Wednesday, December 21, 2016
We tend to be attracted by the idea of “one-stop shopping”, but we can pay the price of convenience by not getting exactly what we want. In fact, we may find ourselves regretting purchases we made just in order to save time. “One-stop thinking” presents the same problem: when we pay attention only to one factor that affects children’s development, we cut down on the time spent in consideration, but we risk making some big mistakes.
In reality, children’s physical and mental development are invariably affected by more than one factor, genetic or environmental. And usually, the influential factors are not just two or three, but many. Often, influences act bidirectionally, so that children affect their parents as much as parents affect their children. Influences can even be transactional in nature, so that bidirectional effects (for example, parents’ and children’s mutual influences, or families’ and schools’) change in their nature over time and experience. Developmental outcomes may depend on some combination of environmental circumstances (helpful or harmful) and the characteristics of the child (vulnerable or resilient), with the best outcomes resulting for a resilient child in a helpful environment and the worst for a vulnerable child in a harmful environment.
In other words, it’s not rocket science-- it’s a lot more complicated than that (even though this statement is annoying to rocket scientists).
Recent years have seen a number of examples of one-stop thinking about child development, not by developmental scientists themselves, but by people popularizing and translating developmental research and theory. Unfortunately, oversimplified translations are often applied to pragmatic topics like how to intervene in children’s mental, behavioral, or educational problems. These may be welcomed by consumers of services, because their simplicity “makes sense”, especially if it echoes claims made familiar by repetition. Those familiar and simple claims amount to what the developmental scientist Jerome Kagan famously called “seductive ideas”—ideas that are so appealing to us that we buy into them without much investigation of their “one-stop” convenience.
Here are some familiar ideas that can lead to one-stop thinking if we do not pay careful attention.
Infant determinism is the idea that everything of developmental importance is accomplished during the first years of life. Early intervention follows on this idea by assuming that there is a desperate need to change completely the circumstances of every child who is abused or neglected in early life, most often by offering services to parents, but sometimes by foster or adoptive placement. One-stop thinking on this topic ignores two facts: that small changes in a family’s situation can help improve a child’s developmental trajectory, and that events such as school availability and neighborhood safety may later help restore derailed development. A 2014 article in the British Journal of Social Work (Featherstone, B., Morris, K., & White, S., “A marriage made in hell: Early intervention meets child protection.” BJSW, Vol. 44 (7), 1735-1749; oro.open.ac.uk/37437/3/329984C2.pdf) pointed to the mistakes made when child welfare workers do not try offering needed support to families rather than hurrying to intervene; this article is of particular interest in that it places this issue in a political context.
Attachment is an important concept in the study of child development as well as in practical decisions about child care and custody. But one-stop thinking about attachment and attachment disorders focuses entirely on these topics as the unique core of personality and behavioral development. As a result, educators and counselors may attend only to a child’s attachment issues and ignore all other child and family characteristics that may be affecting development. In addition, therapies directed at changing attachment may be proposed for an enormous range of mental health problems, from autism to oppositional defiant disorder. Interestingly, the fad of the last 30 or 40 years for an exclusive focus on attachment appears to be waning, and another fad is emerging.
Trauma, in the mental health context, describes experiences of seriously frightening or painful events that interfere with important relationships and thus with development. Trauma-informed approaches are essential for work with children and parents, as reactions to trauma may involve behaviors like fearfulness and aggressiveness, sleep disorders and bedwetting, for which children are brought into treatment. Attempting to treat these without considering the influence of trauma is likely to be ineffective, if trauma is indeed involved. But one-stop thinking about trauma leads to the assumption that where there is a mood or behavior problem, there must be trauma in the background, even though there is no independent evidence that this has occurred. There is only a step from this assumption to the whole “recovered memory” charlatanry that was thriving 20 years ago and is still in existence. Seeing trauma everywhere is the new fad that has replaced the attachment fad; even the organization ATTACh, at one time the Association for Treatment and Training of Attachment in Children and a great proponent of attachment therapies, has now caught the trauma wave and become the Association for Training on Trauma & Attachment in Children.
Neuroscience is both a critical aspect of research on child development and an insidious temptation to one-stop thinking. I recently attended a presentation on the effects of poverty on children that used multiple PowerPoint slides of children’s brains to buttress the strong existing evidence that children growing up in poverty have worse physical and mental health, and worse academic achievement, than those growing up in better circumstances. No one (including me—I didn’t want to offend the speaker who kindly gave his time) demanded to know what on earth the brain images had to do with the argument that poverty is not good for children’s development. Using the slides was only a way to strengthen, not the argument itself, but the reception of the basic argument by an impressed audience. One of the problems with one-stop thinking about neuroscience is that the field itself, and what we know about it today, is too complex and too incomplete to allow us to use this information well. For example, a recent study described by Pam Belluck in the New York Times (Dec. 21, 2016, p. A15) noted that in the course of pregnancy women lose (yes, lose) brain volume in areas that are used in understanding how other people perceive things. Those who lost most volume, in the reported study, were most emotionally attached to their babies. Thus, loss of brain volume can improve certain capabilities, which we already knew from information about hormone-determined brain changes in boy and girl babies. But—according to the famous study of London taxi drivers, increased capabilities can also go with increases in brain volume! One-stop thinking is especially dangerous when the “stop” does not offer much clarity.
A real problem with one-stop thinking about children is that we don’t just create our own mistakes. We also have other people who would like us to make the mistakes they suggest, for the benefit of their own financial or personal aggrandizement. And often they are very attractive and persuasive people who appear to offer simple, achievable solutions to our complicated, intractable problems, or those of our children. They tell us they are world experts, or have cared for thousands of foster children, or even have a direct connection to supernatural powers. When we meet these people, we need to resist their one-factor solutions and remember the adage about rocket science.
And by the way, if it seems too good to be true, it probably is.
Monday, December 19, 2016
I recently published an article in the Child and Adolescent Social Work Journal, under the title “Evidence of Potentially Harmful Psychological Treatments for Children and Adolescents”. Interested people can read this paper at the following link: http://rdcu.be/nRB3.
However, assuming that most readers won’t be quite that interested, I’m going to summarize the article here and add a few comments.
The point of this paper is that there is clear evidence that certain psychological treatments that have been used for children have been harmful, and that in fact it would have been possible to predict these harms beforehand by careful examination of the principles and practices of the treatments themselves. Evidence for harm done by certain treatments goes back to the 1960s, so no one should be surprised to find that this is a possibility. Nevertheless, specific discussion of potentially harmful psychological treatments goes back only to 2007, and even then there was little emphasis on potentially harmful treatments for children. An important publication in 2007 assumed that harms can be identified through systematic research evidence, whereas in fact anecdotes and journalists’ reports may be the first line of information to warn of us of harm to children.
My paper proposes that potentially harmful treatments for children may be identifiable – before harm is done—by several characteristics that make them unusual in comparison to most childhood mental health treatments.
One of these is that they create an emotional burden for the child, making him or her feel distressed by the treatment. Although it has been claimed that people in psychological treatment must feel uncomfortable so they can be motivated to change, this idea is not evidence-based, and the great majority of child treatments focus on comforting the child as he or she tries to master issues like anxiety resulting from trauma. Treatments that are distressing for a child run the risk of re-traumatizing rather than helping.
A second characteristic that is proposed for potentially harmful treatments for children is derived from the Adverse Childhood Experiences (ACE) study, currently underway and revealing that problems of both mental and physical health in adulthood are associated with increased numbers of adverse experiences of painful and disturbing experiences in childhood. There are ten ACE questions used for research purposes; of these, the four following questions are most relevant to potentially harmful psychological treatments for children.
- A parent, another adult in the household, or a therapist often or very often swore at the child, insulted the child, put the child down, or humiliated the child, OR acted in a way that made the child afraid that he or she might be physically hurt.
- A parent, another adult in the household, or a therapist often or very often pushed, grabbed, slapped, or threw something at the child, OR at some time hit the child so hard that he or she had marks or was injured.
- The child often or very often felt that no one in the family loved him or her, and that no one, including the therapist, thought him or her important or special.
- The child often or very often felt that he or she didn’t have enough to eat, had to wear dirty clothes, and had no adult protector.
I propose that when a childhood mental health treatment features these ACE events, this fact helps to identify the treatment as potentially harmful
The third characteristic I suggest for identification of potentially harmful treatments for children is drawn from the fourth National Incidence Study of Abuse and Neglect (NIS-4). NIS-4 identifies for research purposes a list of adult actions that are to be considered abusive to children. The following table shows adult behaviors that are relevant to the identification of potentially harmful psychological treatments for children.
Behaviors coded as physical neglect Behaviors coded as physical abuse
Refusal to allow needed care for diagnosed Hit with hand
condition or impairment Hit with object
Unwarranted delay or failure to seek Push, grab, drag, pull
Refusal of custody/abandonment
Illegal transfers of custody
Inadequate personal hygiene
Behaviors coded as educational neglect Behaviors coded as emotional abuse
Permitted chronic truancy Close confinement: tying, binding
Failure to register or enroll Close confinement: other
Other refusal to allow or provide needed attention Verbal assaults and emotional abuse
to diagnosed educational need Threats of other maltreatment
Behaviors coded as emotional neglect
Inadequate nurturance/affection Exposure to maladaptive behaviors and environments
Other inattention to developmental/emotional needs
I propose that treatments that include these behaviors are identifiable as potentially harmful to children.
Having established these criteria for potentially harmful psychological treatments for children, I examined five psychological treatments for children to see whether they met the criteria: aversive conditioning using electric shock, holding therapy/attachment therapy adjuvant treatments associated with holding therapy/attachment therapy (Nancy Thomas parenting), “holding time” (Festhaltetherapie), and conversion therapy for change of sexual orientation. In practice, although not necessarily in theory, each of these treatments met all or most of the criteria for potentially harmful treatments for children. Two of the treatments, aversive conditioning using electric shock and holding therapy/attachment therapy, have over many years moderated their practices, but their potential for harm remains. Interested readers can look at the paper for many more details about these five treatments and for the sources I used in writing the paper..
I certainly do not mean to suggest that these five treatments are the only child mental health interventions that have the potential for harm. I would have liked to include an analysis of various treatments for children displaying “parental alienation” by rejecting and avoiding one of their parents, but there is little systematic evidence either about the effectiveness of these treatments or about their potential for harm. There is no question that they cause an emotional burden to the children. In addition to this, there is anecdotal evidence that these treatments may be associated with frightening experiences with youth transportation services, and with threats to send an uncooperative child to residential care or to wilderness programs where the child cannot communicate with anyone outside the treatment program and may be at the mercy of staff members.
Monday, December 12, 2016
People keep sending comments to a much earlier post on this subject-- but there have been so many that no more fit on that page. Here is a recent one of these.
Hi Dr Mercer,
I have a 4 month old baby girl that was born 3 weeks early. Had a rough delivery with forceps and she was bradycardic for 8 min.he had mild hypotonia in her arms.
We are very worried as she has not made any eye contact with us yet or smiled at us. She started tracking objects around 3 months, but She doesn't seem interested in anything in particular. She bats at objects but can't grab them yet. Has good control of her head but has not rolled over yet(and doesn't really seem interested in trying). Pediatrician is concerned and went to see a ped neurologist but they say it's early at this age to say anything. I still feel like they must be something that can be done to see why she what is wrong with her.
Thank you so much
Her corrected age is just over 3 months, so it is not surprising that she has not rolled over and can't yet grab things. It's a good sign that she bats at objects, because this shows that she has at least some vision. The head control is also good. I'm not surprised that you are concerned about the lack of smiling by this age. However, please keep in mind that many babies who have a rough start do catch up in growth and development.
I understand how frightening and frustrating this situation must be for you, but the neurologist is right in saying that she is too young to get a clear picture of what, if anything, is wrong.
But while you wait to see the outcome, you can work with her to help support her ongoing development. Do your best to show her a smiling and interested face-- try not to look anxious or stressed when you are face to face with her. Make sure that when you look at her, there is a bright enough light on your face so she can see your features even if she has some vision loss. Don't give up if something you do (big smile, for instance) doesn't seem to get her attention-- do it several more times. Sometimes you can get a baby's attention by "looming"-- move your face toward her while you open your mouth wide, then move away while you close your mouth. In addition, you can combine several sensory events to get her interest by talking or singing while you look at her and tapping or rubbing her hands or feet. There's nothing magic here-- I'm just suggesting that you may be able to draw her into an interaction by giving her more complex stimulation.
It's true that you will have to wait for an accurate assessment, but you and she are not in suspended animation. You can still do things that will give her the best chance for good development. If you notice even a small response, keep on doing whatever seems to get her interested.
By the way, you should be sure to put away your phone and all screens when you're with her so you aren't distracted by them.
Good luck to your family, and I hope to hear in 6 months that she has made great progress!
Thursday, December 8, 2016
Here is a comment on eye contact and other possible "red flags" for autism. It couldn't be placed on any of the pages I have on that topic, for some reason, but I thought it would be useful for other people to read these intelligent questions and my (I hope intelligent! ) responses.
Hello Dr Jean Mercer,Showing is actually a lot more complicated than giving. For giving, he just has to respond by letting go when you put your hand out. For showing, he has to figure out where you are looking and hold an object so you can see it-- not let go, not drop it. To combine showing and giving in the right sequence is even harder. I don't think he plans to fake you out (that would require some pretty advanced cognitive skills), but he is probably not yet able to inhibit the showing action and start the giving action.
I'm not sure if you are still actively replying to comments, but I would love your thoughts on my 12.5 month old son.
In the effort to fully disclose, I would like to mention that my oldest son who is 2.5 followed a similar pattern of development, in which I was convinced he would be diagnosed with autism until about 16-18months old. He is now very advanced in his language and very social (almost too social!).
As with my older son, I have had long time concerns with his eye contact. This has spewed into constantly analyzing if his joint attention is enough. He has many strengths but they seem to be over shadowed by a weakness/red flag. I guess I am not sure if they are developmentally expected at this age or my my expectations are too high. I have brought concerns up to my last two well baby visits only to be brushed off. Here are my strengths and concerns:
1) Showing/giving: He has been showing like crazy lately, everything he picks up he makes eye contact and "says" something BUT virtually no giving. If I reach my hand out he will "fake me out" and hold onto it. He was giving but not showing about a month or so ago.
Pointing can simply be a way of indicating behaviorally that he is interested in something-- I mean indicating it to himself, not to you. If he does do joint attention a few times a day I would say that's fine.
2) Pointing: he points a hundred times a day. BUT never looks at me during/after point. Very occasionally he will quickly glance my way but it's quite rare. He has done some 3 point gazes but I'd say maybe 2-3 times a day definitely not a lot.
3) Engagement: he plays and laughs with me. BUT not much eye contact during it. In fact very little. For example we played with a ball for about 5 minutes together, he was laughing a lot (he would hold the ball and drop it and then I would roll it to him or pass to him) but I was watching intently and as much as I could tell he was enjoying it he didn't once look up at me. He focused on the ball the entire time. He also can play by himself for lengths of time without looking up (my oldest did this as well so I'm not as worried compared to the engagement with the ball example).
I think the ball play is probably still pretty challenging to him. To look up at the same time is kind of like patting your head and rubbing your tummy at the same time. He's not ready to multitask or to stop and start actions easily.
They do things and then don't do them any more for a while, quite often. Sometimes it's because the skill is so well mastered it's not interesting any more-- other times, who knows!
4) other gestures: this one has me stumped. A month ago he wasn't clapping but had waved bye bye a few time on his own. He would also makes kissing noises when I said give me a kiss. Now no waving or kisses but will clap on demand. I thought he caught on to the toy telephone because he seemed to do it once but not again. He continues to say no no no while shaking his head so that's a definite strength that has stuck around. But it's like he completely forgets how to do it???
5) mirror: He shows zero interest in a mirrorDo you mean he doesn't recognize himself in a mirror? I wouldn't expect him to until about 18 months. Then you could try putting a dab of lipstick on his nose and showing him a mirror-- he will probably put his hand to his nose at once.
No reason to be concerned.
6) no walking but my oldest was 16 months before he walked so I'm not concerned about this
Receptive language (understanding) is much more important then expressive language (speaking).. Knowing what they actually say can be so difficult because they may not make the same sounds every time. You may just be missing what he says, or possibly he's busy on some other aspect of development. They don't work on everything at the same time or the same rate of speed.
7) I can tell he understands some things I say, like get the ball, take a drink, where's dad etc. as for words, he has said dog, ball, and bear (along with mama and dadda), but now only seems to say ball appropriately
He gets a kick out of feeding me, which I see as a huge strength but it's the eye contact that has me the most worried. I guess I'm hoping for either reassurance that he seems to be developmenting on the right track or a push to request services regards of being brushed off.
It sounds as if he does a lot of social interaction and that's on the right track. They don't actually make a great deal of eye contact, if you measure it objectively-- a quick glance is all it takes, not a long gaze.
Thank you for the support ;)
Thanks to you for the great descriptions! I'm sure other readers will benefit from them.
Just try to keep in mind that what toddlers can do and do do is so different from what adults do that it's really hard to figure them out. Jean Piaget referred to children this age as "cognitive aliens"-- their thinking is so different from ours that they might as well come from another planet. Or, as one of my grandsons says, They're ca-RAZY!
Saturday, December 3, 2016
My friend and colleague Linda Rosa recently pointed out to me a Wikipedia article about the Columbia University-associated psychiatrist Martha G. Welch. This article contains much about Welch, including her connection with the grape juice family and her current partner’s name. Her interest in autism is mentioned, as well as various honors she has received from Columbia and biological research she is engaged in.
But… a lot was missing in this article, until I went to work and edited it by adding a paragraph that described some of Welch’s complementary-alternative approaches to treatment of autism. Indeed, the article as it stood cleaned up Welch’s professional life thoroughly and positioned her as a conventional researcher with no history of any fringe theories. I checked both the Talk and the History sections of the Wikipedia page, where you can see whether people have discussed or made changes in included material, but I did not see that material had been deleted, so I assume that the gentrified, non-comp-alt version was pretty much the way the article was originally written.
Of course, anyone who knows anything about Martha Welch knows better than to accept this tidied-up version. Here’s the reality.
Martha Welch many years ago visited Foster Cline and other proponents of Holding Therapy in Evergreen, Colorado. She was impressed with their intrusive, potentially dangerous methods of restraining children, techniques that they posited as psychotherapeutic. These methods were based on the work of Robert Zaslow, the California psychologist who in the 1960s and ‘70s claimed that autism and other mental illnesses could be treated successfully with painful physical methods (until he lost his license for injuring an adult patient).
Welch did not exactly follow the Evergreen methods, but she decided that something similar would be an effective treatment for autism. She speculated, like Zaslow, that autism was the result of a disorder of attachment—the child’s mother had not done the right things to create attachment. (On Welch’s behalf, I have to say that this exaggeration of the role of attachment in development was common at that time and has not completely left us). Welch considered that human attachment occurred in an exact parallel to the “imprinting” whereby a recently-hatched duckling follows a moving object and subsequently tries to stay near (and eventually mate with) similar objects. This ethological explanation was maintained despite the fact that imprinting has never really been demonstrated in any mammals, much less in human beings—but the possibility was given serious consideration by Konrad Lorenz and Nikolaas Tinbergen, the ethologists who had investigated such instinctive behaviors in birds and fish.
Welch suggested that attachment (which of course she saw as the key to autism) could be created long after the period when it normally occurs if a child was forcibly kept in close physical contact with the mother. (Sorry fathers, you did not really get much of a role in all this.) She developed a technique she called “holding time” (also the title of a book she published on the subject in the 1980s). “Holding time” was to take place every day, and required the child to be held in close physical contact with the mother for an hour or so, during which time the child would fight, scream, and struggle, but eventually would be exhausted and snuggle closer. Younger children were to be held straddling the sitting mother’s lap and pressed against her chest. If too big to be held in this way, they were to be made to lie supine on the floor while the mother lay prone on top of them, supporting herself on her elbows and looking into the child’s face while she told the child her feelings both negative and positive. Welch presented this method not only as a cure for autism but as a key to good parent-child relations for all families.
As it happened, Elisabeth Tinbergen, the wife of the ethologist and Nobel Prize winner Nikolaas Tinbergen, was a special education advocate, and she came to know Welch and to be fascinated by what she perceived as the benefits of Welch’s method for autistic children. Niko Tinbergen also took an interest and argued that human attachment paralleled imprinting and might be able to be manipulated in the same way (although they stated clearly that no empirical support had been found for this practice). The Tinbergens published a book encouraging Welch’s methods and connecting them with ethological theory; their book included a lengthy appendix by Welch and led to the publication of her own book Holding time. Welch went to England and Germany on an extensive book tour, during which she instructed large groups of mothers of autistic children on using restraint methods with their children. (She also met Jirina Prekopova, another protegee of Tinbergen, who is still doing a similar form of holding therapy in the Czech Republic.) Welch also set up a “clinic” in Connecticut for instruction about this treatment for autism, although no research support had appeared to show that the treatment was effective.
In 2006, a new publication by Welch and colleagues appeared (you can look at the Wikipedia article now for the reference if you want it—it’s not easy to find on her own website). She changed the name of the restraint treatment to Prolonged Parent-Child Embrace therapy and now recommended it for attachment problems and oppositional behavior. A comparison of parents’ assessments of children before and after the treatment was presented was used to conclude that the treatment was effective—a move that ignored the many problems of this kind of research design, including both regression to the mean and developmental changes unrelated to the treatment.
Now, ten years later, Welch appeared in a Wikipedia article as a completely conventional psychiatrist and researcher, quite rehabilitated from her comp-alt days. Of course, I may be wrong in thinking that all the fringe stuff was left out intentionally. Perhaps Welch regrets her involvement with those unsubstantiated claims and recommendations? That would be interesting if true, and I would hope that in that case she would publish a statement about why she has changed her mind (although people who get involved with the fringe rarely do this later on –cf. Dan Hughes). But it is probably more likely that this article’s take was mainly about burnishing the image.