Concerned About Unconventional Mental Health Interventions?

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

Thursday, December 23, 2010

A Quiet Lunch: Baby-feeding May Not Go Well at Parties

A friend was recently telling me about her new grandbaby, a plump but hungry little girl born by Caesarean section not long ago. The grandmother described how the young mother was worried about breastfeeding and fretting that the baby was not getting enough milk. She also told me of the scene at the new baby’s house when both grandmothers, friends, and various other visitors were all there, and the mother tried-- without much success-- to nurse the baby while socializing with the company.

Naturally, the difficulty she had with this nursing was disturbing to the mother. Like most mothers inexperienced with breastfeeding, she was afraid she wasn’t making enough milk and that the baby was starving. And the tenser she was, the more difficult it was for her to nurse the baby. Breastfeeding requires not only the “manufacture” of milk in the breasts, but a reflexive response to the baby’s sucking, the let-down or ejection reflex, that actually squirts milk out of the nipples. (This water-pistol effect is definitely part of the humorous side of breastfeeding!) Babies don’t just draw milk out of the breast as you’d suck lemonade through a straw, and if milk is not ejected, the baby will get only a few drops at a time rather than a mouthful. First-time mothers, especially, may find their milk does not “let down” easily when there is a lot of commotion or tension to deal with. Whether you’re particularly modest or not, you may find it awkward to nurse the baby when a lot is going on around you. From that point of view, it’s not surprising that my friend’s daughter-in-law had trouble breastfeeding while visitors were there.

But there’s another important point about this situation. The other half of the breastfeeding team, the baby, can also have trouble with exciting surroundings. This is so much the case that bottle-fed babies, too, may have trouble feeding when there are visitors-- and the bottle does not share the mother’s problems with letting down milk, of course.

Some years ago I was at a large party where a young mother had brought her toddler son and 6-week-old baby girl. The mother was longing to talk to all the people, many of them her cousins and friends she hadn’t seen for some time. She was trying to give the baby a bottle while she conversed, but guess what, the baby wasn’t having any; she would suck for a minute or so and then let go of the nipple, fretting. I guessed that everything was too exciting for this baby and offered to have a try. We went to a quiet room, sat down and snuggled and talked for a few minutes, then I offered the bottle and the baby slurped up every drop.

What was this all about? Did I have some kind of experienced-mother magic that I applied to this baby? No, but I was aware that even at the advanced age of six weeks, babies may have trouble organizing their feeding if there is something to distract them. In order to suck from breast or bottle, a baby needs to time properly her sucking, which brings milk into the mouth, and her swallowing. This seems simple to adults-- we even have the ability to swallow voluntarily, as in taking pills, or to take food into the mouth and hold it there without swallowing. But for the young baby sucking and swallowing are still primarily reflexive, and they have to occur at the right times and in the right order. Otherwise, the baby will choke on an excessive amount of milk, or the milk will run out of the sides of the mouth rather than going down.

So, what is the connection? Why should hearing people talk interfere with the baby’s coordination of sucking and swallowing? The problem is that a baby’s movements, breathing, sucking, and so on, are easily “entrained” to events in the environment. Entrainment means that the rhythm of actions begins to follow the rhythm of other things that are going on. It’s like adults dancing to music-- the movements of our feet follow the rhythms of the music. As adults, we can decide not to dance, or we can even dance to a different rhythm than the music that’s playing (though it’s hard to do that). Babies don’t seem to have any choice about entrainment. The rhythms of speech and movements around them can take over the rhythms of sucking and swallowing and make it difficult or impossible to do these things in the necessary pattern.

Young mothers may feel very out of things when they need to go away and be alone with the baby in order to nurse. But this may be exactly what’s needed for both parties. The mother may feel hassled and tense in a group of people, even though she wants to be there. The young baby is quite likely to be disorganized when talk, laughter, and movement take over her rhythms. A quiet place gives mother and child their best situation for feeding by breast or by bottle.

Monday, December 6, 2010

When the Romanian Orphans Grow Up: The Recent Report

What happens when children from severely-deprived institutional backgrounds are adopted into caring families? Adoption has been described as one of the most successful interventions, but how good a job does it do?

We are finding some answers to these questions bit by bit, as the English and Romanian Adoptees (ERA) Study continues to follow a group of over 300 children adopted from Romanian orphanages in the early 1990s. The ERA researchers are in the process of comparing the Romanian adoptees to non-adopted children as well as to adopted children who never had institutional care. This work is enormously time-consuming and complex, and involves repeated measurements and interviews at different ages, plus delays associated with analyzing, writing, and publishing the results of each phase of the investigation.

A recent presentation of the children’s characteristics up to age 15 has been published by Michael Rutter and co-authors as Deprivation-specific psycholkogical patterns: Effects of institutional deprivation (Monographs of the Society for Research in Child Development, Serial No. 295, Vol.75, No. 1, 2010). The 252 pages of this monograph are absolutely packed with information, some leading to conclusions, some not. I am going to try to pull out some points that may be of particular interest to readers.

An aspect of the monograph that will be of interest to many is the question raised in the title: whether there are psychological patterns that follow severe social and other deprivation in early life. The ERA investigated a group of characteristics that seemed more likely to occur in post-institutional children than in other adoptees. The following items were included:

1. Quasi-autism: A behavior pattern not identical with autism, but including rocking, self-injurious behavior like hair-pulling, unusual and exaggerated sensory responses, and tantrums in response to changes in routine, as reported in parent interviews (Gindis, B. [2008]. Institutional autism in children adopted internationally: Myth or reality? International Journal of Special Education, 23, 118-123).

2. Disinhibited attachment, as shown in unusual friendliness toward strangers and failure to show strong preferences for familiar people in threatening circumstance. The monograph describes disinhibited attachment as including “inappropriate approach to unfamiliar adults, a failure to check back with a caregiver in unfamiliar settings, and willingness to accompany a stranger and wander away from a familiar caregiver. It is often associated with a lack of appropriate physical boundaries, so that children may interact with strangers intrusively and even seek out physical contact… there is sometimes inappropriate affectionate behavior with strangers and undue physical closeness” ( Monograph, p. 58) .

3. Cognitive impairment, including problems with “mentalization” or the ability to understand what other people might believe or feel about a situation.

4. Inattention and overactivity similar to attention-hyperactivity disorders.

While by no means all children who had come from institutions displayed these problems, even those who had spent more than 6 months in a Romanian orphanage, the ERA group reported that over 90% of those who still showed the behaviors at age 15 had spent more than 6 months in severe deprivation. Those who persisted to age 15 with these problems had often improved (for example, become more likely to be helpful or comforting to others), but odd behaviors still occurred. Some children “annoyed other people but did not know why, and difficulties making or keeping friends were common… In a few cases, … inappropriate remarks included excessively outspoken sexualized use of language” ( Monograph, p. 86). Some children were reported as fascinated with collections, including those of “useless rubbish” like chocolate wrappers.

Can we generalize from the ERA children to other adoptees? While it’s useful for potential adoptive parents to have some idea of the types of problems they may see, it’s important to keep in mind some differences between the ERA group and many other adoptees. Members of the ERA group were aged 42 months or younger at the time of adoption, and most of them had gone to the institution shortly after birth. The Romanian orphanages were characterized by extremely severe deprivation, including confinement to cribs and bathing with water squirted from hoses, conditions unlike those in most other child-care institutions. Children with different histories may be quite different from the ERA group.

In addition to the possible effects of differences in background, the following facts are noted by the monograph: “A striking finding at all ages was the heterogeneity in outcome. Thus, even with the children who had the most prolonged experience of institutional care, there were some who at age 11 showed no indication of abnormal functioning on any of the domains we assessed. Conversely, there was a substantial proportion of children who showed impairments in multiple domains of functioning.” (p. 14). It would be a mistake for potential adoptive parents to assume that they can predict which outcome will belong to a given child.

Federici v. Mercer: The Story Behind the Lawsuit

A phone call this morning alerted me to the fact that the Virginia psychologist Ronald S. Federici is suing me and other critics in Fairfax, VA (CL10-16657, filed Nov. 24). As of today, I have not yet been served in this matter, but I assume that his complaint is that I have defamed him and interfered with his business, as he already brought such a suit in Small Claims Court and lost it, but is allowed to appeal.

What is behind this suit? The event that seems to have triggered it is that I published on my former Psychology Today blog a piece which I will present below. This piece, which I entitled “The Hungry Boy”, was based on a published opinion of the North Carolina Court of Appeals (www.aoc.state.nc.us/www/public/coa/opinions/pdf/090504-1.pdf), which discussed Federici’s involvement in an adoptive family situation that resulted in the incarceration of both parents for felony child abuse. The COA opinion quotes testimony Federici gave during the trial as well as the statements of the abused boy. (After writing “The Hungry Boy”, I obtained the transcript of the original trial, which does not counter in any way the statements in the COA opinion.)

Shortly after the publication of “The Hungry Boy”, Federici complained to and filed suit against me, Psychology Today, and other persons. Psychology Today took down “The Hungry Boy” and told me not to mention Federici’s name again. Although Psychology Today was served with a summons to appear in Fairfax, VA to answer the suit, and although I warned them that they should not default, they did not send a representative to appear in court and as a result a judgment for $5000 was given against them. I appeared and had a chance to see that Federici did not present evidence that he had been harmed by what I wrote nor that what I wrote was untrue (both necessary for a successful defamation case in the United States). As a result, the judge found for me.

Over the following several weeks, I did not mention Federici’s name on my blog, as instructed, but I did mention that I had been in court in a defamation case. Psychology Today responded to this by freezing my account on the grounds that I had broken an agreement with them, and I moved my blogging to http://www.childmyths.blogspot.com/.

Having lost his case in Small Claims Court, Federici had the option of an appeal to a higher court, and he filed this appeal against me and some other people. (He apparently came to some agreement with Psychology Today.) However, after some weeks, he decided on a “non-suit”-- to drop the case for the time being but to keep the option of reviving it. This revival is what he has apparently done as of Nov. 24, 2010.

What did “The Hungry Boy” say that was so disturbing to Federici? I’ll show you by posting the piece below.



The Hungry Boy: An Adoption Story, With Comments

Is starvation the key to good discipline and loving relationships in adoptive families?

In several posts on this blog, and in print publications over the last ten years, I have alluded to the suggestion by unconventional therapists that withholding food from adopted children is an effective way to shape desirable attitudes and behavior. Today, I’d like to tell some of the story of adoptive parents who took this advice, the consequences for themselves and their adopted child--- and the absence of consequences for the therapist who acknowledged in court that he had provided the treatment plan. I draw my information about this case from a document of the North Carolina Court of Appeals, issued Jan.19, 2010, and available at http://www.aoc.state.nc.us/ , as well as from a document prepared for the defense in this appeal and available at http://www.ncids.org/.

Here is the basic story. Paul and Leslie Salvetti adopted in the 1990s a little boy who had been born in Russia in 1993. Leslie later died, Paul re-married, and the new wife, Debbie, became mother to the boy, known as “Pesha”. At some point, the family’s functioning became less than ideal; “Pesha” reported to social services that Debbie had hit him with a frying pan and baseball bat, among other complaints, but it is not clear whether this was investigated.

According to the appeals court documents, Paul and Debbie felt that “Pesha” was “umanageable” by the time he was 13. In about February, 2007, the Salvettis consulted Ronald Federici, a clinical psychologist with a Psy.D. degree, licensed in Virginia, about their problems with “Pesha”. (The fee for this consultation was $5200 for three days of work.) Federici made a number of recommendations about appropriate treatment of “Pesha”, including the suggestion that ordinary meals should be contingent on improved behavior, but that “Pesha” should be provided with bologna sandwiches and fruit in any case.

The Salvettis also confined “Pesha” to his bedroom, where they covered the windows and removed most furniture , and these were the circumstances of his life for three months. “Pesha” later described himself as “cold and hungry” during this time. “Pesha” eventually escaped from the house and made his way to the authorities; at this time he was hospitalized for a week, during which time he gained 10 pounds. The Salvettis pled guilty to felony child abuse (intentionally inflicting physical injury, starvation) and in 2008 were sentenced to a period of imprisonment.

During the Salvettis’ trial, Ronald Federici testified on their behalf, and, unusually for a psychologist, commented on medical and genetic issues as well as psychological concerns; expert witnesses are generally expected to speak within their area of professional expertise. It is of particular interest that Federici testified to his belief that “Pesha” had not been substantially deprived of food. Federici and the defense attorney appear to have taken refuge in the ambiguity of the English language and to have interpreted the term “withheld food” to mean “withheld all food and liquid” rather than “reduced the amount and type of food available”. The defense argued that because some food had been provided, food had therefore not been withheld.

In addition, Federici testified to his opinion that children’s rage could cause them to lose weight, and that this, rather than food deprivation, was the cause of “Pesha”s” condition. (Although the implications of this statement were not discussed in the court documents that are available, I should point out that there is no known evidence to support Federici’s opinion.)
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So, what can we conclude from this case? Is starvation the key to good discipline and loving relationships? If not, what are its consequences? In this case, the consequence for “Pesha” was a terrifying experience and the loss of the home he knew. For Paul and Debbie Salvetti, the consequence was a period of imprisonment. For Ronald Federici , the consequence of his many activities has been popularity with the media, including a recent interview with National Public Radio in which he commented on the latest Russian adoptee scandal. Others who give similar recommendations have also found them lucrative.

If you are a member of an adoptive family, please note that you are not one of the people likely to benefit from using the withholding of food as a child-rearing technique.


*** That’s the end of “The Hungry Boy”. If you’re not sure whether my statements were accurate, you can read the North Carolina Court of Appeals opinion on line. Incidentally, the appeal in this case had nothing to do with any facts about what had actually happened, or any discussion of the appropriateness of Federici’s advice to the parents. The appeal had to do with the type of plea made by the parents in order to avoid trial, and whether they had actually understood that they would go to prison.