Concerned About Unconventional Mental Health Interventions?

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

Friday, October 29, 2010

When is a Five-Year-Old Older Than Another Five-Year-Old?: Interesting News About ADHD

It wouldn’t surprise most of us if a baby of 6 months acted a lot different from a one-year-old, and a one-year-old a lot different from a two-year-old. Those age differences eventually smooth out, of course, so someone who is 23 probably doesn’t behave much differently from someone who is 22. But when does that smoothing-out occur? We usually treat school-age children as if their grade level is more significant than their actual age in years and months, but this may be a mistake. A recent health economics research article suggests that it may be wrong to assume too early that exact age is irrelevant ( Elder, T. [2010]. The importance of relative standards in ADHD diagnosis: Evidence based on exact birth dates. Journal of Health Economics, 29, 641-656. www.ncbi.nlm.nih.gov/pubmed/20638739).

Elder’s work used a group of almost 12,000 children and examined the proportion of children diagnosed with attention deficit/hyperactivity disorder (ADHD) in groups that were the oldest in their grades or the youngest in their grades. Because public schools have an age/ birthday cut-off for school entrance and enforce this strictly, looking at a child’s birth date tells us whether he or she entered public school soon after the required birthday and thus was among the youngest in a class, or did not enter until almost a year after that birthday and was among the oldest in the class. If the cut-off date was September 1, children with August birthdays would enter kindergarten at no more than 5 years and one month, but a September birthday would mean that the child waited a year for school entry and came in at no less than 5 years and 11 months of age. Both August and September-born children would be 5 years of age, but the oldest children would be nearly 20% older (and more developed) than the youngest children.

Elder’s study showed that in fact the nearly-20% age difference had significant effects on the children’s ability to cope with the demands of school. About 10% of the “youngest” children (with birthdays shortly before school entrance) were diagnosed as having ADHD, compared to only 4.5% of the “oldest” children (birthdays almost a year before school entrance). In addition, there are long-term consequences of this diagnosis, and by fifth grade almost twice as many of the “youngest” children were taking stimulant medications intended to treat their attention problems.

This pattern was the same for states with a late-summer cut-off as they were for states that set their cut-off later. In all cases, younger children within a group were more likely to be diagnosed and treated for attention problems than older children were. Looking at teachers’ and parents’ assessments of children, Elder found that teachers were very likely to evaluate younger children as having more attention problems, as they compared them to other children in their class; parents were less likely to do this.

Elder’s work suggests that evaluation of attention problems in kindergarteners is influenced by the child’s maturity relative to that of other children in a group. An accurate diagnosis for a child of this age requires comparison to others who are close in age, not to those who are 10, 15, even almost 20% older than the child in question. A child who is 5 years and one month old is as much less mature than one who is 5 years and 11 months old, as a 13-year-old is in comparison to a 15-year-old. Teachers need to be aware of these facts, as their recommendations and evaluations can play a major role in diagnosis of children.

Elder’s work is of great importance in understanding diagnosis of ADHD, one of the most common mental health diagnoses for children (http://www.mchb.hrsa.gov/nsch/07emohealth/index.html). It is also relevant to the frequent use of medications that have the potential for adverse side effects, and to the creation of adverse expectations in adults who are aware of a child’s diagnosis-- both situations that may worsen the child’s developmental outcome.

The demonstration of relative-age factors for ADHD should also serve as a red flag with respect to various on-line checklists offered for diagnosis of other problems. For example, at http://reactiveattachmentdisordertreatment.com/ssi/checklist.html, a checklist is presented, purporting to be appropriate for children from age 5 through teen-age. It includes the item “has frequent or intense angry outbursts” without noting that what is “frequent” or “intense” for a 5-year-old may be quite different from what is defined in those terms for a teen-ager.

When making decisions about what a child needs, the question “how old is the child?” is always of primary importance. School systems show that they understand something about this by setting age cut-offs for school entry, but teachers, parents, and professionals need to remember that the details of age can make a big difference in a child’s needs and abilities. One 5-year-old can be a lot older than another 5-year-old.

Tuesday, October 26, 2010

Using and Abusing Metaphors: Attachment, Bonding, and Primal Wound

Several posts ago, I referred to ideas like the “Primal Wound” (a posited psychological injury caused by separation of a baby from its birth mother) as metaphors that could be helpful in therapy or in thinking through personal problems. One reader felt insulted by this statement and equated it with saying that proponents of the Primal Wound approach are “stupid”. I certainly didn’t intend to say that, although I think that if they considered the facts of infant development they would be aware that the Primal Wound is a socially constructed concept rather than a “natural kind”. I did mean just what I said-- that thinking metaphorically can be one of our best ways to figure out puzzling and complicated problems.

If any readers are old enough to remember the comic strip “Pogo”, they may recall the time when another character disparaged Rabbit by saying, “Huh! You ain’t nothin’ but a rabbit!”. Incensed, Rabbit declared, “I am not”. When Pogo Possum gently reminded him that he actually was a rabbit, he explained, “Yeah. But not a Nothin’ But A Rabbit!”. When I say the Primal Wound concept is a metaphor, I don’t mean a Nothin’ But A Metaphor.

To say that something is a metaphor is by no means to belittle it. In psychology, especially, it’s so common to deal with events that can’t easily be observed, events that we infer on the basis of other events, that metaphors are a large part of our stock in trade. The Greek root of the word metaphor means “transfer”, and metaphors transfer the characteristics of things we know well to things we don’t know well, in an attempt to understand the latter. Whether this is useful depends on the extent to which the characteristics of the known thing “map onto” (or match with) the characteristics of the unknown thing. Obviously, if the choice of metaphor is not good, this comparison will not be of much help in understanding the unknown, and this can easily happen because, by definition, we don’t really know the characteristics of the unknown.

We can’t do without metaphors, as the work of people like Hacking, Lakoff, and Johnson suggests. But we need to use them cautiously and watch out for misunderstandings that emerge from the metaphor itself. Two good examples of such misunderstandings are the use of the terms “attachment” and “bond”. Transferring all the characteristics of physical “attachments” or “bonds” to psychological relationships (that is, mapping the psychological onto the physical) is useful in some ways, but makes for misunderstandings in others.

When we consider a physical attachment, like a boat tied to a mooring with a rope, or an electronic one like a document sent with an e-mail, we are looking at a situation where each thing is equally attached to the other thing. The boat is tied to the mooring, and the mooring is tied to the boat. The document accompanies the e-mail, and the e-mail carries the document. These situations map onto emotional attachment in the sense that there is a special relationship between the boat and the mooring, and there is a special relationship between a child and an adult caregiver. However, while the boat and the mooring are equally and identically connected, this is not true of the younger and older human beings. The attitude, motivation, and behavior of the child toward the caregiver are much difference than those of the caregiver toward the child, and the two respond very differently to the breaking of the connection. The same is true for “bonding”; Epoxy bonds two pieces of wood equally to each other, but the attitudes of the “bonded” adult are vastly different from those of the child for whom the bond is experienced.

Using the “attachment” or “bond” metaphors is helpful for understanding, but it also carries the danger of misunderstanding. This is evident in the many inaccurate claims made by people who assume that adult and child experience identical and mutual emotional events, and who also assume that once the knot is tied or the glue set, attachment and bonding do not continue to change with development, but retain their original characteristics.

The language of the Primal Wound metaphor maps emotional experience onto a physical phenomenon. The first, second, and third dictionary definitions of “wound” all refer to injury to a physical body, and only the fourth gives the [metaphorical] meaning of an injury to one’s feelings. Characteristics of physical wounds are that they had an onset caused by some external event, that they hurt, that they are potentially dangerous to physical functioning or even to life, that they provide opportunities for infection or further injury-- but also that they usually have at least some capacity for self-healing. How do these characteristics map onto the Primal Wound, as the term is used by Nancy Verrier in her books, The Primal Wound and Coming Home to Self? Verrier and her followers use "Primal Wound" to refer to adult adoptees’ sense of being abandoned, alone, and grieving, and to the events that they believed caused these feelings, just as “wound” might be used to mean both a lingering injury and the initial damage.

The nature of a physical injury does map reasonably well onto the psychological experience reported by some adult adoptees. There is pain, there is potential danger of further related injury, there are reasons why a sufferer might have his or her pain exacerbated by other experiences. But there are some ways in which physical wounds do not seem to map onto this type of psychological pain. An important one is that while a physical wound has an observable onset and cause, the adoptees’ psychological pain does not have an observable onset in infancy; babies separated from their biological mothers at birth do not show distress, slowing of growth, apathy, or any of the other characteristics that signal grief in older children. It’s the use of the “wound” metaphor that implies that there must have been such an onset, rather than an observable onset that supports the use of the metaphor, and this demonstrates another way that metaphors can hinder our understanding--- by leading us to cherry-pick among evidence for the material our metaphor seems to demand. Someone in thrall to the Primal Wound metaphor may say, “Newborn babies must show distress when separated, because that’s what a wound would cause, and if no one has found any evidence of this it must be just because they haven’t looked the right way.”

Abuse of analogies is not just a trivial logical error. By fostering misunderstanding, it can lead to abuse of infants, children, and adults as well. In my opinion, the Primal Wound metaphor, a much-abused analogy, has done exactly that by encouraging mistaken treatments.

Monday, October 25, 2010

"Food for Thought": Dr. Dana Johnson's Webinar on Nutrition and Adoption

Yesterday I watched with great interest a webinar conducted by Dana Johnson,M.D., and organized by Adoption Learning Partners. Entitled “Food for Thought: The Impact of Poor Nutrition in Early Development”, this presentation focused on the nutritional histories of internationally-adopted children, on their nutritional needs after adoption, and on developmental outcomes that appear to be related to diet.

Dr. Johnson was careful to emphasize the difficulty of disentangling nutritional from social factors in development. Infants and toddlers in orphanage settings are likely to be deprived both in their diets and their experience of normal social interactions. For the family child, or for the child in high-quality foster care, mealtime involves far more than simply the ingestion of nutritious substances. It is a “cue-based” process in which the baby’s signals of hunger or satiety are responded to by caregivers. This process involves talking and listening, social communication by facial expressions, turned heads, or open mouths, and anticipation of what another person is about to do (a feature of “theory of mind”). Feeding in the family also involves the pleasures of taste and texture and a sense of gradual mastery of self-feeding, achieved in graduated steps as sensitive caregivers provide food a baby can handle.

In an institution, however, as Dr. Johnson noted, feeding is not cue-based but efficiency-based. Bottle-fed babies have their bottles propped so staff members do not have to sit with them-- thus removing all possibility of social interaction during feeding. Institutional caregivers spoon food into babies’ mouths as rapidly as they can, then go on to the next baby without taking time to socialize or play. Feeding can thus become an unpleasant experience rather than the pleasurable, playful, self-regulated one it ideally should be. By the toddler period, institutional children are expected to be able to feed themselves, and although they eventually become competent at this, months may go by during which they do not have the motor skills to ingest much food. All these problems are intensified for children who have malformations of the mouth or whose motor control is problematic, as might be the case when cerebral palsy is present. Babies who were of low birth weight are particularly affected because of their greater need for calories and trouble absorbing fats and carbohydrates. Fetal alcohol syndrome is another factor determining special needs.

The result of time spent in an institution is very commonly growth failure. Children adopted from institutions are generally undergrown in both height and weight, and may have smaller head circumferences than family children. One of the tasks of the first year after adoption is the fostering of catch-up growth, which is usually rapid when circumstances are good. (However, the tragic news reports of abuse deaths of internationally-adopted children generally note malnourishment of the child; it is hard to know whether this condition is due to failure of catch-up growth to begin with, whether it is part of a pattern of neglect and abuse, or even whether it is due to ill-judged attempts to use food to control the child’s behavior [see, for example, www.ncids.org/Brief%20Bank/Briefs/Salvetti,%20Paul%20J.doc].)

In his webinar, Dr.Johnson recommends a thoughtful approach to the re-feeding of growth-retarded adoptees. First, he suggests establishing a nurturing feeding environment, where eating together can be pleasurable socially and otherwise. As in so many aspects of child development, in the beginning, the relationship between the child and the caregiver is more important than the calories ingested or the parent’s “feeding skills”. A second suggestion is that the adoptive parent begin with foods familiar to the child. The Internet site www.spoonfoundation.org provides information about what children from specific countries may be accustomed to eating and recipes for indigenous foods. Although many adoptive families cook such foods as a way to celebrate the child’s origin, Dr.Johnson’s point is that initially these should not be special holiday foods. They are what the child is accustomed to and therefore will have the greatest appeal for him or her. (And while you might intuitively think that an undergrown child will be famished and ready to eat anything, this is not the case. Chronic underfeeding leads to apathy and lethargy, and these children need to be tempted and encouraged to eat.) This is, by the way, not a time to correct the child’s table manners or make a point of discipline by demanding that the child eat.

Once a child is eating well of a family’s version of familiar foods, other appealing, easy-to-eat foods may be gradually introduced. It’s a good idea to remember that toddlers, even those with excellent care histories, are reluctant to try new things (this is sometimes called neophobia), and will often try foods only after they have seen them a number of times without eating them. Parents should keep an eye on whether a child can handle lumps or other textural differences; if not, a feeding clinic or a speech and language pathologist may be of help in teaching the child to use the mouth and tongue better, which may also minimize later speech problems.

Dr. Johnson also referred to concerns about over-eating and hoarding of food, and recommended treating these issues with sensitivity. A very helpful piece about hoarding is at www.spoonfoundation.org, along with information on other related topics.

Friday, October 22, 2010

Chewing Off the Hand: Demonizing Nathaniel Craver

The Virginia psychologist Ronald Federici has found a new and scary way to blame adopted children for their own injuries. Commenting on the death of a western Pennsylvania boy who had been adopted from Russia, he has referred to another child who “chewed off his own hand” and to children with no sense of pain (http://www.washingtonpost.com/wp-dyn/content/article/2010/10/20/AR2010102004021.html and many other Internet sites). Federici and the defense attorneys for the adoptive parents, Michael and Nanette Craver, argued that the child, re-named Nathaniel, had injured himself fatally. An Associated Press article stated the Cravers’ argument that Nathaniel had suffered from Reactive Attachment Disorder, which, according to the article, “includes a tendency to injure oneself. “

Let’s consider each of these statements. Is it possible for someone to chew off his hand or to feel no pain? Individuals with the genetic disorder Lesch-Nyhan syndrome do chew off their lips and tongues as well as having movement and other problems. Schizophrenic patients have been known to gouge out their own eyes or break off teeth. And there are genetic disorders in which people unfortunately have no sense of pain and accidentally injure themselves as a result, for instance by failing to notice they are touching a hot stove until they smell burning flesh. Individuals with Hansen’s disease (leprosy) lose sensitivity in affected body parts and injure themselves by accident.

In all these situations, the sufferer shows many behavioral and physical symptoms in addition to self-mutilation or frequent accidental injuries. And, it’s clear, none of these problems is caused by adoption, although there’s a minute chance that a child adopted in infancy could have a disorder that is not yet noticeable. By the time any child reached Nathaniel’s age, seven years, ordinary observation and well-child care would have detected a set of problems that were not limited to self-injury, and which don’t seem to be mentioned at the trial . So, when the irrelevant statement about hand-chewing is brought into the discussion of Nathaniel’s death , our response should be, “what do the two things have to do with each other?” In my opinion, the purpose of this scary example is simply to distract attention from the real evidence about the events that led to this boy’s death. The “he did it himself” defense has been seen before in these cases; it was claimed that 2-year-old David Polreis beat himself to death with a wooden spoon, and even the very public videotaped death of Candace Newmaker was claimed by some to have been a deliberate act on the child’s part, for the purpose of punishing her therapists.

To continue the analysis: Is there any truth whatsoever to the statement that Reactive Attachment Disorder involves “a tendency to injure oneself”? Reactive Attachment Disorder is, of course, described in the Diagnostic and Statistical Manual of the American Psychiatric Association. But, no, no such behavior as self-injury is linked with RAD in DSM volumes of any vintage, nor is any such change predicted for DSM-V. This is proof by assertion at work. The Cravers and their attorney have made this statement without the slightest foundation in evidence, which they get to do in their efforts to be acquitted; it’s now up to the prosecution to ask the questions that will reveal that there is no truth to the statement, and the jury to pay attention to the facts.

In an interview with the Harrisburg Patriot-News , Federici also stated that Reactive Attachment Disorder is only a symptom “of a much larger and deeper disturbance”. This statement, like the previous one, would come as a considerable surprise to the committees that work hard to revise DSM periodically. While it’s presumably true that any behaviors, desirable or undesirable, are indications of underlying characteristics, it’s further proof by assertion and further distracting scare tactics to claim that the symptoms of Reactive Attachment Disorder indicate a nameless badness beyond DSM’s ken.

Let’s resist these attempts to depict Nathaniel as a demonic child, one of a group of terrifying, inhuman children who mutilate themselves horribly and cause unfair accusations of their loving caregivers. Let’s focus instead on the reality of this child’s life and the likelihood that he injured and malnourished himself.

And let’s hope the jury focuses on those issues, too.

Tuesday, October 19, 2010

Things Attachment Therapists Want Adoptive Parents to Think

A very sensible, well-educated, and dear friend of mine and her husband adopted a little boy from another country some years ago. He did not come to them straight from his birth mother, but was with a foster family until he was about ten months old. The new family settled down quite quickly, and the boy has developed nicely in every way. They’ve followed everyone’s directions about his transition, kept a life book for him, and stayed in communication with the foster family.

I was surprised a few months ago when the mother, whom I’ll call Mary because that isn’t her name, told me she was concerned that the little boy was experiencing grief for his birth mother. I asked why she thought that, and she said she had been reading that all adoptees have this problem. She also described conversations in which he had expressed concern for what had happened to his birth mother and why it was that she couldn’t take care of him. But it seemed to me that he expressed a lot of concern about many people, animals, bugs, and caterpillars, and that he didn’t seem especially preoccupied with the birth mother-- nor did he seem greatly worried about the foster family to whom he had had some chance to attach.

Recently I had a chance to visit Mary and her husband and son and to see once again what a great job they’re all doing. And Mary solved a puzzle for me by showing me the book that had caused her concern: Sherrie Eldridge’s Twenty things adopted kids wish their adoptive parents knew. In my opinion, this book would be better titled “A bunch of things attachment therapists wish adoptive parents believed”, because people who hold the beliefs Eldridge proposes would be very likely to accept both the theory and the practice of attachment therapy. As neither attachment therapy practice nor its underlying theory have any support in conventional mental health information, it is not surprising that Eldridge’s “things” are also unsupported claims. It would be excellent if adoptive parents knew about these issues, but they need that information in order to avoid inappropriate choices, not so they can follow Eldridge’s advice.

Let me comment on a few of Eldridge’s twenty things. First, we see that Eldridge is a proponent of the “primal wound” theory, claiming that all adopted children are suffering from the grief of separation from the birth mother, and need treatment that focuses on that loss. However, all the facts about early development and infants’ emotional attachment tell us that babies adopted into a stable family in the first months of life show no sign of distress or grief over the separation from the birth mother. Babies’ attachment to adults takes time to develop, and it’s based on a history of social interactions and emotional maturation, not on prenatal experience or genetic relationships. The birth mother may miss and grieve over her lost baby, but the baby does not respond in the same way, as he or she is physically, mentally, and emotionally very different from any adult. Relationship or mood difficulties in adoptive families benefit from pretty much the same kinds of treatment that would help non-adoptive families. Where a different focus is needed, it may involve the needs of the adoptive parents rather than the children, because a history of infertility or loss of children can cast a long shadow on a family.

A second point is that Eldridge proposes that young babies exist in a form of shared identity with the mother, a state described as symbiosis by Margaret Mahler and others, years ago. Eldridge does not refer to Mahler, and appears to have picked up this idea from Henry Cloud and John Townsend’s 1992 book Boundaries, from which she also took some of Mahler’s language (like the term “rapprochement”). The idea of symbiosis suggests that separation would be traumatic. There are some problems for this argument, though. One was that even Mahler did not propose that symbiosis was in place at birth, so it becomes irrelevant to early separation from the birth mother. Second, much of what we now know about communication between mothers and babies tells us that even the very young have some capacity for intersubjectivity, or knowing that another person is not the same as the self. I’ve recently come across people commenting on blogs who say that “it’s accepted” that babies identify self and mother as the same, but, as I just argued, that acceptance, if it ever existed, is certainly no longer the case, and for that reason it is not “accepted” that early separations are traumatic.

I’ll just add one more item to my list. Eldridge gives the standard checklist for identifying children with attachment problems--- the checklist seen on many an attachment therapy website, the one that suggests that disobedience, lying, preoccupation with blood and gore, and so on, are indications of the need for attachment therapy. This simply is not the case, for two basic reasons. Those behaviors have nothing to do with Reactive Attachment Disorder, and may or may not have to do with other mental health problems. In addition, whatever the family’s problems may or may not be, treatment that focuses on infant attachment alone could not solve the problems mentioned.

A look through Eldridge’s bibliography shows that at least half of the sources she cites are attachment therapists. There are several citations to Foster Cline, who is [in]famous for his claim that “all bonds are trauma bonds” and that a child’s emotional engagement with his adoptive family must involve traumatic experience. It’s clear that, without referring to holding therapy or related practices, Eldridge produced a book that reflects the attachment therapy “party line” as it existed in 1999 when the book appeared.

If Eldridge’s material seems to speak to your condition, use it as you find appropriate. Strange things can help people, I know. But please don’t accept all her statements without careful examination, and don’t assume that there must be problems with your child for which there is no visible evidence.

Monday, October 18, 2010

Hurray! The Baby's Crying!

I recently had an e-mail exchange with a friend. I began by saying “Hurray! When I walked up to my neighbor’s baby, he cried and turned away!” My friend answered, “That’s great!”

I looked at this correspondence and it suddenly struck me-- many people would think we were nuts to say such things. Are we people who enjoy being mean to babies? What could possess us to think it’s good when they cry? Well, there is method in our apparent madness.

I had been concerned about this particular baby, whose family lives on my street. When he was about 6 months old and was outdoors with his mother, I walked up and started a conversation. I noticed that the baby never looked at me and didn’t try to get our attention. But he did seem preoccupied with something he was looking at, so I thought perhaps I wasn’t very interesting in comparison. Then, several months later, I saw mother and baby outdoors again-- and the same thing happened. I recounted this to several colleagues at a meeting, and all expressed concern and asked whether the baby was in an early intervention program. They all felt I should talk to the mother about the matter--- although they conceded that she probably wouldn’t speak to me for two years if I did!

Thank goodness, a week or so later, when I walked up to the family, the little guy clouded up, began to whimper, and turned away from me to look at his parents. They were embarrassed that he was being “rude” to me, but I congratulated them on their good work and assured them that this was exactly what he should be doing.

What was going on here? Why do I think this infant should cry when he sees me-- or any other person who is not very familiar to him? I think so, because this changed behavior is an excellent marker of good development. Babies in the first months of life don’t “make strange”. They respond in about the same way to any smiling, sociable person. Somewhere around seven months the baby becomes wary and looks suspiciously and seriously at unfamiliar people, checking them out in the way Margaret Mahler labeled “customs inspection”. After inspecting a friendly-looking new person for a while, the baby warms up and gets sociable. By 8 or 9 months, most babies who have lived in a stable family or other care situation will respond to strangers with anxiety and do their best to turn away and look for or at their “own people”. A common scenario is that the mother is carrying the baby at the grocery store or other public place, and a friendly stranger approaches to talk to the baby. The baby turns away, puts his or her face against the mother, or moves to look to the mother’s other side. Friendly stranger knows what to do about this, and rushes around to look at the baby from the other direction! (Repeat ad lib until baby is bawling and mother is completely frustrated but trying to be polite to this person, who loves babies but doesn’t really think they’re people.)

These changes in the baby don’t occur because there have been bad experiences, or because the baby is spoiled and willful, or because of emotional disturbance. They are natural developments that take place in almost all babies who have had a normal basic level of adult care and social interaction, and they are good evidence that the baby is on a normal schedule of development. If a family baby of 9 months did not show reluctance to deal with a stranger, we would need to ask what the problem was; there might be difficulties with vision or hearing, or even with mental development in general. If a baby who had been cared for by many different people, or often moved from one care setting to another, and was friendly to everyone, we might well conclude that he or she needed to have a long period of consistent care from a few people, in order to have an opportunity to develop special relationships.

But why is it a good thing for babies to avoid strangers? It seems like a nuisance from a practical point of view. It means we can’t leave them with babysitters or at a new day care arrangement, without a whole lot of fuss. It means that people who care a lot about the baby but don’t see her often may be offended when the baby snubs them. What’s to like about it?

One good thing is that this situation acts to some extent like an “invisible playpen” and helps to keep babies near adults who care about them even when they’ve begun to crawl or walk. The safety factors that apply in modern times were probably even more important when our remote ancestors reared their children in wild and dangerous settings, and wandering away might lead to becoming a meal for a predator. In addition, though, treating familiar and unfamiliar people differently is a basic aspect of human behavior. A child who did not achieve the ability to do this would be a very odd person indeed and would not fit well into any human society. As a general rule, we give to and take from familiars and not strangers, we tell secrets to and trust familiars and not strangers, and we are more inclined to be sexually intimate with potential mates we are well acquainted with than those we have just met (twenty-something guys, I don’t want to hear about this-- it’s true of most people, anyway!). By about 9 months, babies have usually come to share these kinds of attitudes with the rest of their species.

If I ever designed a greeting card, I would make it one that said to young parents, “Congratulations! Your baby was afraid of a stranger today!”. That leap forward in development is far more significant than the first step or the first word, and it’s worth celebrating.

"Primal Wound" or "The Blight Man Was Born For"

Over the last week or so , discussions at http://osolomama.wordpress.com have centered around the idea of the “primal wound” (even though that was not the blogger’s plan). The “primal wound” in question is the posited emotional injury done to infants separated from their birth mothers. Those who support this idea believe that such an injury occurs even if the baby is placed with other caregivers at birth, and that the “wound” continues to cause pain all through life, unless it is resolved and healed in some way. Adult adoptees commenting at osolomama and elsewhere have made it very clear that they experience ongoing distress in close relationships, that they feel they have had this experience throughout their lives, and that they attribute their sense of distress to their history of early separation. (I am stating this simply and unemotionally for the sake of brevity, but the adult adoptees tell their stories vividly and with intense emotional engagement.)

But here’s the issue: nothing in all the careful work in developmental science done over the last century would suggest that it is possible for early separation to have a lasting effect on children who soon enter a stable, lasting adoptive family. All the information we have says that early-adopted children do very well (for example, Sharma, McGue, & Benson [1998]. The psychological adjustment of United States adopted adolescents and their non-adopted siblings. Child Development, 69, 69,791-802). Later-adopted children may have more problems, especially if they were in institutions for long periods or had risk factors that led to their being institutionalized to begin with, but often show good recovery over some years (for example, Rutter, Kreppner, O’Connor, and the English and Romanian Adoptees [ERA] Study Team of 2001.[2001]. Risk and resilience following profound early global deprivation. British Journal of Psychiatry, 179, 97-103).

In addition, the study of early development shows that infants do not show concern about attachment and separation until they are 6 months old or older. This does not mean that they cannot tell the differences between people, initially by smell and sound and later by looks. However, it does not seem important to the young baby to be close to a familiar person, as long as the caregivers they are with are sensitive and responsive to the baby’s needs (and of course familiar people may do a better job of reading the baby’s cues, first because they know the individual child well, and second, perhaps, because they may be highly motivated to take good care of that baby). It’s not until about 7 or 8 months that most babies will show by their behavior that they are afraid of a stranger, or temporarily disturbed by the absence of a familiar person, or deeply grieved and disturbed by an abrupt, long-term separation. It does not seem plausible that an event that a baby did not respond to at the time it happened would nevertheless cause later disturbance and grieving. The only possible argument that this could happen would seem to be based on the assumption that memories can be repressed and work some mischief from the unconscious, but the evidence is clearly against that idea.

These well-established facts suggest that there is no “primal wound”. The idea that there is such an emotional injury seems to have come out of the writings of a California marriage and family therapist named Nancy Verrier, whose thinking is strongly connected with that of William Emerson of APPPAH (Association for Pre- and Perinatal Psychology and Health). APPPAH is an organization that stresses the belief that unborn infants have conscious understanding of events going on around them, perhaps all the way back to conception or even before (you’ll have to read that part for yourselves). Verrier and her colleagues are committed to the idea that there is a biopsychological attachment between a baby and its birth mother, which when broken by separation creates a lasting emotional injury. This belief is based on some earlier views like those of Otto Rank, who suggested that birth itself is a traumatic experience for the baby; these approaches seem to be basically a reworking of the old “maternal instinct” assumption. Whatever the reasons behind the “primal wound” belief, it does not seem possible to integrate them with anything we can observe about early development.

A number of adult adoptees have found the Verrier viewpoint to make sense for them as more than a metaphor for their life situations. They feel an intense and disturbing sense of loss, which deserves to be treated with respect even though at the same time I argue against the cause they believe is behind it. People with this view of their life events ask, legitimately, “why do we feel like this if it isn’t because of our early losses?”. And of course I can’t really answer that question (certainly not to their satisfaction). I would suggest, though, that a sense of loss and loneliness is part of the experience of every thinking person. Gerard Manley Hopkins spoke of this in his poem about autumn and loss:
“Margaret, are you grieving… Over Goldengrove unleaving?.. Leaves, like the things of man you… with your fresh thoughts care for, can you?... ‘Tis the blight man was born for… It is Margaret you mourn for.”

We may not need to look to a history of early separation to explain why we human beings mourn for ourselves.

Thursday, October 14, 2010

On "The Road to Evergreen"

For anyone with an interest in adoption, or in the complementary-and-alternative treatment “attachment therapy”, Rachael Stryker’s recent book The Road to Evergreen is a must-read-- although it’s also a must-criticize, with plenty to concern developmental scientists, clinicians, adoptees, and adoptive parents. Although published in 2010, The Road to Evergreen is based on a doctoral dissertation completed in the early ‘00s and approved by a committee which included Nancy Scheper-Hughes, author of the remarkable participant-observer narrative, Death Without Weeping. Stryker, an anthropologist, followed some of her mentor’s approach, but applied it to a complex topic that lacks the fascinating generalizability of the Scheper-Hughes book. It’s important to note that The Road, though published in book form in 2010, is based on observations and interviews done in the late ‘90s. The book thus gives us a detailed picture of events a decade and more ago, and it is arguable to what extent the practices described are still current. (Proponents of attachment therapy usually say they are not; critics like me cite evidence that they are ongoing.)

Stryker’s interest in her subject matter began with investigation of institutions and adoption in Russia following the collapse of the Soviet system and the beginnings of systematic adoption of Russian children by Westerners. Subsequently, the author became intrigued with the functioning of adoption agencies and the behavior and motives of prospective and actual adoptive parents. These interests led her to the small town of Evergreen, Colorado, then, as now, operating a cottage industry for treatment of children whose behavior and attitudes were uncomfortable for their parents. Most of the children in treatment in Evergreen were adopted, and the intervention most likely to be used with them was “holding therapy” or “attachment therapy”. This physically-intrusive technique was claimed to remove the emotional attachments of adoptees to their birth parents, to create attachments to adoptive parents, and (it was argued,”therefore”) to make the children obedient, respectful, cheerful, and grateful.

Stryker is probably the only person other than attachment therapists, adoptive parents, or children to have witnessed attachment therapy sessions. Other information about these practices has come from descriptions by therapists and adult memories of treated children (see http://stopchildtorture.org), from news reports’ films of children in treatment, and from the 30 hours of videotape showing the treatment that ended in the asphyxiation of the ten-year-old patient Candace Newmaker in 2000 (see Mercer, Sarner, and Rosa, Attachment Therapy on Trial). Stryker’s description matches the other information and confirms the general accuracy of previous descriptions of attachment therapy.

Stryker’s real contribution is in her interviews with adoption staff and adoptive parents. She was able to establish rapport with those individuals, who presumably trusted her as they would not have trusted critics of attachment therapy methods. The material Stryker collected led her to a conclusion that may trouble many, although for different reasons: that the strongest motive for adoption was for the parents to feel like a family, and to be able to play the honored role of parents. In return for the care and material goods offered by the adoptive parents, the children had the job of behaving in ways that supported the adults’ actions and affirmed that they were respected and successful members of the adult community. Attachment therapy at Evergreen offered an assurance of bringing about this desired end in one way or another. If a child did not “improve” or “heal” to the point of going back to the adoptive home, he or she was placed in some other form of care, and this was described as “loving at a distance”. Whatever the outcome for the child, the adoptive parents were guaranteed support for their perceived position as parents of a family.

Stryker presents three cases, with one child “reunited” and the others placed for care outside the family. These families and their treatment are described in some detail. However, some important information is missing. At the time of this study, as today, children receiving attachment therapy were often placed in a “respite family” who provide a milieu reflecting the beliefs behind attachment therapy. The respite home experience includes complete control by adults over the child’s food, drink, and toilet access. Bedrooms are stripped of most furniture and decorations and have an alarm on the door. Children are required to sit immobile for long periods and to carry out tedious, unnecessary tasks like moving stones from one side of the yard to the other, and back again. But Stryker gives little description of these methods or their goals.

Although developmental scientists and clinicians would be interested to see Stryker discuss the poorly-designed outcome research that has examined the effects of attachment therapy, it’s obvious that such topics have no real place in her participant-observer work. However, given the time that passed between the initial observations and publication of The Road, Stryker would have done well to follow up her three reported cases and to note whether there were long-term differences between the “successful” and “unsuccessful” cases. The memories and beliefs of the now-adult adoptees would also have provided a rich source of further investigation.

My great hope, on picking up The Road, was that Stryker would examine any changes in attachment therapy beliefs and practices that followed reports of a number of associated child deaths, the most dramatic being that of Candace Newmaker at the hands of her therapists. The organization ATTACh (Association for the Treatment and Training of Attachment in Children) followed that tragedy within a couple of years by policy statements rejecting physical restraint for therapeutic purposes unless the child is willing (and of course it is highly arguable whether a child can give informed consent to such a procedure).However, some practitioners of attachment therapy apparently continue to use physical restraint, and no practitioner has stepped forward to provide a rationale supporting the change or explaining whether an entire belief system has altered.

Once again, I consider The Road to Evergreen a must-read for people interested in adoption and the attachment therapy issue, or indeed in many aspects of parenting and of complementary-and-alternative mental health interventions. But readers will be disappointed if they expect the book to give an up-to-date picture of attachment therapy or to outline the tortuous history of this unconventional practice.