Concerned About Unconventional Mental Health Interventions?

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

Wednesday, July 31, 2013

Speaking vs. Screaming: The Influence of Language Development on Children's Angry Behavior


On the Internet and elsewhere, parents who have adopted children from foreign institutions often express their distress about the children’s angry or violent behavior, tantrums, and “meltdowns”. Although research like that of Michael Rutter has repeatedly shown that delayed language development (not just the learning of the adopted family’s language) is the most common result of early life in an institution, few of the concerns parents speak of are related to language problems.

Is there any connection between the parents’ reports about angry behavior and the researchers’ statements about language development? It’s plausible that there should be, especially if we have to add to language delays the additional challenge of learning a second language. Adults and other children typically talk to institution-reared children as if they expect understanding at the level indicated by the child’s size, but even if the speech is at a relatively low level because of earlier growth problems, the adoptee may respond with frustrated incomprehension. Both adults and other children may interpret this behavior as disobedience, noncompliance, rebellion, unfriendliness, even active hostility, when in fact it may just indicate that a child has no idea what is happening and no way to express frustration verbally.

The same anger problems can occur with nonadopted children  whose language development is slow--  not slow in the sense of when the first word occurs, but slow in terms of the communicative exchanges that usually develop between 18 and 24 months.  A recent study (Roben, Cole, & Armstrong, “Longitudinal relations among language skills, anger expression, and regulatory strategies in early childhood”, Child Development, 84(3), 891-905)  demonstrated that the connection between language and angry behavior is not just plausible, but can be shown by watching children as they develop between 18 and 48 months of age.

The authors suggested that good language development in young children should enable them to think about rules they have been taught, to communicate their needs to adults, and to distract themselves from a frustrating situation by play and imagination. To examine how these predictions work out empirically, the researchers had mothers and children experience situations that was frustrating for the child. At 6-month intervals, the child was given an uninteresting toy, but allowed to see a shiny gift-wrapped package which had to be waited for while the mother did some “work” by filling out a questionnaire. The wait time was 8 minutes. (By the way, here’s an insight into the reality of research on mothers and children: the mothers had to be given their instructions beforehand to prevent them from bursting out laughing when they saw what was going on!) While the children waited to open the fancy gift, their facial expressions of anger, neutrality, or happiness  were recorded, and so were other behaviors like speech to the mother or making faces at themselves in the one-way mirror. Roben and her colleagues had also taken speech samples from the children talking at home and employed several tests of language development.

Children whose early language skills were good, and who continued to develop language rapidly after the toddler period, showed less quick, intense, and sustained anger by preschool age. “Children whose language skills increased more than other children’s appeared less frustrated by a delay for a reward at preschool age, and the nature of their anger expressions improved more over time. Moreover, these relations between language skill and anger expression were partially explained by children’s initiation of regulatory strategies. Language skills were associated with initiation of calm support seeking [from mother] at 36 months of age and of distraction at 48 months of age, both of which were associated with less angry expressions by preschool age.”

As Roben and her colleagues point out, there may be some other explanations for these connections than that good language development enables children to wait and stay calmer than they could manage with poor language skills. Children who are unusually angry by temperament may have their anger interfere with language learning, and parents faced with a very angry child may not do as much of the talking that helps to support early language development. However, the connections found between early language skill and later control of anger were stronger than other associations that were studied.

To go back to the original topic of this post, anger and poor language development in children adopted from institutions: what does this research suggest about interventions for such adoptive families? One thought is that the current constant emphasis on re-working emotional attachment may be self-defeating when other aspects of development are ignored. Assessments of language development and interventions as needed may be the steps that help post-institutional children to become self-regulated and comfortable. But such assessments and interventions require evaluators who are fluent in the child’s first language as well as in speech and language, and although there are such people, they are very few, and almost exclusively to be found in large cities.



  

Monday, July 29, 2013

Be Cruel to Be Kind? Non-Custodial Parents and Visits With Children


Not long ago I received an e-mail from a young father I’ll call Derek. He had read a post about children’s grief from my old Psychology Today blog (interestingly, although they kicked me off, they don’t take the old posts down!) and was wondering how it applied to his child and himself.

Derek said he had a 15-month-old daughter with whom he had a strained relationship. From other things he said, I guessed that he had not been sharing a household with the child and her mother for perhaps a year. Derek referred to what he called the “alienating behavior” of the child’s mother. He seemed to be referring to decisions limiting his time with the child. He had been given two hours a week visitation by court order; the mother had originally been more liberal with the time, but following a quarrel in recent weeks she had cut back to the court-ordered time.

Derek felt the child was confused by this change in contact time. He said he was thinking about whether it was best to stop all contact until the adults worked out their difficulties, and inquired about my opinion on this. He had a visit scheduled for that night and was wondering whether to cancel it. He also said that his lawyer and a psychologist had advised him to “go with his gut.” I was just starting to cook dinner when I saw his e-mail, but I immediately replied: “Derek, go and see her. I’ll write more later.”

Here’s what I wrote to him later:

“I hope you did go, or will go if it’s still in the future, to see your daughter.

I think your gut is telling you what would be most comfortable for you, not what would be best for your daughter--  and you are far from the first estranged parent whose gut has made this statement.  It’s tough to be with a child who is in distress and to know you can’t do much about it. Most of us adults would rather avoid this, and if we can’t see the child as much as we want, we want to just bite the bullet and cut off contact.

But the situation is very different from the little girl’s point of view. Whichever parent she is with, she experiences the pain of separation from the other. When she comes to you, she may be upset because she is away from her mother and because she has been away from you. (It would make more sense if we humans could be happy when we’re reunited with someone who left us, and we think we will be, but on the whole we’re not---just wait until you lose her in a crowd and then find you feel like punishing her when you find her again!) When she goes back to her mother, she probably “acts up” because she was separated from her mother and now has to be separated from you.

This is going to go on for several years no matter how much or how little you see her; in fact, it will be worse if you see her little. It’s for you as the adult to manage what’s happening as well as you can.

You can’t just decide you’ll split and come back when things are more settled. For one thing, they may not get more settled for a long time (excuse my directness, but I’ve divorced too and have even been through the “ex at your child’s wedding” scenario). For another, if you stop seeing your child she will do her task of grieving for you and finish it. When you come back, if it’s soon she’ll give you the cold shoulder and if it’s later she will regard you as a stranger. You will have a great deal of trouble re-establishing the relationship.

My advice is, see her as often as you can. Keep in mind that how often this will be depends on your ex’s decisions and on yours too--- but it does not depend on what your daughter thinks and wants, so whatever you do she will still feel somewhat helpless and abandoned. Try to have your time with her be quiet and well-organized, and don’t include in it any other adults, even your parents. When with her, follow her lead in play as much as you can (this does not mean you have to give her chocolate cake for dinner or let her bite you). If you don’t know how to do this, read something about “Floor Time”.

Some thoughts:
You need to make sure that her mother understands these issues and does not assume it “just upsets the child” to see you. It’s separating from loved people that upsets her, not seeing you.”

There’s no question, it’s difficult for adults to deal with children’s reactions to separations and reunions. How many foster parents can cope with gradually relinquishing a loved foster child to longer and longer visits to a biological parent? Most often, the foster parents just say “if he’s got to go, just let him go, we can’t take this”. Parenting plans in divorce often fail to recognize the agonies for the child and for the parents of having the child go back and forth from one to the other, and of course I’m referring not to a parent’s personal discomfort but to the pain of watching the child’s reactions. We need to provide parental education and emotional support for these difficult periods, rather than supplying parents with terms like “alienating behavior”. Their “gut feelings” won’t do the trick here, because their guts naturally cry out for escape from what is happening. They feel  as if they want to “be cruel in order to be kind” to the child, but that is not the solution to this problem.



   

Sunday, July 28, 2013

Naming the Sources: Where People Get Their Ideas About Attachment and Mental Health


Recently, I published in the Brown University Child and Adolescent Behavior Letter (a monthly publication) a piece entitled “Giving parents information about Reactive Attachment Disorder: Some problems” (CABL, 2013, Vol. 29, August; p. 1, 6-7). I was responding to a parent-education handout on the subject of  RAD that CABL had provided a few months previously. The handout briefly referred to the existence of misunderstandings about RAD, but did not examine what these beliefs might consist of or the ways parents might acquire them. I was concerned that parents who were already committed to mistaken beliefs might not pay attention to an accurate handout, or, worse, might decide that a practitioner who used such a handout was ignorant of the facts and would make their child’s condition worse. In my CABL piece, I pointed out sources of misunderstandings on the Internet and in print media, where journalists all too often repeat incorrect statements about children and attribute harmful behavior to RAD.

Shortly after this article came out, someone called to my attention the following: http://www.wweek.com/portland/article-20902-no-good-deed.html. In this description of a difficult--  and badly mishandled—adoption, a psychiatrist is quoted as attributing the child’s difficult behavior to Reactive Attachment Disorder, which is said to be “common among children who were abused as infants before bonding with their parents”. A most curious statement, it seems to me--  is there a different problem that occurs if they are abused as infants after bonding to their parents? And what exactly does either the psychiatrist or the journalist mean by “bonding”, which, as I pointed out a few days ago, is a term generally applied to the feelings of parents for their infants, not the reverse?

But, be all that as it may, the article goes on to attribute to Reactive Attachment Disorder this child’s behaviors of urinating and defecating around the house, sleeping problems, eating problems, manipulative behavior, and cruelty to animals. Yes, these are challenging behaviors with respect to which the adoptive mother needed much guidance and support; no, these are not symptoms of RAD as described by anything but one of the non-evidence-based checklists promulgated by various “attachment therapists”. Yet, here they are, large as life and twice as natural, displayed in a newspaper for all to see and learn from, without the slightest indication that they should be questioned with respect to their cause.

The Portland article then proceeds to throw in yet another unsubstantiated belief: that children diagnosed with RAD are bright but don’t seem to learn, and don’t learn from discipline (undefined, but presumably equated with punishment). This idea would appear to be derived from the position of “attachment therapists” that obedience is the result of attachment, and that noncompliance is a symptom of an attachment disorder. Once again, the journalist has repeated a belief about attachment and mental health problems that is likely to be accepted by the average reader, and once learned, to interfere with well-supported material describing children’s attachment-related behavior.

So, do people actually absorb various misunderstandings about attachment, mental health, and challenging behavior by children? An article by Sara McLean, an Australian social worker, and her colleagues, suggests that they do (“Challenging behavior in out-of-home care: Use of attachment ideas in practice.” Child and Family Social Work, 2013, 18, 243-252). McLean and her group interviewed foster parents about children’s behavior and the effect of attachment. They found four beliefs that influenced the way foster parents responded to challenging behavior.

First, children showing difficult behaviours were thought of as either unable to form attachments or as wanting not to form attachments. These children were thought to have been permanently damaged and made unlike other children by their early experiences. Aloof or self-reliant children were thought to be better placed in a residential group situation than with individual foster parents with whom they would “fail to attach” and be rejected. McLean pointed out the dangers of assuming that a child’s observable behavior accurately reflects the inner state, an assumption that can lead to giving up on a child.

Second, McLean and her group found through their interviews that foster parents believed that children have a limited potential for attachment, and that unless an adult was to function as a ”primary” attachment figure, a child’s attachment to that person should not be encouraged. People with whom the child had developed relationships felt that they should “get out of the way” if the child had the opportunity to form a relationship with someone who could be a permanent primary figure. McLean pointed out that part of the problem here is a confusion of attachment with dependency on another person. (This confusion is evident among “attachment therapists” who require children to ask adults for everything they need in the way of food, drink, or toilet use, and punish them if they attempt to help themselves in age-appropriate ways.)

McLean and her group also found that many of the foster parents thought of attachment, as a close, trusting relationship with behaviors expressing intimacy. Children who behaved in difficult ways were seen as lacking in trust and therefore unable to give up their need for challenging behaviors. The foster parents expected children to improve their behavior only if they entered into an intimate and affectionate relationship with the adult. Changes in parenting techniques were seen as less important as ways to improve child behavior (and, although McLean did not mention this, the belief stated earlier, that children with attachment disorders cannot learn or respond to discipline, might also be relevant).

Finally, McLean and her colleagues mentioned the belief that attachment is “transferable”, that if a child has developed an attachment to one adult, he or she has essentially learned a skill and can do the same thing readily with the next caregiver. This belief may serve as justification for disrupting placements or for limiting contacts with people who have become important to a given child.

McLean’s article did not attempt to identify the sources of these misunderstandings about attachment. However, looking attentively at the Internet and the media helps to identify at least some of the origins of the mistaken beliefs. How do we go about correcting the situation? That’s a difficult question, and apparently an international one, as we see problems of misunderstanding in the U.S., Canada, the U.K., Australia--  and of course all the places in which holding therapy is presently fashionable.

   

Friday, July 26, 2013

What We Talk About When We Talk About Bonding

If you try to google bonding, you’ll get over five million results--  even if you’ve specified emotional bonding rather than a process for improving your teeth or a kind of insurance policy for people who handle others’ money. Wikipedia says bonding is the process of developing a close interpersonal relationship that is mutual and says that any two people who spend time together form a bond. However, the Wikipedia article then goes on to describe specialized, intense relationships like that between mother and child.

What are people talking about when they talk about bonding? Well, they’re all talking about pleasant and affectionate relationships and actions, but beyond that, what someone means seems to depend on what work he or she does.

Maternity nurses tend to use bonding to describe the actions of mothers toward babies that are encouraged in modern hospital care. They would describe mothers as “bonding” when they are holding their newborns, examining their fingers and toes, and gazing into their faces. Mothers who don’t get to do these things--  perhaps because the baby is premature or sick--  are considered to be at risk for problems in the later relationship with the baby.

In a Linked-in discussion, I recently encountered a person who stated that parents and babies, even very young ones, are bonding when the parent reads to the baby. Another discussant suggested that reading to the unborn baby has the same outcome. When I asked the first contributor what he meant when he said bonding, he replied: “Bonding is the child and parent connecting on a spiritual level, and this happens in so many ways.”

I was and am flummoxed by the introduction of spiritual references into this discussion. Like most other serious students of child development, I am committed to studying measurable events and using them to understand the complexities of  human developmental change. While of course the development of children’s beliefs about spiritual life is a reasonable topic of study, to try to explain other aspects of development by adding a spiritual factor is unparsimonious, to say the least. It also brings in a component that is impossible to measure and that therefore cannot be communicated to another person or validated by anyone else.

For the last 40 years or so, psychologists studying infant development have used bonding in a specific way (when they have used the term at all). That specific way was drawn from the work of Marshall Klaus and John Kennell, who posited, partly on the basis of biological information, that human mothers went through a process that altered their emotional responses when they were able to interact with their newborn infants. They called that process bonding and considered it to be essentially “falling in love” with the baby. At the time of Klaus and Kennell’s work, it was customary in American hospitals to separate newborns from their mothers until they were examined on the pediatrician’s rounds, which might occur almost 24 hours after the birth. Parents were asking for changes in this routine, and Klaus and Kennell were able to carry out research comparing the last babies born in a hospital that had not allowed extended early contact of mother and baby, with the first ones born in the same hospital after it had instituted a new extended early contact policy. Klaus and Kennell reported some significant advantages for the early contact babies over the other group, including better language development at age five years. According to their definitions, the early contact group had had an opportunity for bonding during a posited sensitive period shortly after birth, and the other group had not.

These findings were naturally of great interest to families and to professionals working with mothers and children. It was quickly decided that bonding was, as Klaus and Kennell suggested, a basic change in the mother that depended both on biological factors and on contact with her baby, and that it was essential that parents have the opportunity to bond--  which, if lost, might not be replaceable later, and which had a powerful effect on their ability to care for their child..

However, as so often happens, it soon became clear that Klaus and Kennell’s results might not be generalizable to many mothers who had different characteristics from the study group. The results were not readily replicated, and it began to appear that they were specific to the group Klaus and Kennell had studied--   very young, poor, ill-educated girls without much social support. They seemed to have benefited from a program that supported them and their babies, but it was doubtful that older, middle-class, educated women needed or would benefit from such a program (although they would probably enjoy it, especially if they had been reading about how important bonding was!). By the time ten years had passed from their first publications, Klaus and Kennell were saying that they regretted ever having made the strong statements they had begun with, in which they had claimed a sensitive period for maternal bonding in human beings (see www.nytimes.com/1983/03/29/science/influential-theory-on-bondng-at-birth-is-now-questioned.html).

In spite of some of the exaggeration about their findings, there was one highly significant point made by Klaus and Kennell which has unfortunately been lost in the fray. This was clarification of the fact that the two sides of the mother-infant relationship are reciprocal but not mutual. In other words, the changes in the mother called bonding are shown by different behaviors and emotions and follow a different schedule than the changes in the child called attachment. To say “bonding-and-attachment”, as if the two events are the same, is like saying “apples-and-oranges”.  Klaus and Kennell made it clear that when they said bonding, they were focusing on the mother’s “falling in love” and preoccupation with her baby, and not with the baby’s months-later primitive “falling in love” with adults.

I don’t think it would be necessary or even useful to insist on one or another definition among those I’ve just discussed. However, if you get into a conversation about bonding, it would be a good idea to try to discover what your opposite number thinks he or she means when this word is used.







    

Monday, July 22, 2013

Kafka Meets Parental Alienation Syndrome in Canada

On July 18, I posted follow-up comments on a situation in Colorado, where a mother whose parental rights have not been legally terminated has been prevented for years from seeing her children. The father and stepmother of one child had custody of that boy and his half-brother, but sought the care of an “attachment therapist” who placed the boys in therapeutic foster care and recommended to the courts that they not be in contact with their biological mother, against whom there have been no charges of abuse or neglect. The mother has run through all her resources. A lawyer who was consulted about the matter says that she may as well pretend that her children were run over by a bus, because she will never get them back or get any redress from the county and its employees, who are protected by law from complaints about their actions. This mother, by the way, even proposed voluntarily to relinquish her custody of the children, with the hope of being able to tell her story in court, but was told that she could not do so unless she came for counseling--  although of course the court can terminate her parental rights. She has also been told that her therapist’s statement that she is psychologically normal cannot be correct.

This Kafkaesque situation, where an individual bears the burden of punishment without being accused or sentenced, and where the person is essentially pressed to confess something unknown and to execute himself, can occur because citizens have no recourse against human services and child protective services functionaries. These people can operate outside the law to a considerable extent, or, to be more accurate, can easily bring the forces of the law to support their own decisions. Although most such workers are well-intentioned and do their best in difficult situations, there are a number who are loose cannons, and woe to those who get in the line of fire.

Now, it seems that Kafka has also been visiting Canada. To further complicate the matter, his visit there is in connection with the highly problematic Parental Alienation Syndrome (PAS). The term PAS is used to allude to the fact that a very small number of divorcing parents make a point of persuading their children, inaccurately, that the other parent is abusive and dangerous. Unfortunately, as occurs when a little boy gets hold of a hammer and finds a lot of things that need to be banged, some practitioners have generalized the PAS concept to apply to almost any case where a child prefers one parent to another or seems afraid of one parent. In these cases, too, the practitioners say, an “alienating parent” must have acted to create the child’s mind-set, and therefore the feared parent should be given custody of the child, who should be protected against the abusive alienating tactics of the first parent.

Of course there are children who are alienated from one parent, but to say this is an identifiable “syndrome” is at the very least premature and may simply be wrong. In a small number of cases, the alienation may have been worked by the other parent. In some cases, alienation may have occurred because a parent is genuinely someone to be feared, abusive, threatening, or bizarre in behavior. In still others, alienation is situational; for example, toddlers and preschoolers may show distress and reluctance to engage with a parent who has been absent, simply because this behavior reflects their mourning response when an attachment figure goes away for a period of time. If the absence has been long enough, they are not happy to see the person return, and rather than a joyful reunion they display their anger and detachment, greatly distressing the parent who did not anticipate or understand this normal behavior (and who may assume that the custodial parent has caused the problem).

Proponents of the PAS hypothesis, like Richard Gardner and Richard Warshak, also suggested a form of therapy for alienated children. Assuming that the children had been “brainwashed” into disliking one parent, they assumed that a “reverse brainwashing” or “deprogramming” was needed, in which the children were isolated from the “alienating parent” and persuaded that their beliefs were wrong, then placed with the disliked parent. PAS or no PAS, effective treatment or no effective treatment, Gardner and Warshak should be given some credit for limiting this approach to children older than eight.

However, a Toronto family has given me many details about a custody case where the father claimed PAS, and a toddler and a preschooler were put into a form of treatment whose effects raise the most serious questions. The children, now 6 and not quite 5, were in this “PAS therapy” for a couple of years, and now are in their father’s custody. The mother has not seen them for 6 months and is told (here’s the Kafka part) that she cannot see them unless she admits that she “alienated” them from the father and goes into therapy with the practitioner chosen by the father. According to what has been told to me, a child protective services worker has told the mother that she will probably not see these children until they are adults. A complaint to the Ontario College of Psychologists remains under investigation after a year. The mother’s parental rights have not been terminated legally.

Let me give some details about this early-childhood “PAS therapy” as told me by a family member. Only the father attended these treatment sessions, but the aftereffects were seen and documented by other family members. The children reported that they had been sat upon and lain upon. One stated that the father had pushed his fingers hard into her tummy, the other that the father pushed his head hard into the wall. (These actions, by the way, are characteristic of the more severe forms of holding therapy.) The children had bruises, puncture marks, and cuts, the last being explained in court as due to “playing swordfighting”with plastic mixing spoons with the father during the treatment session. On one occasion, the children came out of a late afternoon session falling asleep and their behavior seemed so unusual that they were taken to their pediatrician, who advised that they be seen at a hospital. One child slept a great deal for three days, was not hungry, but drank a lot. “She talked about colours while looking at her fingers wiggling and seeing things on the ceiling that weren’t there. Her breathing was fast and shallow” and she was restless. The children also mentioned being told to look at a moving “wand” that was waved near their eyes.

I am describing these effects in the hope that someone may recognize what is happening here and get in touch. It seems impossible that this frightening treatment was invented for use with these two young children; there must be others out there who have been through it. Of course, it is reminiscent of many alternative treatments, including holding therapy, some rogue versions of sensory integration therapy, and even EMDR. The location in Toronto brings back memories of the documentary “Warrendale”, banned from television for some years, that showed holding therapy at work in Ontario.

Like the Colorado mother, the Toronto mother has exhausted her resources. She cannot afford legal representation, and even if she were willing to “confess” actions that she did not do, she could not pay for the treatment she is supposed to receive. In addition, if she did “confess” and enter treatment, what are the chances that she would ever be declared to be good enough to have contact with her children?


If anyone has any ideas about what is going on here, or what can be done in either of these cases, I hope you will contact me.     

Thursday, July 18, 2013

More About Kafka in Colorado: No Recourse for a Mother


Over the last 6 or 7 months, I’ve posted a couple of times about a woman who has not been allowed to see her children for some time, although her parental rights have not been terminated and she has not been convicted of any offense that would normally lead to such termination. “Eve Innocenti’s “ story is told in part at http://childmyths.blogspot.com/2012/12/the-attachment-therapist-wears-two-hats.html and http://childmyths.blogspot.com/2013/01/kafka-again-more-on-capture-of-child.html. These posts describe how “Eve” asked the father of one of her children and his partner (now wife) to care for both her little boys for a few weeks, discovered that the caregivers refused to return the children at the end of that time, and found herself lost in a labyrinth of legal issues and unfounded accusations that prevented her from seeing the children.

For four years--  and counting--  “Eve” has been spending her savings and those of her new husband. She has driven for many hours in order to spend an hour with the children, until that was prevented. And now there are further developments.

“Eve’s” younger boy presents the most difficult case in this situation, because the caregivers who have taken charge of decisions for him are neither biological nor adoptive relatives of his. However, they have been treated as if they were by the attachment therapist they brought into the picture and by the county authorities. Some months ago, the therapist and caregivers brought up the suggestion that the boy had been diagnosed with Fetal Alcohol Syndrome--   an apparent proof that the mother had behaved abusively by drinking while pregnant, and an argument for terminating her parental rights. But “Eve” declared that she drank very little at all and certainly not while she was pregnant, and as it turned out, a second examination yielded the conclusion that the boy did not have FAS.

Both boys were placed for a period of time in therapeutic foster homes, as decided by the attachment therapist in the case. The father’s  wife was expecting a baby and did not want them in her home, especially the younger boy. Possibly as a result of these events, the proposal was floated that the younger boy be placed for adoption by a third family, in spite of his mother’s eagerness to have him back, the lack of evidence that she ever mistreated him, and her psychotherapists’ statements that her mental condition was normal and appropriate. (His biological father has elected to stay out of the picture, and the grandparents on that side are not a resource either.)

“Eve” is now living in a different state and trying to find help for her quest to be reunited with her sons, or at least to have contact with them so she can assure them that she has not abandoned them. She is so fearful of having her behavior held against her that when one of the boys e-mailed to her, she did not reply, feeling that whatever she said could be twisted by one of the adults into a reason to continue preventing any contact. She has contacted the ACLU because of the lack of due process in the legal decisions that have been made, but child custody cases are not their bailiwick. She visited a child custody clinic held by a law school in the state where she now lives, but they were willing to deal only with cases where the children were in that state. Her resources are exhausted and she has been experiencing health problems, but her concern remains focused on the experiences the children are having and the impact of this situation on them.   

Some of Eve’s supporters recently visited an attorney to consult on what paths may remain open for “Eve”. They hoped that a lawsuit for recovery of the money “Eve” has spent at the behest of the county and the attachment therapist (for instance, on ongoing psychotherapy) could be brought on a contingency basis, with the lawyer receiving a percentage of the damages awarded. But the attorney, a person knowledgeable about the therapies in use and about the county, held out little hope. He counseled that “Eve” should accept that her children have been kidnapped legally, and should try to think of this as if they had been lost in a natural disaster. He stated that the county employees involved have iron-clad legal protections against lawsuits complaining of their actions.

In addition to state laws and other regulations protecting human services workers from lawsuits of this type, a decision of the U.S. Supreme Court has also set a precedent--- although it is one that has received much criticism. In the 1989 decision on DeShaney v. Winnebago County, the Supreme Court concluded that the state’s return of an abused child to his abusive father, culminating in the child’s permanent brain damage and paralysis, was not contrary to the obligations of the state and did not permit the award of damages based on interference with due process rights, because the abuser was not an employee of the state but was acting as a private citizen.  In a 1990 essay on this subject in the Duke Law Journal, Jack M. Beermann said: “Joshua DeShaney and other powerless victims of private violence should be the beneficiaries of the fourteenth amendment; victims should be able to hold the state responsible for failing to protect them. … The existence of state agencies designed to attack private misconduct strengthens the argument for intervention. The state makes statutory promises to protect the weak; by failing to treat its tort victims the same as victims of torts inflicted by non-governmental actors, the state violates the guarantees of due process. Because of the victim’s weakness, and because state agencies may have displaced other sources of relief, the victims often have nowhere else to seek aid. Thus, states should be forced to live up to their promises of help against private misconduct.”

Despite the arguments of Beermann and others over many years, DeShaney continues to be the law, and it and state laws stand between “Eve” and redress for herself and her children, whom the state has failed to protect.    


Monday, July 15, 2013

Breastfeeding and "Instinct"

In his New York Times  op-ed piece of July 11, Nicholas Kristof described a situation in Mali where a 3-week-old-baby was not-very-slowly starving to death because his teenage mother did not really know how to nurse him. As Kristof commented, “Nursing a baby might seem instinctive, but plenty goes wrong”, and this is very true.

I want to comment on this by examining first the issue of “instinct” in breastfeeding, and then talking about how customs and past history can interfere with nursing a baby.

When people describe a human behavior as “instinctive”, they commonly mean that the behavior does not have to be learned or practiced, but simply emerges, fully organized and in the right sequence, when a certain stimulating situation is present. In this way of thinking, often, most people of the right age and sex are expected to display a particular “instinctive” behavior, but it’s also possible for someone to be lacking the entire behavior--  for example, to have “no maternal instinct”.  Some “instincts” are thought of primarily as motivations, so a woman who did not want to have children might be said to have no maternal instinct, but one who wanted children but was a poor caregiver might also be spoken of in that way.

People talk about human “instincts” as just described because they are working with the analogy of humans to animals, and they believe that animals of all species from worms through mammals are determined in complex, survival-related behavior by unlearned, innate factors. However, this is true only to a limited extent. Lower animals respond to specific stimuli by a series of reflexes, each of which is indeed unlearned, but all of which occur in an effective sequence only when a series of environmental events triggers them. Mammals do not show these complex behaviors like courtship or infant care unless they have had related learning opportunities. For example, it was shown many years ago that female rats that wore a “cone” protector ) like those used after dogs have surgery) during pregnancy, and who thus could not do their usual grooming sequence, which includes the genitals, did not after giving birth go through the normal steps like tearing open the amniotic sac, licking the pups to clean them, and eating the placenta. In similar work, male rats and virgin female rats who had never seen rat pups did not care for them by retrieving them when they wandered from the nest, but after they were able to see the pups for several days, they began to behave as if a “maternal instinct” were at work in them.

Analogies between human and animal behavior are not always productive, but they are certain to be problematic when they are based on a misunderstanding of “instincts” in animals. As it turns out, the more complex the organism, the more experience and the environment affect behavior, and the less behaviors like breastfeeding can be regarded as automatic and innate.

So, what are the factors that guide breastfeeding, and help decide whether human mothers will nurse thriving babies, or will find themselves in the situation that Nicholas Kristof describes? There are certainly some biological factors at work. Colostrum and, later, milk are secreted initially in response to hormonal stimulation. Lactation, or milk production, is followed by actual breastfeeding, the transfer of milk from the breast into the baby’s mouth. Breastfeeding involves two maternal reflexes--  yes, these are innate by definition--- the erection of the nipple so the baby can take it into the mouth, and the “let-down” or ejection reflex that squirts milk out of the breast (it doesn’t flow passively as if the baby were sucking from a straw).  These reflexes are triggered by the baby’s own reflex actions. When the baby’s cheek is touched (for instance, by being held against the mother’s chest), he or she reflexively “roots” with a pecking action that brings the mouth to the nipple. The touch of the nipple far back in the mouth triggers the baby’s sucking reflex; this is again not like sucking from a straw, but  more like “chomping” on the area just behind the nipple, and that pressure stimulates the mother’s ejection reflex, squirting milk into the baby’s mouth.

It all sounds wonderfully organized, and it is--  but when mothers are very inexperienced, when they have no or the wrong advice, or when the baby is weak or sick, there may well occur the vicious circle that Kristof’s column described. What are some of the problems? These are different from one cultural group to another, but some of them are as follows:

In some parts of the world, it is held that babies should not be put to the breast right after birth and should not be allowed to suck colostrum, the sticky fluid that is secreted before the true milk develops. Prohibiting colostrum starts a whole cascade of unfortunate events. Colostrum contains a large dose of antibodies that the baby cannot yet make for itself; colostrum is available at the time when the baby’s sucking reflex is strongest and mother and baby are most likely to get off to a good start. Early sucking stimulates the breast and gives a head-start on establishing the milk supply, which can easily diminish or dry up during the first two weeks after birth. (After the milk supply is established, it is maintained much more easily without so much sucking.)

It’s hard to overcome customs that can interfere with breastfeeding. Unfortunately, several decades ago, there were also some events that interfered even more with breastfeeding than customs did, especially in African nations. The repercussions of these events are still being felt.

In the 1960s and ‘70s, Western formula manufacturers started an advertising campaign in Africa that declared that formula feeding was the way to have healthy babies. This would not have been so harmful, except that formula feeding only works well when there is refrigeration, methods for sterilizing bottles, clean water to make up the formula with, and an understanding of infectious disease. Where these were absent, babies died in their thousands over a period of years. In addition, the mothers who should have learned breastfeeding methods from older women did not do so, and so could not later help new mothers as they began to breastfeed.   

Because this happened, the chain of intergenerational transmission of knowledge about breastfeeding was broken. Most young mothers can benefit from some advice about how to hold the baby and how to be sure that the nipple is taken far enough into the baby’s mouth, but without the traditional access to knowledgeable older women, only those who were fully literate had a good chance of finding solutions to common problems like apparent lack of milk or like painful nipples. As a result, we now see babies dying even though their mothers have abandoned the formula-feeding approach and very much want to breastfeed.


If people make the wrong assumptions about “instincts”, they won’t see that the solution to this problem lies in compensating with helpful support to young mothers for the intergenerational break that started a generation ago.