Concerned About Unconventional Mental Health Interventions?

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

Monday, October 31, 2011

Fallacies: Some Problems of Thinking About Infants and Children

It can be quite hard to think straight about child development, and even harder to think about practical child-related issues like parenting and teaching. One problem is that each of us individually (even teachers) can know only a limited number of children in our lifetimes--- yet we want to use that small number of children to generalize and come to conclusions about millions of children. Another problem is that even when we read about empirical research, or when we do it ourselves, so we have a lot of information, it still doesn’t work to make a prediction about an individual child on the basis of data summarized statistically. These problems make it awfully tempting to jump to conclusions from the information we have. Our jumps don’t always land us on solid ground.

I’m going to describe some fallacies, or errors in reasoning, that are all too easy to make when wrestling with complicated material about child development. Keep in mind that these have nothing to do with whether the basic facts are straight, although getting the facts wrong is obviously a problem too. Fallacies are mistakes we make in drawing conclusions even from correct information.

The ecological fallacy involves assuming that information about a large number of children can give us an accurate prediction about a single other individual. For example, in a recent series of articles, several psychologists have suggested that research work on the Strange Situation as a measure of attachment can justify using the Strange Situation to make a decision in a child custody conflict. Although no one would be justified in dismissing research evidence as a way to think about the family situation, it is fallacious to claim that what was found statistically in a study of a number of children will also be true of a single individual. The statistical findings were calculated from a set of measurements which were different from each other, and no single one of them may have been exactly equal to the calculated statistics. (But this does not mean that it is useless to compare an individual child to characteristics of a group, as is done in calculating the height or weight of a child relative to growth norms.)

The post hoc fallacy is the assumption that if one thing happened after another, the first thing to happen must have caused the second event. (In some cases, of course, the first did cause the second; the error is to think that it must have done so.) This is a common error of reasoning about child development. In its broadest form, it leads to the belief that because childhood happens first and everything else happens later, events in childhood must be the cause of all adult events such as happy or unhappy marriages, success or failure in school, and abusive or nonabusive treatment of one’s own children. By this reasoning, infancy and early childhood are of necessity more important periods than later childhood, as suggested by Bruce Perry and many others. A specific recent example of the post hoc fallacy is the belief that if adolescents who behave violently have been engaged in violent video games, the games are necessarily the cause of the violent behavior. (This idea was in fact shown in the syndicated comic strip “Funky Winkerbean” this morning, which suggests that it’s now something “everybody knows”.)

The misleading vividness fallacy involves the assumption that an event that is experienced, remembered, or imagined with many vivid details and strong emotional implications is more likely to cause an important outcome than events that are remembered or imagined vaguely or without much associated emotion. One special issue for child development discussions is that adults who would experience a strong reaction to an event right now are likely to attribute that same strong reaction to an infant who experienced a similar event. For example, an adult who can experience or imagine vividly a powerful reaction to abandonment or separation from a loved one may incorrectly attribute the same kind of reaction to a newborn baby; this attribution may lead the adult to assume that an experience of separation for a newborn was not only emotionally vivid but must of necessity be the cause of important life outcomes.

The genetic fallacy (nothing to do with heredity!) reasons that the origin of an idea provides the proof of its correctness. A common form of this fallacy looks at beliefs as proposed by one’s grandmother, a member of the clergy, or an experienced foster parent, and takes the sterling qualities of the sources to be evidence that what they say must always be correct. For example, when I was asked to discuss a problem with a young foster mother some years ago, I found she was far from interested in my attempts to re-frame a foster child’s bad behavior; she responded, “My grandmother says something different, and she goes to church every Sunday, so I think she’s right.” The genetic fallacy also applies to situations where people take a position because “I was always taught…” or “in my family they say…”. As in other fallacious reasoning, of course, the claim about child development may be correct, but it is not correct because of its origins--- other evidence must exist to show that it is correct.

If you are in an argument with somebody about a child development issue, don’t expect to be able to win by demonstrating a list of fallacies your opponent has committed! That strategy will just make them madder and more intransigent. The usefulness of looking for fallacious reasoning is really in our individual examinations of our own beliefs. It’s hard for most of us, including me, to ignore vivid experiences, for example, and there’s so much post hoc reasoning around that we can easily be sucked into it. But if we all examined our own beliefs more carefully--- well, we might be able to improve our thinking, and the world along with it.

Sunday, October 30, 2011

What Is Child Abuse? Not Such an Easy Question

Most parents and teachers feel that, although they can’t necessarily define child abuse, they know it when they see it. Given anecdotes about several children’s experiences, they can readily identify each one as having been “abuse” or “not abuse”. Nevertheless, the term “child abuse” can be confusing. At times it’s used simply to mean that the speaker doesn’t like something, as in Richard Dawkins’ famous statement that religious instruction is child abuse. In addition, what is or is not abusive changes historically. I’ve been reminded of that recently by a communication from a distant relative of about my own age, to the effect that the person’s father used to punish his children by imprisoning them in a rabbit hutch. People now past middle age may remember that kind of punishment, or having their mouths washed out with laundry soap, or being sent to bed without supper-- not methods practiced by every family, but frequent enough to be known and recognized, and not widely perceived as abusive.

Even psychotherapists and other professionals may be unsure about whether a parent’s action constitute abuse or neglect, and they want to be sure because they are required to report to child protective services when they have knowledge of such actions. The other day, I was present at a discussion in which a therapist who works with parents was expressing her concern over a patient who had moved away. but had called to tell some things about her toddler’s life that had caught the therapist’s attention. Nothing had really happened, but the therapist was worried not only about the child but about her own obligations and the effect on her licensure if she made a mistake.

If we want a nice clear definition, can’t we just consider child abuse to be a matter of breaking laws about how children should or should not be treated? No, unfortunately that does not work very well. Statutes prohibiting abusive treatment are written as generally as possible for fear of omitting some unusual but undesirable action. There may be no very bright line between a permitted punishment and one that is regarded as abusive. If a child may legally be sent to her room as a punishment, does it matter how small the room is? Is being confined to a bathroom, or to a closet with a light in it, equivalent to being sent to her room? When does a structure become a large cage rather than a small room?

In day-to-day legal decisions, these matters are treated on a case-by-case basis, and considered within the context of factors like past history, the child’s age, and so on. But it would be impossible to do reliable research on child abuse if two cases that were counted in the same way actually had very different characteristics. Over a number of years, the four National Incidence Studies of Child Abuse and Neglect have worked out categories and definitions of child abuse events that are used for the purpose of describing samples of cases and extrapolating the frequencies of events in the United States. The most recent of these studies, NIS-4, is described at https://www.nis4.org/DOCS/ProjectSummary.pdf. The description discusses “sentinel agencies” which are asked to report to NIS-4, and notes that “the kinds of abusive and neglectful situations included in the NIS do not necessarily correspond to those covered by their state’s child abuse and neglect reporting statutes. The study guidelines should not be interpreted as indicating whether an official report is required or appropriate” (important points for professionals who are mandatory reporters of abusive treatment).

Other documents, such as http://www.nis4.org/NIS_History.pdf show the development over time of categories of child abuse. For example, failing to seek necessary medical care is one category of abuse and neglect, but the category was fine-tuned to exclude failure to provide even legally-mandated immunizations, unless the parent had received specific advice that this ought to be done. This decision is obviously arguable, but it involves recognition that failure to immunize, out of ignorance or because of religious objections, is a different matter from failing to have a child professionally treated for a broken leg. The History document shows steps in the development of current definitions, from the original telephone and in-person interviews with parents to more recent interviews with child protective services supervisors.

Does child abuse consist of actions that cause harm to a child? Generally speaking, behavior is likely to come to the attention of authorities only if some demonstrable harm has resulted. However, by NIS standards, there are actions that are so egregious that they are considered to be abusive even if no harm to the child can be demonstrated. These are shown in Table 6.2 of the History document and are described as having “assumed” harm. They include sexual penetration, abandonment, and failure to permit a runaway to return home. Also included are tying or binding of a child, but not confinement to close quarters (for which harm must be demonstrated).

The NIS definitions do not specifically mention (except as “other”) some forms of maltreatment that have been discussed on this blog. “Hot-saucing” (by putting stinging condiments on the child’s tongue) and restraining the child physically in the prone position are not discussed, possibly because they are quite rare or because they were little known at the time the NIS definitions were being developed.

Neither do the NIS definitions address the problem of the therapeutic use of actions that would ordinarily be defined as abusive or neglectful. If there were evidence that methods like prone restraint or food withholding are effective treatments for emotional disturbance, their use under appropriate circumstances could not be defined as abusive-- but of course there is no such evidence. And although there is evidence that aversive treatment like electric shock can be an effective way to stop severely disturbed children from mutilating themselves, there is no evidence that broad-scale, noncontingent use of such methods (as in the Judge Rotenberg Center cases) is a generally-effective disciplinary approach. Quasi-professionals or misguided professionals may advise parents to use such methods and may persuade child protective services or the courts that they are not abusive in spite of all evidence to the contrary. It would be wise if NIS efforts to come followed the thinking of reports like that of the American Professional Society on the Abuse of Children (APSAC; http://depts.washington.edu/hcsats/PDF/Attachment TaskForceAPSAC.pdf) and gave serious consideration to the problem of abuse in the guise of intervention.

Thursday, October 27, 2011

Steve Jobs and That Primal Wound

Once a myth gets into circulation, it’s awfully hard to get it out again. What “everybody knows” comes to be regarded as just common sense, even though it’s actually common nonsense. A case in point: the recent discussion of Steve Jobs’ difficult personality and its attribution to his having been adopted.

Maureen Dowd’s op-ed column in the New York Times on October 26, entitled “Limits of Magical Thinking”, did not claim that Jobs’ conduct was caused by his adoption history, but did quote two other people who thought so. The mother of his more-or-less-abandoned oldest child stated that being adopted had left Jobs “full of broken glass”. His friend Andy Hertzfeld said that Jobs’ cruel behavior toward others “goes back to being abandoned at birth”. Although they did not use those words, both these people seem to be believers in the Primal Wound idea-- that separation from the birth mother, even in the early days of life, causes long-term misery, rage, and grief.

Given the Primal Wound concept, it’s easy to focus on a single possible factor and neglect to consider the thousands of other events that shape a personality. It’s particularly easy to confine oneself to looking at early childhood and to forget that the circumstances of adulthood also contribute to mood and behavior. It’s easy, too, to neglect to consider the Zeitgeist—the spirit of the times-- and the extent to which reprehensible behavior was excused or even admired.

Let’s have a look at the interpersonal behavior of some non-adopted people in the ‘70s, ‘80s, and even more recent times:

1. The famous Newt Gingrich hospital visit to tell his very sick wife he was divorcing her

2. The Roman Polanski drug ‘em and leave ‘em approach to a girl in her early teens

3. Woody Allen-- need I say more?

4. John Edwards and his out of-wedlock child

5. Jesse Jackson and his ditto

Without naming names, I can also mention personal acquaintances from the time when Jobs did his child-abandoning-- non-adopted, non-celebrity people who were enraged at the idea of child support, who insisted that a handicapped adopted child be “given back” as “too much trouble”, or who proposed that a handicapped 18-month-old alternate 6 months with the father and with a mentally-ill mother in another state.

There are a couple of important issues here. One is that there are plenty of non-adopted people who—whether or not they are “full of broken glass” (or any other substance)-- excel at making the world full of broken glass for those who are dependent on them. If Jobs’ sins are to be blamed on his adoption, what do we blame those people’s bad behavior on? Do both adoption and non-adoption create the same outcomes? If so, it’s hardly worth discussing the matter.

A second point is that fame and fortune provide opportunities for bad behavior that may not be available to those who are just soldiering on in ordinary life. Those who sport entourages can count on those entourages to cover their tracks. Those who live outside the rules of employment and family life can leave for distant spots and make sure their paths do not cross with those boring and annoying “exes” and children.

And a third point: there have been periods of time when “going with the flow” and “following your bliss” were widely-accepted goals. The ‘70s and ‘80s were periods when irresponsible behavior of men toward women and children was to some extent admired in the United States. Having shifted toward a greater emphasis on fathers’ responsibilities (for example, couples who say, with social if not biological accuracy, “we’re pregnant”), we find it shocking to look back at a not-so-distant period when that was not the situation. In considering Steve Jobs’ life, it’s easy to forget that he would have been influenced by the prevailing attitudes of the time, in addition to multiple other factors, not omitting his life with his adoptive family. The attitudes that prevailed during his youth may have helped shape his personality development in ways that conflict with today’s popular value system.

Children adopted in the early weeks or months of life have been shown to have no more and no fewer emotional problems than non-adopted children, by extensive research on large populations of children. It would be foolish to expect that no adopted child would behave badly, exhibit mood disturbances, or even have serious psychopathology. Non-adopted children have these problems too, and in about the same proportions as those adopted early in their lives. The two groups share these characteristics, so it makes no sense to say that in one group the problems are caused by adoption and in the other they are not. (Such an argument would require us to claim that the group of adopted children is genetically superior to the group of non-adopted children, and the adoptive parents are better parents than the non-adoptive parents, so that the only remaining cause of problems is the adoption itself. )

No doubt proponents of the Primal Wound myth will add Steve Jobs’ story to their repertoire of evidence that adoption is in itself harmful. Those who think through the facts of early development and of research on adopted children will reject that viewpoint, and will realize that Jobs’ behavior was comparable to that of many other famous, but non-adopted, people, as well as to actions of the less famous.

Incidentally, Nancy Verrier, the author who has drawn attention to the Primal Wound concept, has never answered the questions in my open letter of some time ago.

Thursday, October 20, 2011

More About Reactive Attachment Disorder: "The Boarder" Movie

I’ve mentioned misconceptions about Reactive Attachment Disorder many times before on this blog. But it would seem that it’s possible to promulgate myths and misunderstandings on this topic a lot faster than I or anyone else can correct them.

A new example of the spread of misconceptions about Reactive Attachment Disorder is the movie “The Boarder”, created by Jane Ryan and based on her book “Broken Spirits, Lost Souls: Loving Children with Attachment and Bonding Difficulties” (iUniverse Star, 2004). (Incidentally, iUniverse is a “professional self-publishing” company rather than a traditional publisher that sends manuscripts for expert review before accepting them.) “Broken Spirits, Lost Souls” includes a foreword by Foster Cline, the well-known advocate of holding therapy and proponent of the belief that “all bonding is trauma bonding”; following the surrender of his medical license, Cline became a self-proclaimed expert on child psychopathology and effective parenting. “Broken Spirits” begins with unsubstantiated claims about the increasing incidence of Reactive Attachment Disorder and describes cases of teenagers planning Columbine-like massacres as if this behavior is caused by Reactive Attachment Disorder. It goes on to quote with approval the ideas of advocates of holding therapy like Martha Welch.

www.theboardermovie.com/what_is_rad.html provides a page that purports to offer definitions and descriptions of Reactive Attachment Disorder. In fact, its answers to the question “what is RAD?” are a mélange of accurate and inaccurate statements. Curiously, there is a link to http://en.wikipedia.org/wiki/Reactive_attachment_disorder, a Wikipedia featured article which in fact I wrote much of myself. But much of what is argued on the “Boarder” page is highly questionable. One inaccurate statement is that Reactive Attachment Disorder was once rare but is no longer so, as the number of children affected by neglect or abuse is rising “exponentially”; neither of these claims is supportable by evidence, nor is there necessarily a connection between them.

The author of the “what is RAD?” page-- presumably Ryan or a colleague—states that one possible cause of Reactive Attachment Disorder is separation from primary caregivers in the first 33 months of life, “including while in utero”. This is far from accurate, and is of special concern because of its implications about the developmental effects of adoption. While unpredictable and unresponsive care are factors in the development of Reactive Attachment Disorder and other problems like language delays, separation in the first six months does not appear to be problematic. Abrupt long-term separation after 6-8 months, when attachment emotions and behavior emerge, is associated with intense grief and other emotional reactions for a period of some months, but care by normally responsive and consistent caregivers facilitates recovery and the outcome does not involve Reactive Attachment Disorder.

Ryan (or her colleague) goes on to say that the “criteria for a diagnosis of Reactive Attachment Disorder are more severe and pronounced than the criteria used in the assessment or categorization of other Attachment Disorder styles such as insecure or disorganized attachment”. This statement shows a complete misunderstanding of the nature of Reactive Attachment Disorder and the concept of attachment styles (not Attachment Disorder styles). In “Broken Spirits”, Ryan makes it clear that she believes Reactive Attachment Disorder is shown through the checklist so often presented by proponents of holding therapy/Attachment Therapy-- the fascination with blood and gore, the “crazy lying”, fire-setting, animal torture, sexual molestation of other children, etc., etc.

These “symptoms” are completely non-overlapping with the description of Reactive Attachment Disorder given on the “what is RAD?” page, with any description in DSM or ICD, and certainly, as I can attest, with the linked Wikipedia article. Such child behaviors do occur, sad to say, but they are not aspects of Reactive Attachment Disorder. To claim them as signs of Reactive Attachment Disorder is like saying that because some (unimmunized) children do get an illness that involves swelling of glands in the neck, that kind of swelling should be called chickenpox. Understanding and treatment of mumps would be much lessened in effectiveness if the disease was assumed to be the same as chickenpox, and in the same way understanding and treatment of disorders like early-onset schizophrenia would be lessened by assuming that its symptoms were indications of Reactive Attachment Disorder.

Some readers may find it unimportant whether Ryan speaks of “Attachment Disorder styles” or “attachment styles”. In fact, the difference is an important one. To say “Attachment Disorder styles” implies incorrectly that a wide variety of psychopathologies are based on attachment problems, and that the standard Reactive Attachment Disorder is only one among them. Describing insecure attachment as an “attachment style” communicates corrrectly that this type of attachment behavior is in the normal range of development. Some have even argued that there may be social and family situations where insecure attachment is healthier and more appropriate than secure attachment. Disorganized attachment may be a normal response of toddlers to temporary family dysfunctions like divorce and custody disagreements, and a return to more stable relationships may enable the disorganized child to return to a better attachment style. (However, some methods of assessing attachment do not even use the “disorganized” concept, and it is not a basic part of Bowlby’s attachment theory.)

Will “The Boarder” ever be released? The web site indicates that contributions of money are needed to make this possible, and I have little doubt that it will occur. There are quite a number of quasi-professional therapists who benefit greatly from the spread of the inaccurate beliefs presented in Ryan’s book. Regrettably, there are also many parents-- especially those who have adopted-- who will rush to have their expectations confirmed by Ryan’s book and movie.

Meanwhile, those of us who know something about early development had better do our best to argue against these false and potentially harmful beliefs.

Wednesday, October 19, 2011

Babies and TV: Why Not Have Them Watch?

The American Academy of Pediatrics has again spoken against screen entertainment for children under two. They made their first policy statement about this in 1999, and they haven’t changed their minds. You can see a discussion of their position and thinking at http://www.nytimes.com/2011/10/19/health/19babies.html. When TV first became available, the cautionary joke was that if you watched too much your eyes would become square; the AAP today is seriously cautioning that young children’s mental development can be slowed by exposure to this kind of stimulation.

Is there clear evidence that television, videos, and computer displays do interfere with cognitive development in the first years of life? No, as a matter of fact, the evidence is not very clear, because it’s very difficult to establish. Because the first principle of research on human beings is to do no harm, and because that principle is especially important for the study of the very young, no one is going to do a randomized controlled trial (experimental) study of the effect of screen-watching on intelligence and academic ability. We’re left with nonrandomized studies, in which babies who ordinarily watch screens a great deal are compared with those who watch little or no screen entertainment. But although such evidence should certainly be given some weight, it’s important to remember that it involves confounded variables-- a confusion between the effects of screen-watching itself and other characteristics of families who do or do not expose their young children to screen-watching experiences.

It seems unlikely that chance alone determines the amount of screen exposure young children get, because on the whole they depend on their caregivers to set up a program, turn a device on, etc. Parents do or don’t do these things because of their own beliefs, motives, needs, and understanding of their children’s needs, and those beliefs and so on will also impact other aspects of their caregiving. For instance, parents who are exhausted or overwhelmed by problems may be more likely to want their children to be distracted and to leave the adults alone, but they may also talk to and look at the children less or be more irritable and difficult to communicate with. Parents whose poverty keeps them cooped up in a small apartment with their children, and whose dangerous neighborhood discourages them from going outside, may find screen-watching a lifesaver, but their children’s development may also be influenced by living in a poor and frightening place. When these children with a history of extensive screen-watching do poorly in school, we can’t know which of these factors really caused the problem-- or indeed whether it was caused by all the factors working together.

Nevertheless, all the major thinking of the last century about early mental development has emphasized the idea that children under the age of two are active rather than passive learners. They can learn some things by watching other people, but on the whole their understanding of the world develops through activity and interaction with the environment. They learn, for instance, that an object still exists when it’s hidden from view, and they learn this by crawling, reaching, grabbing, and mouthing objects, not just by observation (and certainly not by instruction).

Jean Piaget, the great Swiss theorist of cognitive development from birth into adulthood, referred to the period from birth to two years as the “sensorimotor” stage. He used this term to describe what he believed was the essential nature of early learning-- that it was based on a combination of information from the senses and from movement. He considered that toward the end of this stage toddlers became capable of symbolic thought and no longer were forced to learn solely through sensorimotor means, but that human beings continue throughout life to have a capacity for sensorimotor learning. Piaget’s theory of early development was based on a small number of direct observations of young children, and more recent work suggests that infants can learn some things by observation much earlier than Piaget believed. Nevertheless, it is a generally accepted idea among developmentalists that combined sensory and motor experience plays the major role in the early learning which forms a foundation for later school success. This view strongly suggests that much exposure to screen-watching will take away time from the needed sensorimotor experience from which young children learn most. The problem is not what screen-watching causes to happen, but what necessary experiences it interferes with.

A more recent thinker, the late Stanley Greenspan, the outstanding child psychiatrist and developmental theorist who founded Floortime/DIR as a treatment for autism and other problems, added an important concept to Piaget’s view of sensorimotor learning. Greenspan saw the senses and movement as essential to early learning, but in addition he emphasized that the most effective learning involved multisensory stimulation. In order to learn efficiently and to be interested, babies need to have a variety of senses stimulated at the same time-- not just vision, but hearing, touch, taste and smell, and movement senses of various kinds. What is most likely to provide excellent multisensory stimulation? It’s interaction with an interested, affectionate, engaged adult. That adult is not planning to give some planned form of instruction or purposely “teach” the baby, but because he or she is attentive and involved, whatever happens next helps the baby learn.

The affectionate caregiver provides the baby with two essential conditions for good learning. One is a combination of sensory experiences-- the warmth of touch, the rhythms of movement, the visual interest of facial expressions and eye positions, and speech or other sounds like humming and tongue-clicking. These are combined with each other into patterns that are more than the sum of their parts, as voice sounds follow the same rhythm as facial expressions and touch changes together with the movement of the adult body. These patterns offer powerful forms of sensory stimulation which draw the intense interest of the baby. In addition, the adult’s movements, speech, and gaze can all be instantly modulated in response to what the baby responds to-- what Greenspan, in talking about slightly older children, called “following the child’s lead”. The interested, caring adult provides multisensory stimulation that engages the baby’s interest and maintains it in ways impossible for any screen that offers entertainment to the passive baby. When babies spend much of their time in screen-watching, the opportunities for multisensory stimulation are limited.

There are other issues about screen entertainment or similar stimulation. One is that infants and toddlers have not yet achieved good control over attention (most of us are never perfect on this point). Where there is a great deal of noise or activity, young children find it difficult to focus mentally on everyday things they would otherwise learn about the world. The National Association for the Education of Young Children makes a point of this in their standards for early childhood education, in which they suggest that early childhood classrooms need to have low noise levels most of the time so that children can pay attention to speech or other sounds. Young children have trouble ignoring loud or distracting stimulation, which may draw them away from important sensory experiences. I recall visiting a foster home where a two-year-old boy was completely distracted by a television set and some music playing simultaneously. He stood between the two sounds and rocked back and forth from one foot to the other, and didn’t respond to his name being spoken. He was totally engaged with a sensory experience that was not meaningful in terms of the learning he needed to be doing--- in strong contrast to what he might have experienced if sitting on someone’s lap looking at a picture book.

The American Academy of Pediatrics and other interested groups are not concerned about what screen-watching does to children, but about what it prevents them from accomplishing. Because of the special nature of early childhood learning, watching passively does not give infants and toddlers the learning experiences that older human beings can achieve through observation. This is true no matter how carefully programming is claimed to have been designed for the very young.

Thursday, October 13, 2011

How Does Maternal Depression Affect Young Babies?

When I’ve mentioned maternal depression on this blog, I’ve sometimes been quite surprised to have readers respond as if the condition was a moral failure rather than a mental illness. That attitude was especially common when the reference was to depression in adoptive mothers-- some seemed to think that such women were simply spoiled brats who changed their minds about what they wanted after they discovered that baby care was a challenge. I don’t think there’s much point to arguing about that belief. Depression is more common in women than in men, and is especially common during the child-bearing years. Although some women who are depressed while caring for young babies have been depressed earlier in their lives, it is also true that life-changing events-- even much-wanted ones-- can trigger depressive reactions, however counter-intuitive that may be.

Mood disorders in young mothers can exist for a variety of reasons. But it doesn’t really matter whether they occur because of moral turpitude or because of a genetically-determined emotional disturbance. In all cases, effective treatment is desirable, because a depressed caregiver cannot provide the foundation for a baby’s good cognitive and emotional development.

Why is this? How can a very young baby even know what a caregiver’s mood is? And as long as it’s fed, warm, and clean, why would the baby care?

To answer these questions, it’s important to look very closely at communications between caregivers and young babies-- communications that are quite subtle and occur very quickly, so a casual observer can notice only a few, if any, of them. Understanding such communications requires a microanalysis of videotaped movements and facial expressions. These can be examined in the order in which they occurred, so it’s possible to see how each member of the pair responded to changes in the other. (As an example of this, I’m going to summarize an article by Reck, Noe, Stefenelli, Fuchs, and others, “Interactive coordination of currently depressed inpatient mothers and their infants during the postpartum period”, Infant Mental Health Journal, 2011, Vol. 32, pp. 542-562.)

Ideally, we’d expect the baby and the caregiver to be coordinated in their behavior and mood, and to respond to each other by matching a communicated mood (what Edward Tronick calls mutual regulation). But we’d also expect that the two will occasionally make mistakes or “mismatches” and respond with a smile to a frown, or vice-versa. Normally, baby and caregiver fairly quickly notice their mistakes and “repair” the communication by moving to match the other’s mood more closely. Those repair events seem to be even more important than frequent accurate matches, because they teach the baby that moods can be changed and regulated, and that mistaken communications can be corrected with effort.

Reck and her co-authors looked at a group of mothers who were hospitalized together with their babies for treatment of serious depression, and compared them to a group of healthy mothers and their infants. They observed the frequency of positive matches (when both partners showed positive emotion) and negative matches (when both showed negative emotion such as crying, withdrawal, hostility, or intrusiveness). Because it has been reported that maternal depression interferes with the development of joint attention (looking at an object and then back at each other), shared looking at objects was also studied. There was particular interest in the pairs’ abilities to repair mismatches and come to similar positive states. The babies ranged from 1 to 8 months in age.

In order to encourage mothers and babies to show their social interactions, the researchers used the “face-to-face still-face” method. In this, mother and baby were seated opposite each other, with one video camera recording each face’s expressions and a single microphone between them. The mothers were instructed to begin just with a normal interaction, to get the babies’ attention and play with them without using toys or a pacifier. After two minutes of this play, the mothers were to do two minutes of an unresponsive “still face”, in which they simply stare into space toward the baby without responding to the baby’s bids for communication. For the final two minutes (the “reunion” phase), the mothers were to return to normal responsiveness and engage with the baby again.

Depressed mothers and their babies did behave somewhat differently from healthy mothers with their babies. When the mother was depressed, repair of mismatches took longer. Healthy mothers were quicker to repair mismatches in the reunion phase than in the initial play phase, as if they were “trying harder” after the difficult period of the still-face episode, but when mothers were depressed the difference was the opposite. There were also differences in the time it took the mother-baby pairs to come to a match. For the healthy mother-baby pairs, half of them got to a positive match in 3 seconds after they began, whereas in half of the cases with depressed mothers they needed 12 seconds to get to a positive match in the play episode and 18 seconds in the reunion episode.

The babies of depressed mothers thus had quite different experiences of social interactions than did those of healthy mothers-- and experiences of this kind would be repeated many thousands of times in the early months of life in ordinary caregiving. Slower development of communication skills would certainly be expectable for babies of depressed mothers. This would be only one of several reasons why treatment of maternal depression is important with respect to infant development. Babies don’t have to know their mothers’ moods, or to care about them-- they are affected by depression in their caregivers in ways that do not support the best development.

Wednesday, October 12, 2011

"Your Brain on Childhood": An Entertaining Book for Serious Parents

A good new book recently came across my desk-- Your Brain on Childhood: The Unexpected Side Effects of Classrooms, Ballparks, Family Rooms, and the Minivan, by Gabrielle Principe (Prometheus, 2011). I recommend this book to parents who are able and willing to confront the complicated realities of early development and to avoid the over-simplified strategies of Mozart and Baby Einstein. Your Brain on Childhood is clever and accessible-- but let’s face it, not everybody wants to do the hard work of understanding developmental change, and I don’t think this book is for anyone who wants a simple high-tech fix. (Unfortunately, the publisher has not provided an index or even a proper bibliography, so what might have been an excellent undergraduate course supplement is not very usable in that way.)

As some readers may know, Prometheus Books is associated with a skeptical and science-oriented publication policy (although I’d love to know why they continue to publish Arthur Janov the primal therapy man!). In line with that policy, Your Brain on Childhood questions a number of commercial ventures like the Your Baby Can Read system, and points out the power of placebo effects and the presentation of testimonials boasting that a given child can do things that are in fact in the normal range for his age. Advertising of this type is successful because many parents are unaware of confounding factors that operate together with supposedly “scientific” treatments, and may be very unclear about developmental milestones expectable at particular ages. Principe points out the commercially-manipulated confusion that tempts parents to pay high prices for products that in fact are not helpful to development.

Addressing the concerns of so many modern parents about their children’s brain development, Principe acknowledges that experience helps to drive brain growth and complexity. But she points out that not all environmental factors are relevant to brain functions. There really isn’t any evidence that Mozart-- or Beethoven, Sibelius, Elgar, or reggae-- has a predictable impact on the developing brain. In fact, it would be a pretty fatuous arrangement that would have organized normal human development so it required a kind of experience that was not present at the beginning of human evolution, in the environment of early adaptation. Could our remote ancestors have had a desperate need to hear stringed instruments in order to develop the normal intelligence and sharp senses that enabled them to survive a most challenging environment? Presumably not, because there were no stringed instruments, and they did survive, otherwise we would not be here.

As Principe points out, what we modern humans need to facilitate our development is similar to what our ancestors needed and must usually have gotten. A critical part of our brain plasticity (the capacity of the brain to be shaped by experience as well as by heredity) is what is called “experience-expectant plasticity”. This capacity involves an association between specific aspects of brain development and events that are very likely to occur during the first year or two after birth. Experience-expectant plasticity is generally a matter of fine-tuning abilities that are only generally governed by genetic factors. For example, good depth perception requires that information from the two eyes be put together appropriately by the brain, which has to taken into account the distance between the eyes. But that distance changes as the head grows during the first year, so the “formula” used by the brain cannot be the same at birth and at age 1. In addition, almost everyone has a slight difference between the distance from the right eye to the midline and from the left eye to the midline. The baby’s preferred head position molds the soft bones of the head so the face is a trifle asymmetrical, and the brain has to deal with this individual difference which is not genetically controlled.

Just as our ancestors 250,000 years ago responded to expectable experiences of this kind, we modern humans do too. And although it’s conceivable that by chance some experiences that were never present in that early environment could have an impact on modern babies’ development, it’s much more likely that present brain development is organized to be facilitated by the same kinds of experiences that made our ancestors’ babies develop normally. To think otherwise is like proposing that the diet our ancestors needed for good health has in some way been altered so that we now need to eat a substance that they did not need.

So, Principe asks, what did those ancestor babies need? What could they get? And what does this tell us about the experiences modern babies need for optimal development? Obviously, early human babies did not need battery-operated toys, DVDs, or flash cards in order to develop normal intelligence and abilities, or they would all have been starved because they couldn’t find food, or eaten because they were not bright enough to know they WERE food. What they needed, and what they had, was play-- play with things, and play with other people. Principe proposes that opportunities for play are exactly what drive the development of certain brain structures and their cognitive functions. When we prevent or interfere with play, we may also slow that development. Babies don’t need to be “entertained” or “stimulated” artificially; they do need the opportunities for play that are part of our evolutionary heritage.

A major reason that babies need to play is that playful manipulation of things and ideas remains an essential part of human life through childhood and adolescence, right on up through vibrant and successful adulthood. One important characteristic of humans is that, like the pet animals we love, we show neoteny-- the tendency to maintain certain child-like behaviors throughout life. (By the way, I haven’t found a page where Principe mentions this, but it may be there; oh for an index!) Play and exploration, not obviously connected with food or safety, are the foundations of our learning and are an important factor that determines our ongoing learning and the fact that it’s not all over at age 3. Play and exploration are also the foundations of science, invention, the arts, and all the other things that are positive achievements of human beings.

YourBrain on Childhood is full of really good stuff about things to do as well as things not to do. In many an aside, it punctures unverified assumptions like “learning styles”. I wish I had written it (but I would have fought for an index). Highly recommended for parents, and even more so for teachers!

Thursday, October 6, 2011

Bring On the Taties, Bring on the Bread: Feeding, Eye Contact, and All That

“Bring on the taties, bring on the bread-- Won’t somebody get this baby fed!” Feeding hungry babies is a universal task of childrearing. Before they reach the toddler period, babies get frantically hungry and seem to think that only desperate crying will bring them anything to eat. Parents and other caregivers sometimes feel that they spend most of their time in feeding, and sympathize with mother and father birds confronted with wide-open beaks every time they return to the nest.

Obviously, feeding enough of the right things, in the right amounts and at the right times, is essentially to babies’ very survival, as well as to normal physical growth and development. The physical effects of feeding are so important and so obvious that it’s easy to forget that much happens during feeding other than transferring food from the outside of the baby to the inside. Studies of preterm infants have shown a number of factors that affect feeding and digestion even in very tiny babies who cannot suck and must be tube-fed-- these include the experience of smelling the mother’s milk, the experience of sucking a pacifier while being tube-fed, and the experience of being fed during a period of activity rather than when deeply asleep (all of these increase growth rate).

Even the youngest babies are actively engaged in the experience of feeding and are paying attention to events that they connect with being fed. This is a simple but powerful type of learning-- the kind Pavlov called classical conditioning-- in which the babies learn to expect one event to follow another one. More and more complicated learning builds on these early feeding experiences, until the hungry one-month-old who quieted when Mother began to undo her blouse becomes the one-year-old who tries to unbutton those buttons herself.

All those moments of learning are closely connected with social and emotional development. Except for the unlucky baby who has to make do with a propped bottle or pureed food in a bottle with a big hole in the nipple, infants almost always experience feeding as an interaction with another person. It’s an interactive experience of communication with a caregiver who does a lot of the physical work of providing food-- but who ideally does this in response to the baby’s communications of wanting to eat or wanting to stop. Both parent and baby use their best communicative skills to do this job. They both use their eyes to gaze at or look away from the other person or the food being offered, as well as putting out their hands to control a spoon or a bottle and their voices to show approval or protest. The baby wants food but may like some foods better than others, and prefers certain feeding rhythms; as he or she experiences a more satisfied appetite, there may be changes toward slower consumption or stronger preferences or avoidances.

These facts mean that ideally babies and caregivers have many sessions of practicing communicating with each other about a topic that is of great interest to both of them. It’s fun to eat when you’re hungry, and it’s fun to see your healthy baby consuming the food you’ve offered, so both of them are likely to find feeding time pleasurable and to associate that pleasure with their communication and social interaction. However, if a baby is sick or developmentally delayed, and if the caregiver is worried, depressed, afraid of wasting food, frightened, or exhausted, neither of them will have much fun in the feeding situation, and they will miss a major chance to learn to enjoy their interactions. They may not advance well in their abilities to communicate with each other, either about feeding or about other important things.

When parents and babies are not doing well together, they need support that pays attention to both adult and child needs and abilities, but they do not always get this even when intentions are good. A few years ago, I observed a program for adolescent mothers and their babies. There had been some concerns about neglect in the case of each participant, and the babies were receiving intervention in the form of supportive day care, while the mothers attended classes and discussion groups. The highlight of the day was supposed to be lunch, with each mother feeding her baby. The babies had high chairs and plenty of food provided. BUT--- nobody had remembered that it was important for the mothers and babies to be able to look at each other’s faces in order to communicate. There were no chairs for the mothers! Each young woman stood in front of her baby and bent over awkwardly to spoon the food into the baby’s mouth. The babies had to look up and away from the spoon to see their mothers’ faces, and even then saw only a tense-looking expression on a face held at an odd angle. What appeared to be a tiny detail actually caused a major impediment to the social and emotional interaction that’s a critical part of feeding.

It’s popular nowadays to emphasize early interactions, “skin-to-skin” experience, and so on, and I don’t dismiss those. But if we want to see how relationships, communication, and understanding of other people develop, I suggest we look at the thousands of feeding experiences that occur in the first year or so of a baby’s life. If someone invented feeding as a brand-new intervention, parents would rush to take workshops and learn how to do it. It doesn’t need to be invented, but parents need to understand its importance, and so do those who “coach” or support parents in other ways.