Concerned About Unconventional Mental Health Interventions?

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

Friday, August 23, 2013

Child Starvation Death in Qatar: Intentional, Accidental, or Ill-Advised?

A reader kindly suggested that I should comment about a recent case in which an 8-year-old girl died of apparent starvation in Qatar (http://www.nydailynews.com/news/world/u-s-couple-jailed-qatar-starving-daughter-article-1.1418610). Gloria had been adopted from Ghana at age 4 by a Los Angeles couple, Matthew and Grace Huang; they had been living in Qatar for about a year while Matthew worked as an engineer on preparations for the 2022 World Cup. Their case is briefly discussed by supporters at www.freemattandgrace.com, where it is stated that the California Innocence Project, an organization that defends wrongly imprisoned persons, is working in support of the Huangs, and a law firm is taking their case pro bono. They have sought the testimony of a pathologist well known for working with parents accused of child abuse. The Huangs have been described as “Christian” at www.worldmag.com/2013/08/american_christian_couple_accused_of_killing_adopted_child_in_qatar, and this presumably means that they are members of an evangelical group rather than, say, Roman Catholics or Presbyterians.

Did Gloria literally starve to death? Probably not, at least in the exact sense. She was said to have been without food for four days--  not long enough to produce death in and of itself, but perhaps sufficient to do some organ damage in a child with a history of potentially damaging undernourishment. It is also possible that her death occurred as a result of ingesting food after a period of starvation. Refeeding syndrome (see www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/) can result after five days of starvation, especially in those who are chronically undernourished.  

Newspaper reports described Gloria as periodically refusing food from her parents and then (depending on the report) either going through several days of anorexia or eating from garbage cans. Between these events, she was said to eat normally. The reports presented the anorexic periods as occurring spontaneously.

I have been unable to find any reference to such spontaneous alterations of eating behavior in searches of Google, Academic Premier Search, PSYCinfo, or PubMed. I’ve asked the Spoon Foundation (www.spoonfoundation.org), a reputable source for information on feeding adopted children, for a comment about this sort of eating behavior but have not heard back from them yet (I will report what they say if I hear from them.) [See comments below this post for responses from SPOON.]

It is certainly true that individuals who have experienced starvation can remain fragile in their appetites, responses to food, and rates of weight gain, when plenty of appropriate food is available to them. Children who were in rough-and-ready group care early in their lives may have experienced being fed as frightening or even painful and may be reluctant to eat. Gloria is said to have been small in size even several years after her adoption, and may have been somewhat difficult to nourish. However, these lingering problems, insofar as they were a continuing feature of Gloria’s life, would ordinarily be expected to be about the same from day to day, rather than showing the intermittent difficulty as it is described.

However, it is true that in some cases where there has been a period of poor nutrition, either a child or an adult who seems to have recovered can respond to an experience by loss of appetite. For instance, someone who has been anorexic for psychological reasons but has recovered may be thrown into a new anorexic episode by an infection that causes gastrointestinal problems. In children who are anxious about eating, an increase in general anxiety could affect the fragile appetite. For example, being pressured to eat a particular food, or other distress surrounding eating, could lead to a period of anorexia.

There are thus some possible explanations for Gloria’s periodic failure to eat--  although the implication that these events “just happened” is probably not correct. It is less easy, though,to explain the reported eating from garbage cans or accepting food from strangers (and surely this would have to mean begging food from strangers or at least watching them eat in a hungry way). Some references have been made to pica, the eating of unusual non-food substances like clay, in some cases in response to dietary insufficiencies, in others simply to cultural practices. However, the most parsimonious explanation for getting food in these ways is that food is not readily available to the child. When children in the U.S. are seen to take food from the garbage, the most likely situation is that they are not being fed at home.

Speculating with very few facts, I would put forward the following hypothesis: Gloria periodically did not eat what her parents offered her because of circumstances that made the food itself inappropriate for her, and/or other circumstances that made it too difficult for her to behave in ways that would give her access to the food.  

Why would this happen? Why would the parents create such circumstances, and why would they then fail to seek expert advice about unusual and potentially life-threatening problems?

Were the Huangs’ actions intended to starve Gloria and bring about her death? This seems most unlikely. Even sadistic parents do  not generally mean their ill-treatment to kill a child, although they may fail to give normal care or seek medical care, in ways that common sense would predict would be fatal.

Were the Huangs’ actions an accidental cause of death? This might be the case if the last anorexic episode was the only one, and the parents simply did not realize that there was a serious problem. But the reported history of eating problems, dating back to early malnutrition, surely indicates that they were aware of her difficulties.

Were the Huangs’ actions ill-advised? Please note that this is a very different question from asking whether they are culpable in Gloria’s death.  I’m simply considering whether the Huangs had a belief system that would lead them to act in ways that made it difficult for Gloria to get the food she needed, or that triggered her food aversion; I name both of these because the reports make it difficult to know whether Gloria did not eat at all or whether she sought food outside the family table.  

There are belief systems in the United States that recommend manipulation of food as a tactic of child-rearing. Such beliefs rarely become public knowledge, although the case of Roxanne Heiser in Texas about ten years ago showed that a child who was eating from the garbage can at school was actually being deprived of food at home by a stepmother who demanded that the 7-year-old hold weights over her head for minutes at a time before she was allowed to eat.  The stepmother believed that such treatment would cause Roxanne to form an emotional attachment to her. Advice to this effect continues to be given by the “parent educator” Nancy Thomas, who stresses that children should not be allowed to get their own food, but must receive it from the hand of the parent in order to cause attachment; she also recommends limitation of the amount and variety of the child’s diet in order to bring about complete compliance by adopted and foster children.  (Once infamous for having declared that peanut butter and jelly sandwiches with milk are a perfectly balanced diet, Thomas has now softened her views slightly.)

At the beginning of this post, I mentioned that the Huangs had been described as “Christian” in a context that suggested that the real meaning was “evangelical”. I alluded to their personal beliefs because there appear to be connections between the acceptance of Nancy Thomas’ advice and membership in evangelical groups, especially those of Pentecostal or charismatic flavor. (I have discussed the broader issues elsewhere http://thestudyofnonsense.blogspot.com/2013/06/religious-beliefs-and-alternative.html.) For these groups, as for some religious thinkers in the U.S. even during the colonial period, a parent’s duty is to make a child obey at all costs; those who disobey as children will be disobedient to God later and will be damned. In addition, evangelicals have in recent years identified adoption as part of the Great Commission (see Kathryn Joyce’s book The Child Catchers) and have focused their energies on supporting adoptive families in ways congruent with evangelical beliefs. These views presumably made the Huangs more likely to adopt Gloria, and may have made them more likely to use her diet as a control measure.

Obviously, I am in no position to say how the Huangs behaved toward Gloria or exactly how she died. I am simply putting forward some possible explanations other than accident or deliberate cruelty.








Sunday, August 11, 2013

When Attachment Therapists Don't Understand Attachment Theory, Bad Decisions Are Made


In several posts in the last few months, I’ve mentioned “Eve Innocenti”, a mother who has not been allowed contact with her children since they were brought to an attachment therapy clinic in Colorado, apparently at the desire of a stepmother. These school-age children were said to suffer from mental health problems that were attributed to their early experiences with their mother, although no inappropriate experiences were ever documented. Like little boys with hammers, attachment therapists are inclined to see attachment problems everywhere, and especially focus on attachment when children have been separated from early caregivers. Attachment therapists also believe that they have methods that can cause children to become attached, or to transfer their attachments from one person to another. These beliefs are in contradiction to well-established evidence about what attachment is and how it develops and changes with age.

“Eve” has recently shared with me a report made by the county Department of Human Services in preparation for a permanency hearing next week. In it, the foster family organization that is taking care of one child is quoted as saying, “At this time his providers at ____   are not recommending that he have contact with his biological mother [Eve Innocenti]. They believe that considering the history that his biological mother would be disruptive to his attempts to gain in attachment [punctuation sic]. They do not recommend any type of contact including written contact.” With respect to the other child, the attachment therapy organization where he is placed is quoted as saying, “ they would be opposed to contact with his biological mother [Eve Innocenti]. They believe that contact with her would set back _____’s developmental progress. They believe that [Eve Innocenti] is a trigger for concerning behavior and that the confusion she brings into his life would prevent him from forming positive attachments. They do not believe it is likely that [he] would be in a good position to have any kind of contact including written and supervised calls with [Eve Innocenti] during the next six months to a year…. It is this caseworker’s understanding that ____’s therapist is recommending no contact, … due to ____’s developmental stage of attachment…”. Eve’s assigned attorney also told her in an e-mail that the boys were not being allowed to see any other family members than the man who is the biological father of one of them and his present wife.

It is hard to know where to begin commenting on the confusion which these therapists and foster care staff are imposing on the established facts and theory of emotional attachment. The first problem is the conflation of attachment with all of personality development and all of behavior. The children have been said to show conduct disorders and aggressive behavior, but these are not symptoms of attachment disorders. In addition, there is no generally-accepted method for diagnosing attachment disorders in school-age children.

One child is said to be attempting “to gain in attachment” and the other to be potentially prevented from “forming positive attachments”. These are meaningless statements. Attachment is not something a child can attempt to gain, nor is there such a thing as a “positive attachment” as opposed to any other kind. One can only assume that the people making these statements are following the lead of authors like Foster Cline and Nancy Thomas, who hold that cheerful, affectionate obedience is a result of attachment, and its absence a symptom of an attachment disorder. In reality, of course, children who are securely attached can be grouchy, disobedient, and unaffectionate, depending on circumstances and on their age. Attempts to correct these behaviors are sometimes justified, but when they are appropriate, the treatment does not involve attachment per se, although it may well focus on the relationship between child and parent.

The age issue is a very important one, and confusion about this is shown in the report’s reference to one child’s “developmental stage of attachment”. It is true that attachment theory, as formulated by John Bowlby, describes stages of attachment, beginning with many months of acceptance of all caregivers, then proceeding to a period of stranger and separation anxiety and intense grief over lengthy separation from familiar people . As toddlers develop better language and understanding of the world, they can more easily tolerate separation and develop excellent relationships with a larger number of adults; toddlers also begin to resist parents’ wishes and negotiate for what they want. By school age, children and parents ideally have developed a “goal-corrected partnership” in which each will make some adjustments in order to maintain a happy relationship. In describing these stages, Bowlby was considering not only maturation of the child’s abilities, but also the results of learning from experience with other people.

However, I would hazard the guess that the people quoted in the report on Eve’s children are not considering  the stages of attachment as Bowlby described them. Instead, I would speculate, they are thinking in terms of notional stages that were invented by Foster Cline and his colleagues several decades ago. These stages are often referred to as the “attachment cycle” (see http://thestudyofnonsense.blogspot.com/2012/08/parsing-attachment-cycle-fox-terrier-of.html). The “attachment cycle” is said to consist of two stages, one in which the child forms an emotional attachment to a caregiver because he or she is completely dependent on that person for the satisfaction of all needs. The second part of the “attachment cycle” occurs when the caregiver displays power and authority to set boundaries and enforce child obedience, once again equating compliant behavior with emotional attachment. Because neither of these stages is actually a part of the development of attachment, they cannot provide a useful way to think about a child’s “developmental stage of attachment”.

In reality, attachment develops because of pleasurable social interaction between a baby and an adult. And, because attachment is a very robust developmental phenomenon, it can and does occur even if pleasurable interactions are relatively few, and even if there is some abusive treatment.  It is important for young children to understand boundaries and rules, and to comply under certain circumstances, but these things have nothing to do with attachment. As children develop attachment, they also learn some things about what to expect from other people, and they may be securely attached to one adult caregiver while insecurely attached to another. As they develop further, they learn more about relationships with other people and may move from insecure to secure attachment or the other way around.

One of the real problems shown in the report on Eve’s children was that attachment was somehow thought of as developing independently of the rest of the child’s development, and being capable of being treated in some independent way. In fact, all aspects of development move ahead in a linked way. Children do not remain “stuck” at an early stage of development, nor can they be made to return to such a stage and rework it by regression and recapitulation. Eve’s son cannot be at some stage of attachment development that is characteristic of a toddler; things just don’t work that way. He may, for all I know, be grumpy or disobedient or worse, but these are not attachment issues. Even children who actually do have concerns associated with attachment need to be treated at their real developmental level, not at a level posited as part of an alternative theory of attachment.

The boys’ therapists apparently believe that they can act as if the children are infants, and by following some rules about how early attachment develops, they can create powerful new attachments. Presumably, this is why they want to exclude from the children’s experience adult contacts other than those with the parents-designate. (Do the foster parents and other caregivers avoid eye contact and so on, as advised by various attachment therapists, so the children don’t accidentally “attach” to them?) They presumably also believe that, like infants or toddlers, the children will grieve over and forget their lost biological mother, and be ready to attach to (i.e. , they mean, love and obey) the persons provided for them. But…  these boys are not infants or toddlers. They understand human relationships in a much more mature way, and although they may develop new and satisfying relationships, they will not forget their mother, but instead will be tormented by their belief that she could contact them but does not want to. Rather than helping them, their present treatment, with isolation from many familiar people and occasional “therapeutic” meetings with the designated parents, simply reminds them of the fearful specter of abandonment, a child’s greatest anxiety.

So far, all decisions about Eve’s children seem to have been made on the recommendation of their therapists. Soon, I hope, an actual judge will consider the facts. I only hope that he or she will have sought some understanding of attachment as it is considered in the world of mainstream psychology and psychiatry, not in the alternative universe of attachment therapy.  


Wednesday, August 7, 2013

"Words of Knowledge" Versus Evidence-Based Practice

It will be no news to anyone that some religious groups reject the materialistic explanations given by modern science and medicine, and consider human lives to be rightly considered as deeply interwoven with the supernatural. Members of some of these groups reject medical treatment in favor of prayer or other religious practices and similarly seek religious treatment for psychological conditions. They may attribute psychological problems entirely to supernatural events. Jenny McCarthy, the anti-vaccination celebrity, is famous for stating that she saw her autistic child’s soul go out of his eyes as he was vaccinated, a statement apparently based on the idea that autistic children have no souls. (Can this be due to a confusion of “soul” with “emotion”, as in “soul music”? It’s hard to say.)

Scientific medicine and clinical psychology are based on the assumption that all human phenomena are in essence material events, although they may not feel that way to the person experiencing them. There is a further assumption that collecting information about material, observable events can eventually allow us to understand causes and effects in human life, and in some cases to correct problems and bring about healthier physical and mental conditions. Although it is clear that some individuals feel comforted by the practice of prayer, a scientific approach does not assume that any supernatural events are actually involved in the sense of comfort.

The clash between these two views of the world, one characteristic of a fundamentalist Christian mind-set and the other of an approach that rejects supernatural explanations, is almost unresolvable, although there are people who manage to compartmentalize the two even in their most contradictory forms. There are also many who are Christians of mainstream groups and who are no part of this conflict because their beliefs do not involve supernatural influences or phenomena as part of everyday life today.

The culture conflict just discussed seems to be most serious for  people belonging to charismatic Christian groups such as the Pentecostals. These groups believe themselves to be potential recipients of the gifts of the Holy Spirit described in the New Testament as occurring at the first Pentecost. Recipients of those gifts were said to have shown the presence of the Holy Spirit by “speaking in tongues”, and to have the abilities to detect, identify, and cast out demons who caused physical or mental disorders. While mainstream Christian groups have long held that such abilities, while genuinely given in the early days of Christianity, are no longer part of life even for the most devout, charismatic groups hold that true believers (i.e., themselves) who have shown their baptism in the Spirit by speaking in tongues are also given the abilities attributed to the early Christians by the description in the book of Acts. This belief in supernatural events and abilities as part of ordinary life is completely at odds with attempts to explain and manage disorders on a foundation of scientific materialism.

Beyond this obvious conflict of world-views, there is another issue that further divides charismatics from mainstream Christians and secular thinkers who are committed to a scientific approach to medicine and psychotherapy. This issue has to do with how evidence for any claim of effective treatment is gathered and displayed. In the last few months, two posts on this blog have been related to the evidence issue but have not entered into a full discussion of the question. These were http://childmyths.blogspot.com/2013/06/conversion-therapy-reparative-therapy.html and http://childmyths.blogspot.com/2013/08/behind-kickstarter-request-helping.html. In the first, I commented on a hearing on New Jersey legislation to prohibit the use of “conversion therapy” to change minors’ same-sex orientation, in which members of the Assemblies of God argued that the treatment was an effective way to correct a condition which they predicted would have terrible repercussions if untreated. (This bill became law, by the way.) In the second, yesterday, I referred to a Ukrainian charismatic pastor who has been taking children from the street and treating them in some way for drug and alcohol addiction; I asked whether his methods were known to be safe and effective.

Practitioners of scientific medicine and clinical psychology generally share a viewpoint about how we know whether a treatment is safe and effective, or safe but not effective, or effective but unsafe, or both unsafe and ineffective. This shared viewpoint requires empirical research that identifies a specific treatment, then follows outcomes for persons who have received the treatment and compares them to another group who have received another treatment of known effectiveness. Ideally, people are assigned randomly to one treatment or another, although this is not always practical. Researchers examine not only the immediate outcome, but events several years after treatment, as we want treatment methods to provide long-term benefits.   

Why would charismatic groups not follow the same procedure in making decisions about the safety and effectiveness of treatments? There are several reasons, which I have discussed in a published paper (“Deliverance, demonic possession, and mental illness: Some considerations for mental health professionals.” Mental Health, Religion,& Culture, 2013, 16 (6), 595-611). One is the fact that  charismatic Christians do not expect problems of mental health, mood, or behavior to be cured permanently; attributing these difficulties to the individual’s spiritual condition, and acknowledging the sinful nature of human beings, they believe that most humans will “backslide” spiritually and periodically show symptoms of their problems. The most important part of their cure, commitment to religious beliefs, is accomplished, but the observable outcome may not show this--  in fact, repeated worsening of observable symptoms is very much to be expected. Considering mood and behavior alone as the foundation of supportive evidence  is simply ignoring the essential spiritual change, whose long-term benefits are to be assumed even when observable outcomes are poor.

In addition, charismatic groups reject the traditional scientific view that  investigation is a public process in which communication to and correction by others is essential to the development of reliable evidence. Instead, they are committed to the belief that knowledge is given by God to individuals, who correctly identify it as truth.  Acording to D.H. Boshart, writing in 2006 at www.christcenteredmall.com, such truth may appear in the form of a “word of knowledge”, which is “a definite conviction, impression, or knowing that comes to you in a similitude (a mental picture), a dream, through a vision or by a scripture that is quickened to you. It is supernatural insight or understanding of circumstances, situations, problems, or a body of facts by revelation; that is, without assistance by any human resource but solely by divine aid. Furthermore, the gift of the word of knowledge is the transcendental revelation of the divine will and plan of God.”

One aspect of God-given knowedge is the capacity for “discernment”. This is a form of spiritual diagnosis, and a person with this gift is able to identify whether the spiritual causes behind an event are of God, or whether they are Satanic in nature and thus require treatment by the casting out of demons. Evidence-based practice that does not include discernment would presumably seem to charismatics to be highly ineffective and even dangerous (because of the demonic factors), even though science-oriented practitioners might consider that their evidence shows a treatment to be safe and effective.

It is hard to imagine how this culture war can be resolved or even how skirmishes like the fight about the Ukrainian pastor Gennadiy Mokhnenko will turn out. However, it would be a mistake for the scientific side to assume that their opponents are simply lacking in knowledge, when in fact they are operating within a complex belief system of their own and interpreting the observable world in terms of a posited invisible realm to which only they have access.  
   


   

Tuesday, August 6, 2013

Behind a Kickstarter Request: Helping "Social Orphans", Evangelizing, and Corporal Punishment

N.B. I thank Yulia Massino for passing on this information and for her remarks at http://www.liveinternet.ru/users/julia_ma/post286118762/

Nobody gives to all kickstarter requests, but when people do give they generally accept that the proposed project is what it appears to be. I would doubt that many people do a serious investigation before giving, and in most cases it would be hard to know what to investigate. But here’s a project that can be looked into: http://www.kickstarter.com/projects/dannyyourd/gennadiy-our-new-documentary, a project that plans to tell the story of Gennadiy Mokhnenko, a Ukrainian who dresses as a priest and “abducts” street children, taking them to an orphanage (so the project description calls it) and detoxing them. The project description does not make it clear how this apparently informal and unofficial rescue effort is funded or why it is tolerated by the authorities, or indeed on what happens to the children as a result of this intervention—whether it is either safe or effective. Instead, it focuses on Mokhnenko’s “heroism” and on the philosophical issues associated with treating people against their will. (The project description does not make clear whether the children pictured in the documentary will have given permission for their names or images to be used.)

So far, we might identify Mokhnenko as a sort of rogue social worker who has tired of the slow grinding of bureaucratic wheels. But Yulia Massino has suggested that he may better be compared to Ostap Bender, the con artist in The Twelve Chairs. For an American comparison, we might go to Elmer Gantry, or to any of many televangelists who have done well without necessarily doing good.

Mokhnenko is the pastor of an evangelical church in Ukraine, the “Church of Good Changes”,associated in the United States with the Pilgrim Orphanage Foundation (http://www.pilgrimusa.org/who_we_are/). According to Internet sources, this foundation was incorporated in 2011 in Houston and has three employees. It is incorporated as a 501c3 entity, so it does not pay taxes, and if it is dissolved must transfer all holdings to another educational or charitable organization. Although Pilgrim does not clearly state its connection with religious organizations, there is a link on its website to www.hopeinternational.org. Hope International, in an on line statement of faith, refers to the complete authority of the Bible and to the indwelling of the Holy Spirit, thus identifying not only with evangelical but with charismatic groups. Kathryn Joyce has discussed the attitude toward adoption of such groups in her book The Child Catchers, quoting a foster mother of more than fifty children as writing: “Your main goal is not to raise well-adjusted children, but to bring the life-changing message of the Gospel to lost souls. If you work with a troubled, damaged child and he never becomes a successful or productive citizen, but he believes the Gospel and has a saving faith in Jesus Christ, you have succeeded. Adoption is a ministry to unsaved souls.”

Mokhnenko is said to be fostering over 30 children, whom he believes he has saved from orphanages, although he does not explain why living in a large group called a foster family is superior to living in a large group in a section of an orphanage. Interestingly, he has also stated his belief in the value of corporal punishment and can be seen at http://megamost.tv/twobriefcases/280.html demonstrating the belt he uses for this purpose. In this video, he also calls attention to a documentary made to criticize the use of corporal punishment in some schools in the U.S., but instead claims that the punishments shown are beneficial. Such punishment has, incidentally, been illegal in schools in both Russia and Ukraine for almost a hundred years.

If I were considering contributing to kickstarter to finance this documentary project, I would certainly like to have some questions answered first:

How does Ukrainian law regard a private individual who  takes children off the streets and keeps them confined?

What happens if parents ask for their children to be released to them?

What methods does he use to treat children who are addicted to alcohol or drugs? Are these methods known to be safe or effective? Are they related to charismatic methods aimed at healing by casting out demons?

Does Mokhnenko employ the corporal punishment that he has advocated?

Presumably Mokhnenko has no medical training. What medical services are available for children being treated for drug or alcohol addiction or for related illnesses or injuries?

What happens to children who have been in Mokhnenko’s care?  Are there any records documenting their physical or mental health or educational progress?

What amount has been donated to Pilgrim Orphan Foundation on behalf of Mokhnenko’s work, and how much has been spent on care for the children?


Perhaps Mokhnenko or his supporters will provide acceptable answers to these questions. Until then, I would keep my wallet in my pocket as far as the kickstarter request is concerned.

  





Thursday, August 1, 2013

Why Breastfeed?

Enthusiastic proponents of breastfeeding are constantly bringing up reasons why it’s important to nurse your baby, so I was surprised when looking at a webinar put on by the University of Albany Public Health Department today. The webinar, which was about community support for breastfeeding, spent little time on the good outcomes to be expected from breastfeeding, but went directly to issues like employer decisions that can help or hinder nursing mothers.

Personally, I am a breastfeeding enthusiast, and calculate that I’ve spent about 30 months of my life nursing. I agree strongly with the novelist Eudora Welty’s character who declares that “a woman never feels so good as when she’s got milk in her”. But I’m disturbed when I see claims made about breastfeeding that cannot be supported by systematic research.

So, why is it good to breastfeed? Well, it’s not because it raises the child’s IQ. The differences reported between breast-fed and formula-fed children’s test scores are so small that they are actually less than the variation you’d expect for a single individual to show on two separate test administrations. In addition, because educated mothers in the U.S. are more likely to nurse their babies, and because genetically-determined factors help people achieve high levels of education, it’s possible that breast-fed babies on average carry genetic material that helps to raise their tested intelligence--  thus, we could argue just as well that higher intelligence makes babies more likely to be breast-fed, as that breastfeeding makes them have higher test scores.

And it’s not because breastfeeding causes bonding, attachment, or any combination of the two. There are a number of ideas left over from the 1970s that emphasize skin-to-skin contact as a factor in maternal bonding (“falling in love”) with the baby, and obviously breastfeeding mothers are more likely to be skin-to-skin than formula-feeding mothers. However (and I say this cautiously because measures of bonding are so poorly developed), it seems that mothers’ attitudes toward their babies are about the same after a couple of weeks whether they breastfeed, bottle-feed, or use a combination of the two--  except for some bottle-feeding mothers who have been convinced that they are not doing the right thing for their babies. As for attachment, the great majority of mothers in developed countries have weaned their babies months before any clear signs of attachment appear; naturally, early experiences might influence later development, but there is no evidence that they do so in this case. Bowlby’s studies of attachment were done at a time when breastfeeding was relatively infrequent, but his measures seem to apply in pretty much the same way now as they did then. There are cultural and ethnic differences in breastfeeding in the United States, but no evidence that babies in groups that breastfeed less tend to have less secure or less organized attachment than babies in other groups.

Is breastfeeding physically beneficial for infants?  As is well-known, human milk contains antibodies that help protect against infections that occur through the gut, including not only gastrointestinal disorders but some other diseases like polio. Although babies are born with a supply of antibodies against diseases that their mothers have developed immunity to, in the early months they are not very good at mounting defenses against new diseases they may be exposed to. The mother’s milk allows her body to be an “auxiliary immune system” that is good at developing antibodies against new infections and passing the antibodies on to the baby. This means that breastfed babies have some advantages, especially because it is easy for them to become dangerously dehydrated if they have repeated vomiting or diarrhea. But on the whole, babies in developed countries, with access to modern medical care, clean water, heat for sterilization of bottles, and refrigeration of formulas, are not likely to suffer from being formula-fed--  provided that they do not encounter problems of formula production like those recently in the news from China. Babies in Third World countries, however, may suffer serious, even fatal, health problems if their mothers do not breastfeed.

Is breastfeeding physically beneficial for mothers? The baby’s sucking at the breast does stimulate contractions of the mother’s uterus and helps return the uterus to its pre-pregnant size more quickly than would otherwise happen.  Breastfeeding mothers resume menstruation months later than do bottle-feeding mothers, but this does not necessarily mean that they do not ovulate and cannot become pregnant. Breastfeeding for a year or more seems to reduce later breast cancer rates somewhat. But there can also be mild downsides to breastfeeding, and most nursing mothers occasionally experience clogged ducts (“caked breast”), sore nipples, or breast infections.

How about the family in general? Is breastfeeding beneficial or not? It is certainly cheap compared with formula feeding, and the savings in money can be put to good use by most young families. Breastfeeding involves less extra work during the early months, since there are no bottles or nipples to clean and sterilize. Bottle-feeding can appeal more strongly to fathers who otherwise feel left out of the mother-baby loop, although the bottle can contain the mother’s milk rather than formula. The impact of breastfeeding on the mother’s return to work after some months can depend on her employment and the time and situations that allow for nursing the baby or pumping milk; however, returning to work in the first two weeks, when the milk supply is not yet well established, will probably mean that breastfeeding will not go on for long.
Breastfeeding does provide some assurance that a baby is getting picked up and attended to as much as is needed. Most bottle-fed babies also get all the attention they need, but bottle-feeding does make it possible for parents or caregivers to skimp on attention by propping bottles for the supine baby--  a practice that is illegal in many states that regulate what goes on in infant day care. Only occasionally does one encounter a breastfeeding mother who limits the baby’s nursing time (I once met one who used a stopwatch!), because most nursing mothers know that more sucking means more milk being produced.

Breastfeeding also pretty much assures that parents respond to a baby’s communications. Because adults cannot easily know how much milk a baby has taken, they rely on the baby’s signals to let them know what he or she needs. Bottle-feeding parents can do this too, but they can also pay more attention to how much milk is left in the bottle  and thus have the option of attending less to the baby’s cues. There is one unique situation of this kind associated with breastfeeding: the breastfed baby indicates to the nursing mother when it’s time for the switch from one breast to the other. Most women nurse on both sides at each “meal”, and although they can feel that a breast becomes softer to the touch as it is emptied of milk, they really cannot tell whether the breast is producing the fat-rich hindmilk or whether it is close to dry--   nor do they know whether the baby is hungry for the hindmilk or would like to proceed to the more watery foremilk being produced by the second breast. The baby’s communication, letting go of one nipple and fussing until the sides are switched, is essential. Does this stress on communication during breastfeeding make any difference to the development of gesture and speech communication? As far as I know, this has never been studied systematically, but it’s not implausible.


Most nursing mothers find breastfeeding gratifying (or probably they would stop). It can be a wonderful quiet time during which nobody will bother you, and you and the baby can just peacefully do your thing. There are several other good reasons for choosing to breastfeed, but the extravagant claims about the benefits for babies in the developed world have not been supported by evidence.  Some possible benefits have never been investigated carefully. But, like most other things about infant development, it’s more complicated than it appears, and is not a miracle cure for every infant and family problem.