting activities. We would all like to think that a magic device could let us detect autism early, and some other magic ritual could allow us to prevent atypical development, but so far--  it just isn’t so, and all parents can do is the best parenting they can.          

Friday, October 9, 2015

On Rolling Over and Autism (the Latest Parental Worry)

Over the last several years, I have had dozens of queries from concerned parents who had read some “red flag” websites that describe symptoms of autism. These parents were terribly worried that their babies did not make enough eye contact and that meant they would be autistic. There have been a few cases where the parent’s description was worrisome, but in most of the cases the problem was simply that the baby was very young. What those websites often neglect to tell you is that young babies normally show many of the behaviors that would be symptomatic of autism if they were older. The autistic toddler or preschooler continues to show some behaviors that are normal in earlier life; the typically-developing child stops doing things that belong to earlier development. Autism is primarily characterized by developmental delays, not by doing things that are never seen in the lives of typically-developing children. For example, the hand-flapping and toe-walking often noted as indications of autism are also seen in typically-developing children, but at an earlier period of development.

In the last few weeks, in addition to the usual questions about eye contact, I have noticed some new questions about motor development and especially about the way a baby rolls over. I see references to this issue on various chat groups and on Youtube too. They all refer back to a particular publication, and I want to talk about that.

In the mid-1990s, the researcher Philip Teitelbaum became interested in the idea that atypical movement patterns might precede and predict more obvious symptoms of autism. This was by no means a silly idea—many other neurological problems of childhood involve movement anomalies. It’s been known for a long time that infants who already have “handedness” (they use one hand consistently rather than alternating) or who crawl asymmetrically, with one side of the body doing more work, most often have some damage to one side of the brain. Cerebral palsy, which can interfere so badly with speech, may not be diagnosed at birth, but it may be seen in anomalies of movement in the first year. That autism might also involve problems of motor development was a reasonable hypothesis.

In order to see whether babies who were later diagnosed as autistic had unusual movement patterns later on, Teitelbaum advertised and announced his work in various newspapers (this was before much Internet). He asked for parents to send him home videos of their babies, so he could examine movement patterns in early life and see whether he could identify any unusual movements in those who were later considered autistic.
Teitelbaum and some co-authors published the results of this study in 1998 in the Proceedings of the National Academy of Sciences. They had found videos for 17 babies who were later diagnosed as autistic, and reported that these babies showed unusually movement patterns. Delays and asymmetries in sitting and walking were evident, and rolling over was described as not only delayed and awkward, but as involving a different use of head and legs to turn the body that is characteristic of typically developing infants. However, there has been little replication of this work, and there is ongoing discussion of the method that should be used to observe and describe motor behavior (see ).
There are several points to be made here. One is that the rolling pattern described has not clearly been shown to be a precursor of autism, and in fact Teitelbaum was criticized for the lack of control or comparison information he provided. Failing to roll at all, past the usual time when this milestone is achieved, is probably a more significant issue.

Second, and very important, Teitelbaum’s work looked at the motor development of babies of whom the great majority slept in the prone, tummy-down position. Babies in the United States, Australia, and Great Britain today are very likely to be put to sleep supine, lying on their backs. This practice is known to delay motor development compared to what was seen years ago for prone-sleeping babies (see ). The sequence and timing of motor development Teitelbaum found in typically-developing babies were not what we would see today in typically-developing babies, so delays that Teitelbaum considered to be characteristic of later-found-to-be-autistic infants cannot be used to assess babies today.

Third, every baby has his or her own schedule of achieving motor milestones. There may be a long pause between two milestones, or one may come very rapidly after another--  as when babies hardly creep at all, but go quickly to walking. There is a normal range of development, not a deadline to get something accomplished. That means that only a rather sophisticated observer will be able to detect something out of sequence or dramatically delayed in motor development; Youtube won’t do the job!

Fourth, let me point out that if a baby does have unusual movement patterns, there can be many reasons for them other than autism, and it is important to seek medical care if such patterns are seen.

Conclusion?  The concern about how babies roll over has recently been whipped up on various websites devoted to encouraging parents to be anxious about the possibility of autism. Let me remind you that the present high reported rates of autism are probably caused primarily by changes in diagnostic approaches that include some minimal disturbances in the same category with debilitating autistic disorders. Also, it is clear that quite a few children who are diagnosed as autistic in the preschool period no longer have that diagnosis several years later. Finally, because parents who are worried about eye contact and rolling over also want to know about “early intervention”--  the best thing you can do for any baby is to have fun together and respond to the baby’s communications as best as you can. If you’re worried about movement problems, by sure you do plenty of tummy time. Minimize screen time, and that means the time you are on your phone in the baby’s presence as well as screens for the baby to look at. Talk to the baby a lot. All babies, typical or atypical, will benefit from these actions.