If You See Something, Say Something, But Don't Expect to Be Thanked

Since 9/11, we’ve been cautioned repeatedly with respect to potentially criminal or terrorist acts: If you see something, say something. And very wise this is, because there are many more eyes of ordinary citizens to see problems than there are of “authorities”.

More recently, I’ve seen that catch-phrase used with respect to the Sandusky child molestation case. According to trial testimony, Sandusky was seen molesting boys, but the people who saw him didn’t mention it, or spoke only to others who in turn failed to report the facts to anyone who might have intervened. Now various sports journalists are trying to encourage those who see evidence of child abuse to take their observations to someone in a position to enforce the law.

This is all good advice, but it fails to take into account the retaliation of those whose plans are disturbed by a report of “something seen”. (And of course some of those people may be completely innocent of any wrongdoing.) While that retaliation may not go as far as the anti-snitch culture in which you can get shot for reporting, nevertheless it is severe enough that even whistleblower-protection laws are not perfectly effective.

“If you see something” is also at odds with the cultures of mental health and social services professionals, as I mentioned at http://childmyths.blogspot.com/2012/06/mental-health-mantras-versus-evidence.html. Most of those professionals would not dream of failing to report child abuse (although as the Barahona case showed, being friendly with parents may make caseworkers too comfortable with missed observations and appointments), but they are most reluctant to offer criticisms of other professionals’ work or belief systems. It’s not nice, especially if the criticism is offered in a public way. Ethics guidelines for both psychologists and social workers recommend that any concern about a colleague should be taken privately to that person and worked out, with complaints to a state organization or licensing board reserved for desperate problems. My own experience, in reporting a mental health professional whose online advertising was not truthful and who had attempted to self-plagiarize in a professional publication, was that the problems were said not to meet the threshold for an ethics complaint--  even though the lack of truth in advertising was misleading to clients. One blog, at www.goodtherapy.org, contains repeated complaints of therapy clients whose therapists have failed to provide appropriate services and who have been turned away when they filed complaints. (For full disclosure, by the way, this blog kicked me off several years ago when I criticized the claims of a therapist who was at that time a major player on the blog!)

A recent case of retaliation against a professional critic is told at http://jamescoynequickthoughts.posterous.com. Jim Coyne, a clinical psychologist and professor in the University of Pennsylvania Department of Psychiatry, wrote a post for his Psychology Today blog that questioned the research of pharmaceutical companies on antidepressants used to make cancer patients feel more comfortable psychologically during treatment. In short order, he found that his post and his picture were taken down by Psychology Today and his post was replaced with a new title. He was also told that in future his posts would need preapproval. This experience with Psychology Today echoes my own story at http://childmyths.blogspot.com/2010/12/federici-v-mercer-story-behind-lawsuit.html. Interestingly, in both cases, the criticism had not been directed against Psychology Today itself, but the retaliation was by the magazine, presumably in preemptive strike against litigation or removal of advertising. The intention, wherever it was framed, was clearly to have a chilling effect on professional criticism and to uphold marketing strategies.

In an article published some years ago (Kennedy, Mercer, Mohr, & Huffine [2002]. Snake oil, ethics, and the First Amendment: What’s a profession to do? American Journal of Orthopsychiatry, 72, 5-15), some colleagues and I argued that professional ethics, as well as personal ones, should require us to say something if we see something. In the personal arena, we would be concerned with  individuals or small groups harming others. In the professional area, our obligation should be to speak up when we see what we consider to be systematic professional errors; this does not mean jumping on every colleague who makes a mistake, but it does mean responding to genuine misrepresentation or clearly misguided treatment strategies.

Between the pressures of the marketplace and the cultural demands of mental health and social services professions, few of those who see something now feel ready to say something. This means that much that needs saying is going unsaid—in the professional world as well as in reporting of child abuse.  Isn’t it time that we stood up against the anti-snitch culture? If enough of us do it, we may be able to create a culture of responsible criticism.

I’ll say “thank you” to anyone who stands up--   but at this point very few other people will, unless our criticisms speak to their personal conditions.  

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Evolution, Attachment, and Megafamilies

Like almost everybody else except possibly creationists, I love to speculate about evolutionary psychology. (Is there creationist psychology, by the way? It might be even more interesting.) What fun, thinking about our remote ancestors wandering the Serengeti or painting horses in caves. I think it was in “Reindeer Moon” that Elizabeth Marshall Thomas described women marrying men from a different group and teaching them to have sex face to face—talk about your paradigm shifts!

On the other hand, even while having fun, I acknowledge that a lot of evolutionary psychology is along the same lines as the Just So Stories. It’s only a step from How the Elephant Got His Trunk to How the Human Babies Got to Be Attached to Familiar People. You can’t always work backwards from the present to past causes, because the same cause can sometimes have different outcomes, and a single outcome can have a variety of causes.

All the same, the evolutionary lens provides interesting images when applied to certain topics. Let’s think about emotional attachment of babies to caregivers. It’s easy to see the evolutionary advantage of having toddlers emotionally attached to familiar people--  the attachment works like an invisible playpen. When mothers gathered food in the wild, or cooked on a campfire, or carried water from a distance (as they still do in the developing world), a toddler who ran off or who approached unfamiliar people or animals might well not survive to reproduce. Those who were attached, who stayed near without being supervised closely, and who scurried back to mama when anything strange or startling happened--  they were the ones most likely to survive, and, given that their behavior was genetically determined, the ones likely to pass their traits along to their own offspring, who in turn would survive better  than cousins who were bolder.

But what about the claim that babies are really already attached at the time of birth, when they can’t yet get around on their own? In the environment of early adaptation, that would have been a problem, if it had been true. Maternal death rates were high. Even today, in Sierra Leone, the rate of maternal deaths within the 6 weeks after birth is 2000 per 100,000 births, or 2 maternal deaths per 100 births. Deaths of mothers for reasons unassociated with birth were also common, and probably more so for women who had been weakened by childbirth. This meant that by no means all babies could count on being cared for at age 12 months by the same woman who had given birth to them. For those who were orphaned, it was not necessarily easy even to find in a small band another nursing mother who could feed another child. Caring for an orphaned infant would have been made much more difficult if a young baby had experienced grief over separation from the dead birth mother, because grief interferes with feeding as well as sleep and play. The best arrangement from an evolutionary point of view would have been for infants to develop emotional attachments only after months of experience and familiarity with caregivers--  not that caregivers might not die later on, but they would be less likely to do so if they were not experiencing the risks of childbirth--  and this is how things turned out.

Then there are the megafamilies, adoptive and otherwise. Is it likely that human beings would have evolved to care effectively for many young children at the same time? If we’re talking about adoption, there could be two or more children who are actually about the same age--  would this have occurred in the distant past? Is it likely that any family would have, as well as a lot of young children, many older children who could be put to work at child care? The answers to all these questions are probably in the negative.

Poor diets delay puberty, so it may well be that many of our remote ancestors became sexually mature relatively late and therefore had fewer children than they might have had with early maturation. In addition, regular ovulation depends on having quite a high fat level (24% of the body, believe it or not), which would be less likely with limited food supply and high energy demands from exercise. Of children who were born alive, a high infant mortality rate would have carried off large numbers; even in the 19^th century in some European countries, the infant mortality rate (proportion of deaths before the first birthday) was as high as 250 per thousand births--  one quarter of the children born. These facts mean that few, if any, of our remote ancestors--  the people from whom we presumably receive our genetic heritage--  ever had a baby every year and saw all those babies live. If they had twins or triplets, or babies with any handicapping conditions, chances are that they exposed some of  those babies to the elements and wild beasts, just as many of our less remote ancestors have done. Giving birth to a small number of children, and rearing relatively few of those, was the situation in the environment of early adaptation.

Assuming that human caregiving behavior evolved to suit that early environment (which it may or may not have done), it would seem that we are not likely to have inherited much ability to care for and respond to large numbers of children. Interestingly, some of the research of Mary Dozier of the University of Delaware has suggested that foster parents who have cared for many children in succession are in fact less capable of developing attachment relationships with children than are those who have cared for fewer foster children. The glamorization of large families by the media (and even those are usually 12 or less) does not reflect reality. Even the originals of “Cheaper by the Dozen”, the Gilbreth family, depended on affluence and faithful servants to achieve their good child-rearing outcomes. It is no wonder that when megafamilies meet real challenges in the form of special-needs children the results may be disastrous; it may not be “natural” for humans to have so many children.

These things said, I should point out that different species have different amounts of genetic variability. Look at cats and dogs--  there are small numbers of cat breeds, and only minor differences among them. Dogs, on the other hand, are highly variable, and that variability has made it possible to breed for many different sizes, appearances, and behaviors.How about humans? Are we invariable enough that reasoning based on “our remote ancestors” applies equally to all of us? It’s hard to say, because we’re so cross-bred, even the few groups who pride themselves on their “racial purity”. But in the 1970s Daniel Freedman put together a fascinating short film on behaviors of newborn infants of a number of different ethnic backgrounds, including Native Americans, Japanese, and people of sub-Saharan Africa. These babies during the first 48 hours of their lives showed behavioral differences in their reflexive responses to stimulation--  some of them, in perfect health, showing behaviors that would have been considered abnormal in Caucasian babies. The idea that there might be some basic differences between groups belonging to the human species did not sit well at that time and is rarely mentioned today--  but perhaps it should remind us that all human evolution may not have taken place in the same environment, and all our traits may not be subject to the same explanation.

Abusive Adoptive Megafamilies and Child Hoarding: A HIGHLY Speculative Post

Periodically, newspaper reports emerge of adoptive “megafamilies” who neglect and abuse their children and who isolate themselves or move from location to location in order to avoid detection. One example is the Schmitz family, reported to authorities in Tennessee, who had 11 children, some with special needs; the parents had children “dig their own graves” for punishment, and took away needed spectacles and walkers as discipline of some special needs children. Another such family was the Gravelles of Ohio, also adoptive parents of 11 children, who used cages as disciplinary techniques. (The USA Today reporter Wendy Koch gave details of these cases at www.usatoday.com/news/nation/2006-01-18-swapping-children_x.htm and www.caica.org/NEWS%20Enclosed%20beds.htm.)

It seems unlikely that having a lot of adopted children is in itself the cause of the parental abuse and neglect, although these megafamilies are actually larger than most that research has investigated so far. It seems more likely that pre-existing characteristics of the adoptive parents led both to adopting many children and to abusive and neglectful treatment. If that’s the case, it would be very advantageous for adoption agencies to be aware of those characteristics.

But how to find out the characteristics? Most parents of large families, special needs or otherwise, adoptive or otherwise, do an adequate job of caring for their children. Although it happens too often that megafamilies are abusive, it’s nevertheless actually quite infrequent when you consider all such families.  Here’s where the speculation comes in: what if we could find a similar kind of behavior that would be more frequent and easier to study?

It turns out that there is such a similar behavior, and I’d like to propose it as potentially comparable to megafamily child abuse, and as a possible window into that kind of abusive treatment. I refer to the behavior often called animal hoarding—possession of dozens, even hundreds, of  cats and dogs, none of which are properly fed or cared for. These animal hoarding cases crop up often in the news, generally when revolted neighbors have demanded that the authorities at last do something about a house that turns out to have its floors six inches deep in garbage and animal feces. Animal rescue personnel carry out dead and dying animals, some of which have been partially eaten by others, and take away the living, often to be euthanized. The owner is heartbroken, denies that there was any problem, and just wants the pets back. The animals’ suffering, so obvious to anyone else, seems invisible to the animal hoarder.

Many people have a lot of pets, but until those pets are neglected, nobody would call them animal hoarders. When they become animal hoarders, however, it appears that elements of mental illness are as important as their love for their pets. Animal hoarders have been compared to people who hoard objects and go beyond a nice collection to the point where their homes and lives deteriorate because of their hoarding (see Frost, R.O., Patronek, G., & Rosenfield, E. [2011]. Comparison of object and animal hoarding. Depression and Anxiety, 28(10), 885-891). Hoarding disorder has actually been proposed as a syndrome to be included in DSM-5, and it has been discussed as related to anxiety and obsessive-compulsive behavior.

One student of animal hoarding, Gary Patronek, has discussed ways in which animal hoarders might be grouped in terms of their behavior and motivations (Veterinary Medicine, 101(8), 520-530). It’s interesting to think how these categories might apply to abusive megafamilies (although it wasn’t clear to me exactly how the types were arrived at).

Patronek began with an “overwhelmed” group. These were people who did not seek out more animals and who were somewhat concerned about their pets’ conditions, but because of factors like their own age or illness the owners had become less and less capable of caring for the animals. This does not seem very parallel to megafamilies, who have generally made some effort to collect a large number of children, and who if abusive may need to work to avoid attracting attention to their homes. Patronek’s other two categories seem much more relevant to abusive megafamilies, though.

He identified one group of animal hoarders as “rescuers”. These people were afraid of death and so worried about euthanasia that their pets’ present suffering seemed irrelevant or invisible to them. They felt that only they could provide the needed care, and thus avoided authorities or prevented their access to the home. They worked with a “network of enablers” who protected each other and passed pets along. These animal hoarders felt they had a mission to save the animals, and that mission led them to a compulsive need to acquire and control pets.

The second group Patronek referred to as “exploiters”.  These people denied any harm to the animals from the time they were acquired and were indifferent to suffering. Their interest was in achieving control, and the hoarded animals were tools for this purpose.   They rejected authority, and behaved toward others in manipulative, exploitive, and charming ways. They felt no guilt about what they were doing and had little empathy for people or animals. (Remember, these are not people who have directly harmed the animals--- no torture or dog-fighting is involved.)

Although typologies always raise some questions, I find these categories of animal hoarders strikingly similar to the abusive parents of adoptive megafamilies like the Schmitz and Gravelle couples. The compulsive missions, the drive for control, the network of enablers--  some of these factors do seem to characterize such people.

Are abusive parents of adoptive megafamilies actually what we might call child hoarders? Do they play out their own anxieties by collecting and controlling children--  an easy thing to do when there is popular admiration and nostalgia for the “old-fashioned” big family? (And might it even be that abusive adoptive parents in general are following some version of this scenario?)

Once again, I am speculating freely here. However, I think it’s time we considered more of the background of abuse of adopted children. Yes, certainly, those abusive parents are bad guys--  but why? Is there anything about them that we might detect beforehand, so that we could screen them out of the adoption process? They don’t seem bad to other adults, or they would never have been able to adopt, so it’s background material that’s needed. We need to go much farther than blah-bah-blah, they were abused as children, blah-blah. And adoption agencies need to drop the assumption that if adults are “nice people” they will make good parents. Screening out potential “child hoarders” --  if there are such, and I can’t prove that there are--- may seem unfair to the adoption candidates--  but it would certainly be more than fair to the children.    

Food Pouches, or, Bringing Up Mama

The topic of the week seems to be “food pouches”--  containers of pureed food that can be held and squeezed out by toddlers and even older children--  providing some nutritious food without any of the hassle of utensils, sitting at the table, being careful not to spill, etc., etc. They’re available at considerable cost, filled with elite foods like quinoa. A recent New York Times article discussed the use of these pouches by parents who are too busy to supervise their children’s meals and who want to make sure that foods their children eat are not just junk (also, presumably, who can afford the expense).

Food pouches would seem to be ideal for traveling families who can’t be sure of getting appropriate food for older babies and toddlers, or for situations where a sick or injured child has a poor appetite and may be intrigued by the container. But, for all the kids, a lot of the time? No, and for several reasons.

When babies don’t have any teeth--  or just the front ones—they obviously are not ready for corn on the cob or steak frites. But they do want to chomp on things (“how sharper than a child’s tooth”, as Pogo used to say), and they like to practice that chomping. Given a spoonful of applesauce, they slurp off the applesauce and then bite the spoon too. Bottlefed babies can be seen biting on to the bottle nipple and then yanking it out between their closed teeth.  

What’s the advantage? Part of it is that when teeth are being cut and gums are itchy, biting on things relieves some of the discomfort. But there’s more to it than that. When older babies negotiate lumpy foods, they develop skills in controlling how hard they bite and in using the tongue to chase lumps around the mouth. These skills help prevent choking and gagging, and toddlers who have not had this experience are all too prone to gag on any lumpy foods, like vegetable soup or rice pudding with raisins in it.

In addition, learning to control the tongue and biting pressure also contributes to well-articulated speech, because producing an exact speech sound involves using the positions of the jaw and the tongue to shape the sound-producing air stream coming up from the lungs. Many speech sounds, even though we hear them as the same sound throughout, actually involve exceedingly quick movements of tongue and jaws with changes right in the middle of the sound, so a nimble mouth is required in order to speak clearly. A diet stressing pureed foods after 8 or 9 months may not give the right kind of exercise.

Although the growth of the upper jaw is largely genetically determined, the growth of the lower jaw is guided by exercise and experience of pressure. This enables the growing child’s upper and lower teeth to fit together perfectly in spite of factors like preferring to sleep on one side, which may slightly change face shape. Without exercise and pressure, the lower jaw may not grow adequately, may have an unusual appearance, and may not provide for good speech articulation. (This is a problem for some individuals with cerebral palsy, whose difficulties in swallowing and tongue control have required a soft diet.)  One “evolutionary dentist” writing recently in the magazine Science, even suggested that foods like beef jerky might be important ways to get children enough jaw exercise in this time of soft processed foods. (Bubble gum, I wonder?)  Certainly pouches of puree are not going to do the job, not after the point when teeth are coming in quickly.

There’s more to this issue, too. Let’s think about parent-child communication (which is, by the way, a foundation of attachment as well as of language). Spoon-feeding is an excellent situation for practicing communication. Face-to-face, caregiver and child are ideally arranged for seeing each other’s facial expressions and gestures. They imitate each other--  can any adult offer a spoonful of food to a baby without opening his or her own mouth? For successful spoon-feeding, parents are forced to be sensitive and responsive to the baby’s cues. They can’t just keep shoving food in when the baby doesn’t want it, because baby will just spit it out, close the mouth and turn the head away. If the baby wants more, she will signal more and more clearly and loudly. When enough is enough, everybody slows down and sees that the meal is over. The spoon-feeding set-up is also ideal for practicing hand-to-mouth control. The hungry baby can pick up bits of finger food or hold an empty spoon in one hand and manage a full one with the other. (For some reason, both hands have to be occupied in this task.) As appetite is sated--   which the caregiver has to notice, thus practicing sensitivity and responsiveness-- the caregiver can offer more spoonsful  until no more is wanted.

What I’m saying here is that being spoon-fed, and eating lumpy or chewy foods, is beneficial for the baby’s development. But it’s also beneficial for the growth of the parent as a parent. Experience with babies teaches us to be parents, and the skills we learn at that time will benefit us right through their childhood and adolescent years--  not that we’ll still feed them, but we’ll be skilled in adapting to their changing needs.

[By the way--  wondering about the baby dumping food out of the spoon? Until he or she can rotate the hand on the wrist, it’s awfully hard for the baby to keep any runny food in the spoon. But something stickier will stay in even when the spoon is upside down. ]

On Babywearing

Everywhere I turn these days, I see something about William Sears, “attachment parenting”, and babywearing (carrying babies a lot of the time in various kinds of slings and carriers). It all seems to have to do with the fear that attachment just won’t happen properly, and that if it doesn’t a whole cascade of bad outcomes will occur.

Obviously this isn’t something we can do randomized controlled trials on. Even if there weren’t ethical issues about any possible harm to babies (either of being “baby-worn” or of not having this experience), there’s no way to be sure that parents would follow the routine they were assigned--  and why on earth should they, after all?

What we can do, though, is taking an anthropological approach and look at ways different groups of people have cared for their babies. Much of the decision has been based on the physical and social environment--  did they need to keep babies warm? Did they need to keep them from falling into the fire? Were there lots of other people around, or was the family pretty isolated?  Was it customary to space babies by prohibiting sexual relations until the child was weaned at age 2 or 3? Was there a high infant mortality rate so that most families would not have living children close together in age?

Thousands of ways have been used to care for babies under different sets of conditions. Margaret Mead and Gregory Bateson did a wonderful book of photographs of Balinese life, including babies being carried at all waking times until they could walk , because as creatures who had come recently from the divine they should not go on all fours like animals (by the way--  so much for having to crawl, right?). In the Middle Ages in Europe, and in Russia perhaps even until the present day, babies were swaddled by wrapping in cloths from foot to head until they could be picked up by the ankles and not bend. In cold countries where people stayed indoors much of the time in the winter, babies were kept in cradles where they could be wrapped warmly and rocked to sleep while their mothers did other tasks. In Polynesia, babies could be wrapped into a container and hung from a hut roof, away from animals and adult activity. Some Native Americans bound the child to a cradleboard, so the baby got a handsome flattened head and could be carried easily on the mother’s back. (On the whole, fathers didn’t do these things, although they might be very fond of their children.) In parts of Africa today, although mothers may carry babies in slings as they work in the fields, if they have any 5- or 6-year-old girls around, those girls become “child nurses” and are in big trouble if they let the babies cry.

Let’s not forget an interesting one: in traditional Israeli kibbutz life, babies lived in the babies’ room, where the group was cared for by one or two caregivers who might or might not have much interest in the task. The mothers came in periodically to breastfeed but were encouraged to wean soon and put their energy into the communal organization. The whole point was that there should not be intense emotional connections between family members, but that instead that emotion should go into loyalty to the group.  

And, you know what? All those babies formed emotional attachments to familiar people in pretty much the same way, no matter what their experience had been. Most were securely attached, some were insecurely attached, but the great majority in every group grew up to have ordinary cognitive abilities, social skills, and relationships with others.

The moral of this story is that just as human beings can thrive on a lot of different kinds of food, emotional attachment can grow robustly on many different social diets. If everybody in the family wants to go with babywearing, it isn’t going to do any harm, but it isn’t going to do any special good either. Babies need caregivers who are sensitive and responsive to the babies’ communications. Exactly how they go about being sensitive and responsive can vary enormously depending on the family situation and individual personalities, and they don’t have to be sensitive and responsive every minute. There are limits to tolerance for unresponsiveness, of course, and caregivers who change frequently or are otherwise unable to figure out a given baby’s cues do not provide the ideal situation for secure attachment or other important parts of development.

Having read some of Sears’ work, I have to say that I’m not clear on what he thinks attachment is, or bonding either (and he does seem to use the terms interchangeably). I remember one statement he made some years ago, to the effect that a baby separated from its mother in the hospital was “bonding to the bassinet”. I have no idea what this could possibly mean, unless Sears thinks that human beings, like ducklings, become imprinted on whatever they see in the first hours of life.

So-- Do what works for you and your family. If you have time and energy and want to wear your baby, that’s fine. If you work full time and hand off the baby with your spouse or another caregiver, and nobody wears that baby, that’s fine too. Neither family is going to guarantee a child with no problems, or a child with a lot of problems, by taking one route or another. And don’t snub people who don’t do what you do. It really isn’t a competition.

One thing, though--  babywearers and non-babywearers both, watch it with the cellphones! Don’t imagine that you’re being sensitive and responsive to your baby if you stare toward the baby and talk at length in an adult voice. What do you think this conveys to the baby? It certainly must be confusing to see what appears to be “eye contact” but no response to facial expressions, and the wrong kind of talk for someone looking at a baby. Get a look at a baby’s face some time when Mom is yakking away on the phone and looking vaguely toward the baby. Talk to your friends some other time! For the baby’s sake, Be Here Now.

More About Adoption and Reactive Attachment Disorder: Mind That Diagnosis

At http://www.facebook.com/ReactiveAttachmentDisorderCommunity, some people are incensed by the fact that “someone” has said that the diagnosis of Reactive Attachment Disorder does not include symptoms like violent behavior. They say that anyone who says that ought to see what their kids can do.

But, as Lyndon Johnson and the Bible used to say, “Come, let us reason together.” No doubt their children are violent, as reported. If they aren’t, well, some children assuredly are. No one has said that children aren’t ever violent, just that violence is not one of the symptoms of Reactive Attachment Disorder.

So, we have kids whose violence has been reported, and those are also kids who have been said (by somebody) to have Reactive Attachment Disorder. Suppose one of those things is not true? Which is it more likely to be--  that they aren’t really violent? No, it would be a bit too conspiracy-theory to imagine that a group of parents have invented this report. What about the alternative—that they don’t actually have Reactive Attachment Disorder, or, if they have it, they have some other serious problems as well? Those problems could be other diagnostic categories that haven’t been stated or mentioned, or of course the problems could result from various difficulties of one or more other people in the household, as family therapists have told us over and over.

Not knowing the families, I am not about to say whether violence may reflect family problems. Knowing how the Internet has presented Reactive Attachment Disorder, however, I am prepared to say that a diagnosis that is based on one of the many “checklists” (like the one at www.attach.org) is not going to be an accurate statement about the presence or absence of that specific disorder.  And I’d like to put in a request: before people fulminate about whether their beliefs about violence and RAD have been attacked, they should get a complete assessment done by a licensed clinical psychologist, with a doctoral degree in clinical psychology from an accredited university, and by a physician with some training in behavioral issues. Do those practitioners diagnose Reactive Attachment Disorder, or was the diagnosis done by the parent using a checklist, or by a “registered attachment therapist” with no training in any other aspect of childhood emotional disturbance? If the latter, I would suggest, folks, that you re-think what you’re dealing with.  An assessment, by the way, doesn’t stop with a diagnosis, but describes specific problems that need help.

To go on with this issue, let me point out that only your health insurer really cares what name you give a disorder. Treatment focuses on what symptoms are shown, and within some limits that treatment will be the same no matter what DSM code is written on the bill.

A lot of people have gotten the idea that if a child has had a poor care history—is post-institutional, for example--  that’s all the evidence needed for a diagnosis of Reactive Attachment Disorder. As I’ve pointed out in other posts, the work of Michael Rutter and the English-Romanian Adoptees study group has shown that most children adopted from really awful orphanages do very well. The biggest general problem in the early years is delayed language development.  An American group has shown that improving orphanage conditions improves child outcomes (even though they’re all still separated from their birth mothers, etc. etc.).

Writing in Infant Mental Health Journal (2011, Vol. 32[2]), Christina Groark, Robin McCall, and Larry Fish, in “Characteristics of Environments, Caregivers, and Children in Three Central American Orphanages” have described both children and experiences in those institutions.  The authors point out that children may have very different experiences in orphanages, and that they may have had harmful experiences even before entering the institution.

The characteristics of the orphanages give some possible insight into children’s developmental difficulties and show us how much more there is to think about than a simple diagnostic category. Most of the wards had 8 to 12 children aged birth to 7 years (grouped by age), but in one orphanage there was also one single room with about 50 infants and young children, with each caregiver informally taking charge of a certain part of the room. Child to caregiver ratios were from 8:1 to 12:1. Caregivers worked long shifts—even 24 hours—and then had 1-3 days off. Children thus had little opportunity to spend much time with any one caregiver, and there was little time for a caregiver to get to understand each child well. Children also “graduated” to a new ward periodically. As Groark and her colleagues put it, “while caregivers were stably employed, they were not consistently present in the lives of children, who tended to see new caregivers from a set of 6 to 9+ every day or every other day, experience different substitute caregivers as needed, and graduate to new wards.”

The children (mostly under 7 years of age) were described as having “exceedingly low” behavioral development. They also showed quite high rates of indiscriminate friendliness to a stranger and were frequently noncompliant and provocative, and even interpersonally violent, but unlike some other post-institutionalized children who have been described, they did not show much impulsiveness, impatience, or frustration, or stereotyped or withdrawn behavior.

It’s notable that this article did not use the term Reactive Attachment Disorder or any other diagnosis of the children’s characteristics, and it’s hard to see what good would come of anything other than describing what the children were like. Groark’s work was not a study of therapy, but it’s easy to see how helpful it would be for parents or therapists to have specific information about child behavior rather than a diagnosis which gives a general--  possibly incorrect--  description, which may apply much better to some children than to others. A diagnosis describes the disorder, not the child, and when we come down to it, we treat, or adopt, children, not disorders.    

ATTACh Tells Us About Attachment Disorders: An Unrecommended Video

You can see at www.youtube.com/watch?v=WV6d1nAgBNI a video entitled “ Attachment Disorder: Diagnosis and Treatment”. The video does not make it clear who made or sponsored it, but shows the logo of the Association for Treatment and Training of Attachment in Children (ATTACh), a parent-professional hybrid group that claims special expertise in mental health problems of children. Those presenting on the video are leaders in ATTACh, but would not be regarded as prominent in mainstream approaches to infant and child mental health. You may want to watch this production, but please read this post first.

Here are some statements from the video that I want to comment on:

1.      (1:25) Sally Popper comments on the inadequacy of the usual definition of attachment disorders, presumably referring to the DSM-IV-Tr criteria for Reactive Attachment Disorder and the ICD-10 criteria for Disinhibited Attachment Disorder. She states that these definitions are not very useful, and that discussion of attachment disorders should include facets such as attention problems. She also states that attachment disorders involve children’s lack of  trust in the caregiving environment. Finally, she refers to such disorders as being caused by interruptions (or other difficulties) in caregiving, especially for babies, but she does not comment on an age range in which such interruptions are most likely to have ill effects.

Popper’s remarks reflect many years of ATTACh claims about the existence of some form of attachment disorder which is “not yet” included in DSM. Unless, it has suddenly been changed, www.attach.org lists a series of signs and symptoms of attachment disorders that are completely incongruent with the DSM criteria. The Randolph Attachment Disorder Questionnaire, once well-thought-of by ATTACh proponents, was stated by its own developer not to be an evaluation of Reactive Attachment Disorder, but of “something else”. ATTACh members have claimed for many years to be able to recognize a disorder caused by a  poor attachment history and not known to anyone else; Elizabeth Randolph stated that she could diagnose this problem when children were unable to crawl backward on command. These claims have been ways of positioning ATTACh as possessed of an expertise that was not available to mainstream mental health practitioners.

The absence of any statement about an age period in which children are especially sensitive to disrupted caregiving relationships is also typical of years of ATTACh statements. Omitting this critical point allows practitioners to claim that any adopted or foster child, no matter how old the child was at placement, suffers from an attachment disorder. There is a connection here to the claim that emotional attachment occurs prenatally and that babies adopted on the day of birth nevertheless suffer emotionally from the separation from the birth mother.

2.      (2:48) Richard Kagan talks about the discoveries of neuroscience about the impact of the brain of neglect and abuse and states that abused or neglected children show poor self-regulation because some brain structures are “shrunken”. Then, abandoning the showing of the neuroscience flag, he goes on to say that children may have learned frightening behaviors as ways to get help when neglected. As Kagan does not mention any diagnostic or treatment usefulness of information about brain structures--  and as he does not seem to see that frightening behaviors as he discusses them may be a form of self-regulation—it is difficult to see the relevance of any of these statements to the supposed topic of the video.

3.      (5:39) Victoria Kelly introduces the idea of Developmental Trauma Disorder, the diagnosis suggested by Bessell van der Kolk but probably not to be included in DSM-V, and proposes that this diagnosis is what really captures the nature of attachment disorders as proposed by ATTACh. Kelly stresses the difficulty of diagnosis and states that children may be seen as having ADHD or bipolar disorder--  but because the real, underlying problem is not being treated, interventions are not successful.

N.B. Nobody in this video talks about how appropriate therapy would be different from ordinary methods, but van der Kolk’s claims that the real problem cannot be accessed cognitively imply that physical methods associated with emotional reactions might be the way to go, in spite of the fact that such methods have no foundation in systematic evidence.

4. (7:11) Gregory Keck is supposed to be speaking about the history of understanding of attachment disorders, and of course I listened to this with great interest. He even begins by citing Foster Cline--  but rather than talking about holding therapy and why (or whether) they don’t do that any more, he simply says that Cline had seen attachment disorders (as he defined them) as psychosocial in nature, and now the field sees them in terms of trauma and brain development. What difference this would make to diagnosis or treatment, the supposed topics of this video, was left unstated.

5. (8:40) Barbara Rila comments on what will happen to children with attachment disorders (undefined)  if they don’t get  proper treatment (also undefined). She claims that the consequences in adulthood will be borderline personality, anti-social personality disorder (this of course has been the mantra of ATTACh for years, usually with names like Jeffrey Dahmer associated), depression, and suicidality. Proper treatment is supposed to ameliorate all of these.

Rila does not compare these statements with the reports of Michael Rutter and the English-Romanian Adoptees study to the effect that the great majority of the children they studied, who had been adopted from the worst possible conditions and therefore most likely to show attachment disorders, did very well. Some were reported as having quasi-autistic features, and some were unusually friendly with strangers as young children, but all were doing quite well in their teens. None were reported as anti-social in behavior; the most common problem was delayed language development.


Rila, by the way, was the author of a chapter on attachment disordered adoptees in a 1997 book edited by Roszia. In the abstract for that chapter, she says "The process of attachment therapy essentially reenacts the attachment cycle. An attempt is made to elicit the child's emotional pain or experience that is blocking present attachments"--  in other words, Rila at that time, at least, was a supporter of holding therapy.

             6. (10:49) Michael Trout states that practitioners now have most of the tools needed to treat attachment disorders (undefined) and that there is hope for children with problematic early experiences. One of his reasons for this statement, he says, is that “babies remember” and their behavior has meaning that helps us understand what they remember.

Let me just point out that Michael Trout is involved not only with ATTACh (which gave him an award) but with the Association for Pre- and Perinatal Psychology (APPAH), a group dedicated to the idea that babies are conscious of their prenatal and even pre-conception experiences as well as remembering the details of their births, and that telepathic communication before birth traumatizes babies whose mothers consider terminating their pregnancies.

One member of APPAH, William Emerson, has performed and encouraged infant massage techniques that will make babies re-experience the discomforts of birth, cry, and thus experience catharsis. His position is that babies need to cry in order to express themselves and escape the effects of early experience. This APPAH position, and Trout’s statements about how “babies remember”, raise the question of physically-intrusive treatment of the holding therapy type and the extent to which they have actually been rejected by ATTACh.

As is so often the case, a careful examination of this ATTACh production in the light of other information suggests that there is less expertise here than appears to meet the eye.

Why Tummy Time?

A young baby I’m acquainted with has been sleeping on his back (the supine position), as recommended, for the last two months. His parents have been busy with a list of things you can well imagine, and had not been doing any “tummy time” with him. Now he has a little flattening of the back of his head, and his pediatrician has started to urge “tummy time”--- putting him in the prone position (on tummy, not back) while he’s awake and ready to play a bit.

What’s the purpose of this? Is it all about keeping a nice round head?

It’s true that people in industrialized countries (as well as many others) don’t like a person’s head to be flattened in back. Some cultures have liked skull shapes that we would think strange, and put babies on cradleboards or bound their heads in other ways so they would grow into high-fashion shapes. Babies’ skulls are not yet completely hardened and bony, nor are the skull bones fused into a solid dome—that’s why there’s still a “soft spot” on top of the head. Because the individual bones are still somewhat soft, and because not all the skull plates are connected, it’s easy for continuing pressure on one spot to change the shape of the skull. Lying in one position all the time may deform the skull, and it’s a lot easier to prevent this deformation than to cure it.

But---  there’s a lot more to the issue than having a nice head. Babies’ muscular, bone, and motor development is affected by the movements they get to make. This seems surprising, I know, because we usually think of the baby’s development as just unfolding bit by bit, physical growth and movement control emerging according to a genetic timetable as long as the baby is well fed and cared for.

Young babies (let’s say, birth to three months) can make some movements when lying on their backs. They can kick, wave their hands, and so on--  although for the first month or so they’re “prisoners” of their own reflexes, and their movement of one arm forces the other arm and the head to go into new positions. They can’t lift their heads, though. The head is very heavy compared to the rest of the baby, and even adults find that to lift the head in the supine position (back-lying) is much harder than to lift it when prone. Remember, too, that young babies are likely to lie with the legs somewhat drawn up rather than extended, and this makes it even harder for the weight of the body to counterbalance that big head.

When in tummy position, babies can work toward a lot of new skills that are too difficult in the supine position. Even a newborn can usually lift the head enough when in prone to be able to turn the head from side to side, which is difficult for the back-lying baby. Lifting and moving the head in that way fosters the development of the neck muscles and helps steady the head in all sorts of positions--  which, by the way, helps the baby move the head to look at interesting things and get more involved with the world around him.

Once the head is being lifted a bit, it’s easier for the hands to come forward and provide a steadying base for the baby in tummy position. This works the arm and shoulder muscles, and enables the baby to move toward pushing on the supporting surface and bit by bit getting not only the head but the chest up--  essential steps toward crawling, but also important for getting a good look at the world. Incidentally, while pushing up, the baby works on opening up and flattening out the hands that were clenched fists most of the time in earlier weeks. The increased arm and shoulder strength, and the development of the chest muscles, also contribute to being able to sit on someone’s lap with a little support of the hips, and to join in the social whirl. Sitting up makes it easier to reach, also to see people’s faces and learn about them--  and so on and on.

Would it be a big problem if the baby didn’t get tummy time? The possible flattening of the head is certainly undesirable, but everything else would probably develop after a while. Even a back-lying baby eventually learns to turn over into the prone position and goes on from there, but with motor skills emerging later or in a different order than what you might think.

Here’s one of the issues to keep in mind: most “baby books” and lists of motor milestones tell you what babies did many years ago. Until perhaps ten years ago, parents in the United States had been advised for decades to keep their babies on their tummies. As a result, the babies developed head and chest control and other abilities earlier than back-lying babies do. “What the book says” may be somewhat different from what today’s back-lying baby does. “Tummy time” is designed to give the babies the health and safety advantages claimed for back-lying as well as the types of motor development the prone position encourages, and the cognitive development that goes along with them.

A baby who has been lying on his back for a couple of months will probably not be best pleased when placed in the prone position. Lifting that big head may be frustrating and difficult, and he’s not used to it. The most helpful thing a parent can do is to put is to put his or her face where the prone baby can see it with a little effort. The social support of a smiling, attentive face helps the baby organize this new activity. If the baby is on the floor, it may be hard to put your face in the right place without dislocating your neck, so try a tabletop with a blanket on it, and sit right beside it. (Naturally, you’re not going to step away for even a minute and leave the baby there!) If you have an old-fashioned crib whose side lets down, that makes an even better arrangement.

One other hint: if you place a hand lightly on the baby’s bottom, you help him counterbalance the heavy head so it’s easier to lift. When he succeeds, it’s so exciting that he’s likely to work even harder and can soon manage without your help.

There’s no real need to rush development along, and I don’t mean to suggest that your child is in some kind of race or won’t get into Harvard if you haven’t done plenty of tummy time. But as motor and cognitive skills move along, babies and parents have more to do together and have more fun, and that always helps when young families are navigating this complicated part of life.

  

"Adoption Today" and the ATTACh Belief System

The June 2012 issue of the magazine Adoption Today is available for free at http://bluetoad.com/publication/?i=113582. (It’s supposed to be available at the magazine web site, too, but I wasn’t able to make the pages turn when I went there.) It’s worth looking at under a strong light--  in a discouraging kind of way.

This issue contains no articles by people with advanced professional research backgrounds, or by anyone usually considered to be an outstanding researcher or clinician in adoption or related fields. (It has an advertisement by someone who has claimed his methods are evidence-based, but that’s a whole ‘nother story.) That situation may not be too surprising in a publication that’s aimed at adoptive parents, of course—but it is surprising to see that many of the articles are by leading members of the Association for Treatment and Training of Attachment in Children (ATTACh), an organization that has its own belief system about attachment and has shown little interest in the realities as demonstrated by systematic investigation. Those who doubt this statement may want to go to www.attach.org/signssymp.htm and look at the list of behaviors that are claimed to be indicative of disorders of attachment; compare those with the actual definition of Reactive Attachment Disorder in DSM-IV-Tr, and note the absence of any other “attachment disorder” in that volume, and you’ll see what I mean.

Adoption Today, at least in this issue, is a vehicle for advertisement of the books, videos, and services offered by a small number of practitioners. But it also includes articles under the bylines of many of the same people, and some of these deserve closer attention as they reveal how the authors follow the “party line” rather than evidence-based material about either attachment or adoption. Incidentally, the last page of the issue contains a “CEU quiz” for pre-adoption preparation, although it acknowledges that most states have no requirement for this type of training.

Starting on p. 14, an article by Lark Eshleman, who I believe is an educational psychologist, discusses attachment in terms borrowed from ATTACh. (Eshleman apparently worked with the Craver family who were recently convicted in the death of their adopted child, as I discussed at http://childmyths.blogspot.com/2011/11/nathaniel-craver-case-many.html.) In her article, Eshleman provides a definition of attachment quoted from ATTACh: “Attachment is a reciprocal process by which an emotional connection develops between an infant and his or her primary caregiver.” Let’s give this some consideration.

First, is attachment actually a reciprocal process? Its foundations are in reciprocal behaviors, but attachment itself is not reciprocal. Attachment is the name given to a motivational change in a young child, one which leads him or her to show preferences for familiar people (not just the primary caregiver, by the way). Attachment is shown most often as an attitude, or readiness to behave, in which social preferences are acted upon when threat or discomfort is present, not all the time.

To say that attachment is a reciprocal process implies mutuality and suggests that the caregiver is experiencing the same motivational changes as the child, which is certainly not the case; if it were, mothers with headaches would rush to be with their children, rather than hoping for some quiet time alone. If the process were reciprocal, there would be no sad cases of young children grieving over their removal from the homes of neglectful or abusive parents who show little sign of caring about the kids.

It is true that attachment develops in the context of social interactions with other people. But infants are so ready to form attachments that they need relatively little encouragement or reciprocity from adults to do so--  in fact, many adults would much rather that their toddlers showed less attachment behavior, and rather than encouraging the behavior may actively discourage it (but without successfully altering it).

It’s also true that adult caregiving and infant bids for care  (the usual context of attachment development) are reciprocal. Students of parental behavior used to use the terms epimeletic (meaning caregiving) and etepimeletic (meaning soliciting caregiving) to emphasize the interactions between these two types of behavior. And most social interactions take place in the caregiving situation, so attachment is developed in association with reciprocal actions--  but that is not the same as saying attachment is reciprocal. When the claim is made that attachment is reciprocal, it’s easy for adoptive parents to feel that “something is wrong” when an adopted child does not share the parents’ excitement, pleasure, and love.


Incidentally, the focus of the ATTACh definition on the "primary caregiver" is problematic. Attachment to several familiar people (even those who are sociable but not caregivers) is a feature of toddlers' lives. We can see this because toddlers can use people other than the primary caregiver as secure bases for exploration and also can turn to those people when threatened or uncomfortable. The ATTACh approach turns on the theory that the mother is absolutely central to the child's emotional development, as originally assumed by Bowlby, later dropped by Bowlby, and shown to be unlikely in this age of LGBT etc. families.

So Eshleman is pushing a concept created by ATTACh which is in fact not in line with the realities of attachment as systematic research has shown them to be, and Adoption Today is presenting this idea as reliable thinking about attachment. What else can we find in this issue, other than advertising for Eshleman’s services and publications? Ah—let’s look at this article by Mershona Parshall, starting on p. 18. (Parshall was the business partner of Elaine Thompson, an “attachment therapist” who was involved in the case of the caged Gravelle children in Ohio; Parshall was not accused in that case nor as far as I know was she involved in the treatment of the Gravelle children.) Parshall’s article describes the use of “neurofeedback” for treatment of severe behavior problems in an adopted boy. Over a period of two years, the boy received the treatment (usually described as “possibly efficacious”), and his behavior improved, an outcome that Parshall attributes to neurofeedback rather than to maturation. Parshall states that apparent regressions in behavior are to be expected at the beginning of the treatment and that it is critical not to increase medications, but actually to decrease them, at this point--  a potentially dangerous statement if there are serious biological reasons for the problems, and one which Parshall makes without explanation.

Interestingly, on p. 24, we see an article (and accompanying advertisement) by Terry Levy and Michael Orlans, founding members of ATTACh and formerly attachment therapists involved with Evergreen, CO (the home of holding therapy), and still listing an Evergreen address. Levy was the editor of a 2000 book published by Academic Press that featured a chapter by Nancy Thomas, the “therapeutic foster parent”, who advised removing furniture from children’s rooms and placing alarms on their doors, requiring them to ask for all “privileges” including use of the toilet, limiting the quantity and variety of their food, and insisting on periods of “strong sitting” without motion or speech. Thomas also advocated withholding information from children in treatment, including answers to their questions about when they would see their parents again (these, of course, were children who were said not to be attached to the parents they were asking for).

Speaking of Nancy Thomas, the piece by Julie Beem on p. 30 seems to be on the same page with the Thomas philosophy. A sidebar lists “therapeutic parenting” programs as suggested by Thomas, by Heather Forbes, by Katherine Leslie (all fans of the restrictive approach), as well as by the Love & Logic company, headed up by Foster Cline, one of the originators of holding therapy and related approaches.

Have I said enough to show what’s going on here? I could, but won’t, go on to discuss the numbers of therapists listed at the end of the issue who have been associated with potentially harmful treatments for children and with the less harmful but not demonstrably effective approaches now sponsored by ATTACh. I do not see on that list the names of respected, evidence-oriented clinicians like Mary Dozier or Sheila Eyberg!

Adoption Today, can’t you do better than this? Adoptive parents need information that is both reliable and accessible. A magazine that functions as the house organ of ATTACh and as an advertising medium is not living up to its responsibilities.

Who Can Pick Up the Baby? Or, If It Doesn't Walk Like a Duck, It Won't Imprint Like a Duck

A recent phone call reminded me how easy it is for a little learning to be a dangerous thing--   or, to be more specific, how easy it is even for highly educated people with backgrounds in the social sciences to get confused about attachment and bonding.

Here’s the story. A friend of mine was calling to tell me about the adventures of another friend, just recently a grandmother for the first time. New Grandma had been asked by her daughter to come and “help out” after the baby was born, and she had traveled some distance for that purpose. But New Grandma now discovered that there was a rule about the baby that she was not to break: he was to be picked up only by his mother or father. That rule was planned to last until the baby was about two months old and had “settled”; then others could pick him up. New Grandma found this situation not only frustrating but deeply puzzling. What could the new parents be thinking?

I’m not in touch with the new parents, nor is my crystal ball functioning well in this hot weather, so of course I don’t know exactly what’s going on. But I’m going to hazard some guesses about the beliefs the “rule” could be based on.

My first guess is that the rule is focused on the baby’s relationships with other people. It’s not just about health and safety--  if it were, the parents might refuse to let strangers touch the baby, and be concerned about anyone who is careless or inexperienced with little ones, but not prohibit other contacts. The parents believe, not foolishly, that there is something special about the relationships between the parents and the baby.

My second guess is that the parents believe that a baby of less than two months old is forming a special kind of relationship to the parents called “attachment”, a powerful developmental phenomenon that is thought to determine some aspects of later behavior, thinking, and emotion about relationships. While it would be harsh to call this belief foolish, in fact it is not an accurate understanding of early emotional development. Babies of less than two months--  actually, of less than 6 or 7 months--  do not  behave in ways that suggest the formation of attachment to familiar people. They may seem more comfortable in the care of people who know them well, but this is probably because the people who are familiar to the baby are also familiar with the baby and know how he or she responds to handling. If the parents are worried that the baby will not form attachments to them, they should actually be more concerned about social interactions when the baby is older and closer to the age when attachment usually becomes evident--  a baby who has not “settled” is nowhere near that age.

Of course, although the young baby is not yet forming attachment relationships, his or her caregivers are experiencing “bonding”, a change in their feelings, rather like falling in love, in which they become preoccupied with the baby and even forget their own personal concerns in favor of worrying about the baby’s needs. Just as lovers often imagine that their feelings are mirror images of each other’s, parents can easily feel that the baby is as concerned about them as they are about her--  although all the evidence is against this idea. Parents do need to interact with the baby in order for bonding to progress, so a rule forbidding others to care for the baby might help them bond if there were any difficulty in this (which there usually is not if everybody is healthy). Even then, there would be no reason why New Grandma or others should not occasionally have some baby time, as long as all was going well with the parents and their attitudes toward the baby.

One more guess to hazard: why are the parents so concerned about this early time period? I think this may be because much of the early discussion of attachment by the British psychiatrist John Bowlby was connected in some ways to the work of ethologists like Konrad Lorenz on the behavior of young birds toward a parent bird. Anyone who has done an introductory psychology course is likely to remember the famous picture of Lorenz walking in a crouch across a field, followed by a little crowd of ducklings. Lorenz’s work examined the phenomenon of “imprinting” (the behavioral, not the genetic kind), in which ducks and some other birds learn rapidly to prefer and follow the first moving object they see after they hatch. In the wild, this is likely to be their mother, but it could be a fox---  and in captivity it could be another duck, a toy train, or Konrad Lorenz. Imprinting learning occurs within a critical time period of a couple of days after hatching and is impossible after that time has passed. Imprinting is also extremely powerful and long-lasting, and affects not only the entity that the ducklings follow in early life, but also their choice of mates in adulthood. In zoos, bird caregivers who are hoping to breed more birds must be careful not to let the young birds see them, or the adult birds will later refuse to mate with members of their own species and instead try to court human beings.

Although one of the indications of attachment of a baby to an adult is that the baby tries to follow and stay near the adult—a situation similar to the results of imprinting--  there are very few other resemblances between the two phenomena. (And, by the way, not all birds imprint, and few mammals do.) While some have argued that there is a critical period for attachment, the ability of orphaned children to develop new attachments later contradicts this, and in any case it is clear that such a period does not occur in the earliest months of the baby’s life. Babies may be “ducky”, but they aren’t ducks.

Nevertheless, the young parents in question, like many other people who know a little about this, may well have confused human attachment with duck imprinting and developed some unnecessary worries about how they should regulate their child’s social interactions with other people in order to have a good developmental outcome. The result is a family fuss that need not have happened, and a situation where they do not get the help and social support that they could probably use just now. However, I want to point out that unless the parents are too exhausted to do their jobs, it’s not going to make any difference to the baby--- and New Grandma can develop an excellent relationship with him in times to come. All the same, it’s a shame that this confusion exists.

Mental Health Mantras versus Evidence-based Treatment: A Clash of Attitudes?

Several days ago I was at a meeting of the board of a non-profit child mental health group, and a discussion ensued which was both predictable in its attitudes and suggestive of behind-the-scenes beliefs in mental health and social services circles.

The discussion began when I brought up some concerns about bad advice to parents--  for example, a couple of things I’ve mentioned on this blog, like the idea that babies must be made to crawl, and the idea that instead of spanking one can put nasty tastes like Tabasco sauce on children’s tongues. I tried to float the idea that the group might publicly oppose such advice. But in fact I knew that this very pleasant, kind, energetic, well-trained, intelligent group of colleagues would not agree to any such thing, and sure enough they didn’t.

Several people carefully explained their reasoning to me.

One recommended that we should speak only in positive terms and about the right way to do things. If something negative must be mentioned, it should be more than balanced by a discussion of positive ideas.

Another member of the group suggested that when we object to an idea, we should not say that it’s wrong, but present it as an alternative point of view and describe our own views in the same way.

A third member gave the opinion that “talking about it gives it life” --  that we give energy to mistaken ideas by discussing them at all, and need to ignore them and emphasize better ideas.

Now, these were all attitudes that I have met many times before, and two of them stem from educational principles. Teachers are reminded again and again not to begin by telling students what is NOT true, but to focus on what is true, and to deal with common mistakes later if at all. In teaching and in behavior modification, professionals are advised to withhold reinforcement for undesirable behavior, to “catch them being good” and to reward desirable performance rather than calling attention to undesirable actions. These two ideas have to do with the best way to get a message across and to influence other people.

The third idea is not so much about how to persuade, but about moral conduct. Considering other people’s views as genuine alternatives to our own, however much we disapprove of them, can be morally right and even intellectually productive. It’s also possible that we can be more persuasive if we do not waste time arguing about whether a belief is totally unacceptable, or offending by our attitudes people whose co-operation we need.  

As a general rule, these mantras of mental health and of social services apply pretty well to real life. Most people appreciate it if we “accentuate the positive” and treat their views as worthy of respect.

But what if there are beliefs and practices that are actually wrong and demonstrably harmful—or even wrong and harmless, but a waste of time and resources? Adults who molest children often have excellent rationales for what they do and believe they do no harm; should we treat their claims as just “a different point of view”? And if the molesters are in the wrong and should be stopped, why does the same reasoning not apply to less sensational harmful behavior and beliefs?

I understand very well that sermonizing and shouting about issues is less persuasive than cheerful proselytization of better methods. However, I believe it is a mistake to fail to point out to professionals working in mental health and social services that some ideas  may be attractive but are nevertheless unsupported by reason or evidence.

I am especially concerned about these issues because I wonder whether they are behind the reluctance of many mental health and social services professionals to stress evidence-based treatments--  interventions whose effectiveness has been supported by several well-designed empirical studies. It was not long after the concept of evidence-based treatment came into mental health circles that the principle of an evidentiary foundation began to be diluted into “evidence-based practice”, in which “practice wisdom” and patient preferences were given equal weight with  evidence of effectiveness, and the very definition of evidence-based treatment became so blurred that it came to mean little more than that a study had been done.

What’s the connection with my colleagues who want to stick to the positive, ignore the negative, and frame rejection of a treatment as an opposing point of view? You can’t consider the evidence basis of an intervention unless you are willing to say that the treatment was more or less effective than another treatment or than no treatment. You can’t assess any treatment accurately unless you pay attention to adverse events--  cases in which harm seems to have been caused by the treatment itself. In order to examine and report on the effectiveness of  a method, you must be willing to talk about whether it worked as well, better, or worse than another method, not just about how good it was. You must be willing to talk about failures or adverse events, not to assume that they will go away if you don’t mention them. And you must be able to marshal and describe all the facts of your data and analysis as they support a considered opinion which is by no means simply a “point of view”.

Sticking with the mantras keeps people from paying attention to the evidence for a method, and thus potentially wastes resources or does other kinds of harm. Would we be happy if a physician treating cerebral palsy had not considered what harm a treatment might do? Then why is it all right to ignore negative aspects of mental health, social services, and child welfare practices, including parenting techniques? If anyone can argue that it is all right, I’d like to hear from them.