Concerned About Unconventional Mental Health Interventions?

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

Friday, February 17, 2017

Children and Obedience: A Clinician's Perspective

A recent discussion on a child psychology listserv brought up once again some misunderstandings about Reactive Attachment Disorder. One correspondent, who spoke of a child who had been diagnosed with RAD, surprised me by offering the old holding-therapy-related symptom list, including “superficial charm” and “lack of cause-and-effect thinking”. I responded by pointing out that even now, when few practitioners do holding therapy, there are dangers in the associated authoritarian belief system—a system that considers disobedience a symptom of poor attachment and holds that once a command is given, a child must be made to comply with it. (This view was the one that led to the death of Candace Newmaker in a situation which was not in itself dangerous unless pushed much too far.)

 During the ensuing discussion, some really valuable comments about obedience were made by Dr. Bradley White, a clinical child psychologist at Virginia Tech, and I asked him whether I could summarize and quote some of what he said for this blog. In his very nice message of agreement, Dr. White commented on how much he has learned about these issues from his own children, but I want to point out that he learned from them because he was paying attention, not because he just happened to be in the same house with them!

Dr. White’s remarks stressed what early-childhood educators call developmentally appropriate practice: the understanding that an action can have different motives and meaning when performed by a child at different times in his or her life. When belief systems or associated treatments assume that all disobedience or noncompliance is pathological, they fail to take developmental changes into account and therefore lack real understanding of what the child’s behavior means from his or her own perspective. These mistakes lead to behavior that fails to provide an adequate model for the child—often at the same time that the adult is expressing concern about the child’s lack of empathy.

Dr. White commented: “If one sees noncompliance as developmentally appropriate and expected, it may simply be accepted and either ignored or redirected. If it is seen as problematic but functional or reflecting a skills or knowledge deficit, it may be helpfully viewed as a learning opportunity requiring extra support including gentle exploration, guidance, and rehearsal of alternatives.” (When adoptive or foster children have had few opportunities for leaning about social behavior and social relations, this viewpoint may be especially helpful. JM) Dr. White pointed out that when child behavior is always interpreted as provocative or manipulative, parents may see punishment as the only suitable  response—potentially damaging the child’s attachment relationship with the adults as well as teaching the child coercive methods for solving problems. Parents’ interpretation of child behavior helps determine how, and how effectively, they respond to the behavior.

Commenting that becoming socialized (understanding social rules and taking the perspectives of other people) takes many years and progresses slowly, Dr. White also made this important statement: “I think we adults are … often impaired at seeing the world through the eyes of a child or adolescent, since it calls for empathic sensitivity and perspective taking, which often don’t come automatically but require effortful focus. Yet from a child’s point of view caregivers are often overly demanding and distracted due to their over-involvement in boring, confusing, or simply weird and senseless adult-level responsibilities e.g. getting the kids to school on time, holding down a job, maintaining order and organization), in contrast to the things  perfectly reasonable kids care about (e.g., eating sweets, sleeping in, grabbing others’ attention with gross/silly/provocative acts, having fun now, and exploring how the world works by pushing and pulling on it and tossing it all around the house and yard, etc.).” In addition, Dr. White pointed out, it’s hard to cope with adult demands when tired, hungry, excited, and so on—“which arguably summarizes at least half of the day of an average healthy young child.”

Neither Dr. White nor I wants to argue that children don’t need to comply with rules and adult requests. Safety alone demands a certain level of obedience and cooperation, because adults often are able to foresee dangers that children know nothing about. The point here is that there are many reasons why a developing  child may sometimes--  perhaps often—fail to comply with adult rules, ranging from the limited abilities of the young child to the budding negotiating powers of the preschooler to the growing autonomy of older children and adolescents.

 From a practical point of view, a partial solution to this problem may be to have few rules and make few demands, but to follow through carefully on the ones you have. A corollary of this would be never to institute a rule or make a demand that cannot be enforced, especially if the issue is that a child is not capable of obeying.  And, of course, working toward a good, mutually supportive and cooperative relationship between adult and child will do more good than all the exertion of authority in the world.

It is a huge mistake to define obedience or disobedience as indications of mental illness or as related to emotional attachment. Thinking in those terms increases parents’ anxiety and makes them feel that there is a crisis that must be addressed every time a child fails to comply. Such anxiety limits the parents’ ability to use the “effortful focus” Dr. White mentioned. It also makes the parents vulnerable to unconventional and potentially harmful ideas about children’s mental health. 

Thursday, February 2, 2017

Is Psychological Treatment the Same Thing as Education? (Not Really!)

On the whole, it’s pretty easy to tell whether a method of working with people should be labeled psychotherapy, or should be considered as an educational approach. Psychotherapies usually have as their primary goal some changes in a client’s moods and the behaviors related to those moods, and although there may be associated cognitive changes, the latter are not the major concern of the treatment. Education is ordinarily thought of as involving cognitive change and the mastery of new information and skills; the information and skills may have to do with social or emotional concerns, and a person may feel happier because of mastery, but these latter  are relatively minor points.

What do these differences have to do with the price of beans, or anything else? I am bringing them up here because I see that to an increasing extent, practitioners whose goal is mood and behavior change are claiming that what they do is not psychotherapy, but is education. It is certainly true that education can play an important role in psychotherapy, as clients or their families learn useful information about the nature of mental or behavioral disorders and come to understand better what is happening in their lives. (This is what is usually meant by the term “psychoeducation”.)  However, psychological treatment has different goals and principles from education.

Why would practitioners of one approach claim to be doing the other? The answer may be a simple one: psychologists’ work is regulated by state professional licensing boards to a much greater extent than educators experience. As a result, a person who is not licensed as a psychologist may be punished for claiming to provide psychological treatment, but almost any person may freely present himself or herself as providing education, “family life coaching”, or “parenting coaching”.  To be hired as an educator in a public school, an individual must have appropriate state certification as a teacher, but no such certification is required for “coaches”, teachers in independent schools, or tutors. If a person wants to provide services focused on mood and behavior change, but is not licensed as a psychologist (or other mental health professional), the easiest solution to the lack of licensure is to redefine the treatment as education. 

Let’s look at some examples of this problem. I recently posted an account given by a young woman who had experienced a program that claimed to alter her relationship with her mother ( She and her sister were taken against their will by youth transportation service workers and transported to another state, where they were confined to a hotel room and forced into interaction with the mother and her boyfriend. They were shown videos of the kind often used in introductory psychology courses, but in addition they were threatened with disturbing options if they did not cooperate—placement in residential treatment centers or wilderness programs where they would be unable to communicate with anyone outside, and where escape would be difficult or even dangerous. A psychologist in charge of this treatment had already had his license to practice psychology suspended, but he argued, so far successfully, that what he was doing was not psychotherapy but was simply education, and that the state psychology licensing board could therefore not discipline him.

A New York Times article (“Weak support for treatment tied to De Vos”, 1/31/2017, A1, A21) yesterday discussed similar issues with respect to the company Neurocore, which has called itself an educational organization in the course of a trademark dispute. Neurocore employs neurofeedback methods, recording brain wave patterns that indicate attention or inattention and manipulating interesting material clients are watching, so that indications of inattention cause a video to freeze. The method is used for both children and adults with autism, anxiety, ADHD, depression, and so on, and there are plans for marketing the approach to elderly people with cognitive problems. Unfortunately, however, evidence that this method effectively treats any of the listed disorders is missing. If Neurocore called itself a purveyor of psychotherapy, regulation would be possible (although professional psychology licensing boards do not usually concern themselves much with the use of ineffective treatments), but as long as the treatment is “education”, it is not.  Yet it seems that that the purpose of the Neurocore treatment is to alter mood and behavior, not to effect cognitive changes, so classifying this approach as educational rather than psychotherapeutic does not make sense—except from the financial and regulatory perspectives.

A third example of calling a psychological treatment “education”  under questionable circumstances comes from the history of the Miracle Meadows School in West Virginia, which I discussed some time ago in this blog ( Miracle Meadows, which was closed down some months ago, was a Seventh Day Adventist-sponsored institution that focused on emotional and behavior problems of teenagers, many of them adopted from other countries. In one case, a child was sent to Miracle Meadows from another state when her adoptive parents were under investigation for abusive treatment. In another, children in a Tennessee residential treatment program that has been accused of child abuse were threatened with being sent to Miracle Meadows if they did not cooperate. Miracle Meadows had been investigated several times for abusive treatment of residents, but had successfully argued in court that staff need not comply with guidelines about the use of physical restraint and seclusion with children, because as an educational institution they were not required to follow guidelines that were intended for residential treatment centers dealing with psychological problems. More recently, a series of complaints and investigations of staff actions led to the closing of Miracle Meadows, as the argument that abusive practices could be classed as “education” could no longer be sustained.

The moral of this story? When choosing a treatment for mood, emotional, or behavioral problems, especially one for children, watch out for those programs that call themselves “education” but claim to help non-cognitive problems. They are not well-regulated and may present themselves as educational only to avoid compliance with guidelines for mental health practices. If you like the idea of an “education” approach because you dread the stigma of mental health treatment, do think carefully about your choices—by avoiding the idea of emotional disturbance, you may be placing your child in treatment that is not only ineffective but potentially harmful.

Thursday, January 12, 2017

A Mother Tells It Better Than I Can (About Those Autism Fears)

Every now and then I get a comment that I think really
 needs to be read by a lot of people, so although this 
and  some other comments by this mother and  by me 
are posted  at
eye-contact-with-babies-part-2.html, I want to put her
 important remarks out where it's easier for people to
 see them. If you are worried  about developmental
 problems,please read what she has to say 
about "milestones" and about mood disorders.

Please forgive the slightly cut-off word endings-- when
 I moved this here from my gmail account it seems to
 have established a format that I can't correct.

"First, I am specifically writing to tell you thank you
for your work to help parents feel less burdened by
 the weight of our own anxieties, often brought about
 by what we don't know, and what the  internet tells us
 when we google our fears at 3am.
 I was just that new mama! My daughter who will be
 20 weeks this Friday, and is the absolute joy of my life,
 has blossomed over the past month. Before this, I was
 sick with worry that she had autism or any other number
 of developmental delays as many parents in your comment
 sections also worry about. I was so busy comparing her 
to other babies her age. A friend of mine oncetold me,
 "Comparison is the thief of joy." This was profoundly true
 for me. I could not fully enjoy my daughter just the way 
she was. And what she was, and is, is a little girl who
 has developed  and met milestones in her own time.

She would give a passing glance around 11 weeks, but
 even then I had to really work for it and it was only 
if you were a certain distance from her face. She gave
 her first smile around this time as well, but again, I had
 to REALLY work for it. She seemed rather disengaged
 and not very interested in socializing. She also would
 not bat at or grasp at toys, she actually ignored them
 even when held right in her line of sight. She seemed to
 be at a standstill in making progress in this area until
 week 16 when she really blossomed. She began making
 eye contact very effectively, started smiling on 
her own without me making an effort to get her to do so. 
She found her first chuckle at 17 weeks and her first belly 
laugh at 18 weeks. She discovered her hands around week
 17 as well and now  grasps at and bats at her toys to her
 great amusement. I'm detailing this to show that it really
 can take our little ones time to learn how to socialize and
 learn. She, I believe, chose to observe and absorb her
 new world as long as she needed to (which was longer
 than every  development milestone book/blog/website ect.,
 listed it should
 take) before she was really to actively engage in it. 

Additionally, I, like some of your readers, struggled with
post-partum anxiety. My daughter’s pediatrician referred me to 
get help, which I did. Incidentally, once I had begun taking
 anxiety medication and seeing  a therapist and started feeling
 considerably better, my daughter also
 began to blossom. Whether my emotions had an effect on her
 or not,
 I'm not sure, but I think it's worth being aware of.

Anyhow, thanks again for your blog! I actually found it
while I was googling "8 week old not making eye contact" 
and came across several  “red flags about autism” sites and
 forums full of anxious moms worrying  about the same thing.
 One mom posted a link to your blog and how
 much it helped to relieve her excessive worry and I'm forever
 to have found you through her!"

As I mentioned above, we had a further discussion in the
 comments at the link given above. (I don't seem to be able
 to move her other comments
 here, for some reason, but do look at them--I think many
 people will find 
them helpful.)

Wednesday, December 21, 2016

One-Stop Thinking Makes People Misunderstand Child Development

We tend to be attracted by the idea of “one-stop shopping”, but we can pay the price of convenience by not getting exactly what we want. In fact, we may find ourselves regretting purchases we made just in order to save time. “One-stop thinking” presents the same problem: when we pay attention only to one factor that affects children’s development, we cut down on the time spent in consideration, but we risk making some big mistakes.

In reality, children’s physical and mental development are invariably affected by more than one factor, genetic or environmental. And usually, the influential factors are not just two or three, but many. Often, influences act bidirectionally, so that children affect their parents as much as parents affect their children. Influences can even be transactional in nature, so that bidirectional effects (for example, parents’ and children’s mutual influences, or families’ and schools’) change in their  nature over time and experience. Developmental outcomes may depend on some combination of environmental circumstances (helpful or harmful) and the characteristics of the child (vulnerable or resilient), with the best outcomes resulting for a resilient child in a helpful environment and the worst for a vulnerable child in a harmful environment.

In other words, it’s not rocket science--  it’s a lot more complicated than that (even though this statement is annoying to rocket scientists).

Recent years have seen a number of examples of one-stop thinking about child development, not by developmental scientists themselves, but by people popularizing and translating developmental research and theory. Unfortunately, oversimplified translations are often applied to pragmatic topics like how to intervene in children’s mental, behavioral, or educational problems. These may be welcomed by consumers of services, because their simplicity “makes sense”, especially if it echoes claims made familiar by repetition. Those familiar and simple claims amount to what the developmental scientist Jerome Kagan famously called “seductive ideas”—ideas that are so appealing to us that we buy into them without much investigation of their “one-stop” convenience.

Here are some familiar ideas that can lead to one-stop thinking if we do not pay careful attention.

Infant determinism is the idea that everything of developmental importance is accomplished during the first years of life. Early intervention follows on this idea by assuming that there is a desperate need to change completely the circumstances of every child who is abused or neglected in early life, most often by offering services to parents, but sometimes by foster or adoptive placement. One-stop thinking on this topic ignores two facts: that small changes in a family’s situation can help improve a child’s developmental trajectory, and that events such as school availability and neighborhood safety may later help restore derailed development. A 2014 article in the British Journal of Social Work (Featherstone, B., Morris, K., & White, S., “A marriage made in hell: Early intervention meets child protection.” BJSW, Vol. 44 (7), 1735-1749; pointed to the mistakes made when child welfare workers do not try offering needed support to families rather than hurrying to intervene; this article is of particular interest in that it places this issue in a political context.

Attachment is an important concept in the study of child development as well as in practical decisions about child care and custody. But one-stop thinking about attachment and attachment disorders focuses entirely on these topics as the unique core of personality and behavioral development. As a result, educators and counselors may attend only to a child’s attachment issues and ignore all other child and family characteristics that may be affecting development. In addition, therapies directed at changing attachment may be proposed for an enormous range of mental health problems, from autism to oppositional defiant disorder. Interestingly, the fad of the last 30 or 40 years for an exclusive focus on attachment appears to be waning, and another fad is emerging.

Trauma, in the mental health context, describes experiences of seriously frightening or painful events that interfere with important relationships and thus with development. Trauma-informed approaches are essential for work with children and parents, as reactions to trauma may involve behaviors like fearfulness and aggressiveness, sleep disorders and bedwetting, for which children are brought into treatment.  Attempting to treat these without considering the influence of trauma is likely to be ineffective, if trauma is indeed involved. But one-stop thinking about trauma leads to the assumption that where there is a mood or behavior problem, there must be trauma in the background, even though there is no independent evidence that this has occurred. There is only a step from this assumption to the whole “recovered memory” charlatanry that was thriving 20 years ago and is still in existence. Seeing trauma everywhere is the new fad that has replaced the attachment fad; even the organization ATTACh, at one time the Association for Treatment and Training of Attachment in Children and a great proponent of attachment therapies, has now caught the trauma wave and become the Association for Training on Trauma & Attachment in Children.

Neuroscience is both a critical aspect of research on child development and an insidious temptation to one-stop thinking. I recently attended a presentation on the effects of poverty on children that used multiple PowerPoint slides of children’s brains to buttress the strong existing evidence that children growing up in poverty have worse physical and mental health, and worse academic achievement, than those growing up in better circumstances. No one (including me—I didn’t want to offend the speaker who kindly gave his time) demanded to know what on earth the brain images had to do with the argument that poverty is not good for children’s development. Using the slides was only a way to strengthen, not the argument itself, but the reception of the basic argument by an impressed audience. One of the problems with one-stop thinking about neuroscience is that the field itself, and what we know about it today, is too complex and too incomplete to allow us to use this information well. For example, a recent study described by Pam Belluck in the New York Times (Dec. 21, 2016, p. A15) noted that in the course of pregnancy women lose (yes, lose) brain volume in areas that are used in understanding how other people perceive things. Those who lost most volume, in the reported study, were most emotionally attached to their babies. Thus, loss of brain volume can improve certain capabilities, which we already knew from information about hormone-determined brain changes in boy and girl babies. But—according to the famous study of London taxi drivers, increased capabilities can also go with increases in brain volume! One-stop thinking is especially dangerous when the “stop” does not offer much clarity.

A real problem with one-stop thinking about children is that we don’t just create our own mistakes. We also have other people who would like us to make the mistakes they suggest, for the benefit of their own financial or personal aggrandizement. And often they are very attractive and persuasive people who appear to offer simple, achievable solutions to our complicated, intractable problems, or those of our children. They tell us they are world experts, or have cared for thousands of foster children, or even have a direct connection to supernatural powers. When we meet these people, we need to resist their one-factor solutions and remember the adage about rocket science.

And by the way, if it seems too good to be true, it probably is.

Monday, December 19, 2016

When Proposed Childhood Mental Health Treatments Are Potentially Harmful

I recently published an article in the Child and Adolescent Social Work Journal, under the title “Evidence of Potentially Harmful Psychological Treatments for Children and Adolescents”. Interested people can read this paper at the following link:

However, assuming that most readers won’t be quite that interested, I’m going to summarize the article here and add a few comments.

The point of this paper is that there is clear evidence that certain psychological treatments that have been used for children have been harmful, and that in fact it would have been possible to predict these harms beforehand by careful examination of the principles and practices of the treatments themselves. Evidence for harm done by certain treatments goes back to the 1960s, so no one should be surprised to find that this is a possibility. Nevertheless, specific discussion of potentially harmful psychological treatments goes back only to 2007, and even then there was little emphasis on potentially harmful treatments for children. An important publication in 2007 assumed that harms can be identified through systematic research evidence, whereas in fact anecdotes and journalists’ reports may be the first line of information to warn of us of harm to children.

My paper proposes that potentially harmful treatments for children may be identifiable – before harm is done—by several characteristics that make them unusual in comparison to most childhood mental health treatments.

 One of these is that they create an emotional burden for the child, making him or her feel distressed by the treatment. Although it has been claimed that people in psychological treatment must feel uncomfortable so they can be motivated to change, this idea is not evidence-based, and the great majority of child treatments focus on comforting the child as he or she tries to master issues like anxiety resulting from trauma. Treatments that are distressing for a child run the risk of re-traumatizing rather than helping.

A second characteristic that is proposed for potentially harmful treatments for children is derived from the Adverse Childhood Experiences (ACE) study, currently underway and revealing that problems of both mental and physical health in adulthood are associated with increased numbers  of adverse experiences of painful and disturbing experiences in childhood. There are ten ACE questions used for research purposes; of these, the four following questions are most relevant to potentially harmful psychological treatments for children.  
  1. A parent, another adult in the household, or a therapist often or very often swore at the child, insulted the child, put the child down, or humiliated the child, OR acted in a way that made the child afraid that he or she might be physically hurt.
  2.  A parent, another adult in the household, or a therapist often or very often pushed, grabbed, slapped, or threw something at the child, OR at some time hit the child so hard that he or she had marks or was injured.
  3. The child often or very often felt that no one in the family loved him or her, and that no one, including the therapist, thought him or her important or special.
  4.  The child often or very often felt that he or she didn’t have enough to eat, had to wear dirty clothes, and had no adult protector.
I propose that when a childhood mental health treatment features these ACE events, this fact helps to identify the treatment as potentially harmful

The third characteristic I suggest for identification of potentially harmful treatments for children is drawn from the fourth National Incidence Study of Abuse and Neglect (NIS-4). NIS-4 identifies for research purposes a list of adult actions that are to be considered abusive to children. The following table shows adult behaviors that are relevant to the identification of potentially harmful psychological treatments for children.

Behaviors coded as physical neglect                             Behaviors coded as physical abuse  
Refusal to allow needed care for diagnosed                  Hit with hand
condition or impairment                                                 Hit with object
      Unwarranted delay or failure to seek                             Push, grab, drag, pull
needed care
Refusal of custody/abandonment
Illegal transfers of custody
Inadequate nutrition
Inadequate personal hygiene
Inadequate clothing
Inadequate shelter

Behaviors coded as educational neglect                       Behaviors coded as emotional abuse 
Permitted chronic truancy                                             Close confinement: tying, binding
Failure to register or enroll                                           Close confinement: other
Other refusal to allow or provide needed attention       Verbal assaults and emotional abuse
 to diagnosed educational need                                      Threats of other maltreatment

Behaviors coded as emotional neglect
Inadequate nurturance/affection             Exposure to maladaptive behaviors and environments
                   Other inattention to developmental/emotional needs

I propose that treatments that include these behaviors are identifiable as potentially harmful to children.

Having established these criteria for potentially harmful psychological treatments for children, I examined five psychological treatments for children to see whether they met the criteria: aversive conditioning using electric shock, holding therapy/attachment therapy adjuvant treatments associated with holding therapy/attachment therapy (Nancy Thomas parenting), “holding time” (Festhaltetherapie), and conversion therapy for change of sexual orientation. In practice, although not necessarily in theory, each of these treatments met all or most of the criteria for potentially harmful treatments for children. Two of the treatments, aversive conditioning using electric shock and holding therapy/attachment therapy, have over many years moderated their practices, but their potential for harm remains. Interested readers can look at the paper for many more details about these five treatments and for the sources I used in writing the paper..

I certainly do not mean to suggest that these five treatments are the only child mental health interventions that have the potential for harm. I would have liked to include an analysis of various treatments for children displaying “parental alienation” by rejecting and avoiding one of their parents, but there is little systematic evidence either about the effectiveness of these treatments or about their potential for harm. There is no question that they cause an emotional burden to the children. In addition to this, there is anecdotal evidence that these treatments may be associated with frightening experiences with youth transportation services, and with threats to send an uncooperative child to residential care or to wilderness programs where the child cannot communicate with anyone outside the treatment program and may be at the mercy of staff members.


Monday, December 12, 2016

Another Eye Contact Query

People keep sending comments to a much earlier post on this subject-- but there have been so many that no more fit on that page. Here is a recent one of these.

Hi Dr Mercer,
I have a 4 month old baby girl that was born 3 weeks early. Had a rough delivery with forceps and she was bradycardic for 8 min.he had mild hypotonia in her arms.
We are very worried as she has not made any eye contact with us yet or smiled at us. She started tracking objects around 3 months, but She doesn't seem interested in anything in particular. She bats at objects but can't grab them yet. Has good control of her head but has not rolled over yet(and doesn't really seem interested in trying). Pediatrician is concerned and went to see a ped neurologist but they say it's early at this age to say anything. I still feel like they must be something that can be done to see why she what is wrong with her.
Any advice?
Thank you so much 

Dear Unknown--

Her corrected age is just over 3 months, so it is not surprising that she has not rolled over and can't yet grab things. It's a good sign that she bats at objects, because this shows that she has at least some vision. The head control is also good. I'm not surprised that you are concerned about the lack of smiling by this age. However, please keep in mind that many babies who have a rough start do catch up in growth and development.

I understand how frightening and frustrating this situation must be for you, but the neurologist is right in saying that she is too young to get a clear picture of what, if anything, is wrong.

But while you wait to see the outcome, you can work with her to help support her ongoing development. Do your best to show her a smiling and interested face-- try not to look anxious or stressed when you are face to face with her. Make sure that when you look at her, there is a bright enough light on your face so she can see your features even if she has some vision loss. Don't give up if something you do (big smile, for instance) doesn't seem to get her attention--  do it several more times. Sometimes you can get a baby's attention by "looming"-- move your face toward her while you open your mouth wide, then move away while you close your mouth. In addition, you can combine several sensory events to get her interest by talking or singing while you look at her and tapping or rubbing her hands or feet. There's nothing magic here-- I'm just suggesting that you may be able to draw her into an interaction by giving her more complex stimulation.

It's true that you will have to wait for an accurate assessment, but you and she are not in suspended animation. You can still do things that will give her the best chance for good development. If you notice even a small response, keep on doing whatever seems to get her interested.

By the way, you should be sure to put away your phone and all screens when you're with her so you aren't distracted by them.

Good luck to your family, and I hope to hear in 6 months that she has made great progress!


Thursday, December 8, 2016

Is It Autism? Interesting Questions about a Toddler

Here is a comment on eye contact and other possible "red flags" for autism. It couldn't be placed on any of the pages I have on that topic, for some reason, but I thought it would be useful for other people to read these intelligent questions and my (I hope intelligent! ) responses.
Hello Dr Jean Mercer,
I'm not sure if you are still actively replying to comments, but I would love your thoughts on my 12.5 month old son.
In the effort to fully disclose, I would like to mention that my oldest son who is 2.5 followed a similar pattern of development, in which I was convinced he would be diagnosed with autism until about 16-18months old. He is now very advanced in his language and very social (almost too social!).
As with my older son, I have had long time concerns with his eye contact. This has spewed into constantly analyzing if his joint attention is enough. He has many strengths but they seem to be over shadowed by a weakness/red flag. I guess I am not sure if they are developmentally expected at this age or my my expectations are too high. I have brought concerns up to my last two well baby visits only to be brushed off. Here are my strengths and concerns:

1) Showing/giving: He has been showing like crazy lately, everything he picks up he makes eye contact and "says" something BUT virtually no giving. If I reach my hand out he will "fake me out" and hold onto it. He was giving but not showing about a month or so ago.
Showing is actually a lot more complicated than giving. For giving, he just has to respond by letting go when you put your hand out. For showing, he has to figure out where you are looking and hold an object so you can see it-- not let go, not drop it. To combine showing and giving in the right sequence is even harder. I don't think he plans to fake you out (that would require some pretty advanced cognitive skills), but he is probably not yet able to inhibit the showing action and start the giving action.

2) Pointing: he points a hundred times a day. BUT never looks at me during/after point. Very occasionally he will quickly glance my way but it's quite rare. He has done some 3 point gazes but I'd say maybe 2-3 times a day definitely not a lot.
Pointing can simply be a way of indicating behaviorally that he is interested in something-- I mean indicating it to himself, not to you. If he does do joint attention a few times a day I would say that's fine.

3) Engagement: he plays and laughs with me. BUT not much eye contact during it. In fact very little. For example we played with a ball for about 5 minutes together, he was laughing a lot (he would hold the ball and drop it and then I would roll it to him or pass to him) but I was watching intently and as much as I could tell he was enjoying it he didn't once look up at me. He focused on the ball the entire time. He also can play by himself for lengths of time without looking up (my oldest did this as well so I'm not as worried compared to the engagement with the ball example).

I think the ball play is probably still pretty challenging to him. To look up at the same time is kind of like patting your head and rubbing your tummy at the same time.  He's not ready to multitask or to stop and start actions easily.

4) other gestures: this one has me stumped. A month ago he wasn't clapping but had waved bye bye a few time on his own. He would also makes kissing noises when I said give me a kiss. Now no waving or kisses but will clap on demand. I thought he caught on to the toy telephone because he seemed to do it once but not again. He continues to say no no no while shaking his head so that's a definite strength that has stuck around. But it's like he completely forgets how to do it??? 
They do things and then don't do them any more for a while, quite often. Sometimes it's because the skill is so well mastered it's not interesting any more--  other times, who knows!

5) mirror: He shows zero interest in a mirror
Do you mean he doesn't recognize himself in a mirror? I wouldn't expect him to until about 18 months. Then you could try putting a dab of lipstick on his nose and showing him a mirror-- he will probably put his hand to his nose at once.

6) no walking but my oldest was 16 months before he walked so I'm not concerned about this
No reason to be concerned.

7) I can tell he understands some things I say, like get the ball, take a drink, where's dad etc. as for words, he has said dog, ball, and bear (along with mama and dadda), but now only seems to say ball appropriately
Receptive language (understanding) is much more important then expressive language (speaking).. Knowing what they actually say can be so difficult because they may not make the same sounds every time. You may just be missing what he says, or possibly he's busy on some other aspect of development. They don't work on everything at the same time or the same rate of speed.

He gets a kick out of feeding me, which I see as a huge strength but it's the eye contact that has me the most worried. I guess I'm hoping for either reassurance that he seems to be developmenting on the right track or a push to request services regards of being brushed off.

It sounds as if he does a lot of social interaction and that's on the right track.  They don't actually make a great deal of eye contact, if you measure it objectively-- a quick glance is all it takes, not a long gaze.

          Thank you for the support ;)

Thanks to you for the great descriptions! I'm sure other readers will benefit from them.

Just try to keep in mind that what toddlers can do and do do is so different from what adults do that it's really hard to figure them out. Jean Piaget referred to children this age as "cognitive aliens"-- their thinking is so different from ours that they might as well come from another planet. Or, as one of my grandsons says, They're ca-RAZY!