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Child Psychology Blogs

Concerned About Unconventional Mental Health Interventions?

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

Thursday, December 23, 2010

A Quiet Lunch: Baby-feeding May Not Go Well at Parties

A friend was recently telling me about her new grandbaby, a plump but hungry little girl born by Caesarean section not long ago. The grandmother described how the young mother was worried about breastfeeding and fretting that the baby was not getting enough milk. She also told me of the scene at the new baby’s house when both grandmothers, friends, and various other visitors were all there, and the mother tried-- without much success-- to nurse the baby while socializing with the company.

Naturally, the difficulty she had with this nursing was disturbing to the mother. Like most mothers inexperienced with breastfeeding, she was afraid she wasn’t making enough milk and that the baby was starving. And the tenser she was, the more difficult it was for her to nurse the baby. Breastfeeding requires not only the “manufacture” of milk in the breasts, but a reflexive response to the baby’s sucking, the let-down or ejection reflex, that actually squirts milk out of the nipples. (This water-pistol effect is definitely part of the humorous side of breastfeeding!) Babies don’t just draw milk out of the breast as you’d suck lemonade through a straw, and if milk is not ejected, the baby will get only a few drops at a time rather than a mouthful. First-time mothers, especially, may find their milk does not “let down” easily when there is a lot of commotion or tension to deal with. Whether you’re particularly modest or not, you may find it awkward to nurse the baby when a lot is going on around you. From that point of view, it’s not surprising that my friend’s daughter-in-law had trouble breastfeeding while visitors were there.

But there’s another important point about this situation. The other half of the breastfeeding team, the baby, can also have trouble with exciting surroundings. This is so much the case that bottle-fed babies, too, may have trouble feeding when there are visitors-- and the bottle does not share the mother’s problems with letting down milk, of course.

Some years ago I was at a large party where a young mother had brought her toddler son and 6-week-old baby girl. The mother was longing to talk to all the people, many of them her cousins and friends she hadn’t seen for some time. She was trying to give the baby a bottle while she conversed, but guess what, the baby wasn’t having any; she would suck for a minute or so and then let go of the nipple, fretting. I guessed that everything was too exciting for this baby and offered to have a try. We went to a quiet room, sat down and snuggled and talked for a few minutes, then I offered the bottle and the baby slurped up every drop.

What was this all about? Did I have some kind of experienced-mother magic that I applied to this baby? No, but I was aware that even at the advanced age of six weeks, babies may have trouble organizing their feeding if there is something to distract them. In order to suck from breast or bottle, a baby needs to time properly her sucking, which brings milk into the mouth, and her swallowing. This seems simple to adults-- we even have the ability to swallow voluntarily, as in taking pills, or to take food into the mouth and hold it there without swallowing. But for the young baby sucking and swallowing are still primarily reflexive, and they have to occur at the right times and in the right order. Otherwise, the baby will choke on an excessive amount of milk, or the milk will run out of the sides of the mouth rather than going down.

So, what is the connection? Why should hearing people talk interfere with the baby’s coordination of sucking and swallowing? The problem is that a baby’s movements, breathing, sucking, and so on, are easily “entrained” to events in the environment. Entrainment means that the rhythm of actions begins to follow the rhythm of other things that are going on. It’s like adults dancing to music-- the movements of our feet follow the rhythms of the music. As adults, we can decide not to dance, or we can even dance to a different rhythm than the music that’s playing (though it’s hard to do that). Babies don’t seem to have any choice about entrainment. The rhythms of speech and movements around them can take over the rhythms of sucking and swallowing and make it difficult or impossible to do these things in the necessary pattern.

Young mothers may feel very out of things when they need to go away and be alone with the baby in order to nurse. But this may be exactly what’s needed for both parties. The mother may feel hassled and tense in a group of people, even though she wants to be there. The young baby is quite likely to be disorganized when talk, laughter, and movement take over her rhythms. A quiet place gives mother and child their best situation for feeding by breast or by bottle.

Monday, December 6, 2010

When the Romanian Orphans Grow Up: The Recent Report

What happens when children from severely-deprived institutional backgrounds are adopted into caring families? Adoption has been described as one of the most successful interventions, but how good a job does it do?

We are finding some answers to these questions bit by bit, as the English and Romanian Adoptees (ERA) Study continues to follow a group of over 300 children adopted from Romanian orphanages in the early 1990s. The ERA researchers are in the process of comparing the Romanian adoptees to non-adopted children as well as to adopted children who never had institutional care. This work is enormously time-consuming and complex, and involves repeated measurements and interviews at different ages, plus delays associated with analyzing, writing, and publishing the results of each phase of the investigation.

A recent presentation of the children’s characteristics up to age 15 has been published by Michael Rutter and co-authors as Deprivation-specific psycholkogical patterns: Effects of institutional deprivation (Monographs of the Society for Research in Child Development, Serial No. 295, Vol.75, No. 1, 2010). The 252 pages of this monograph are absolutely packed with information, some leading to conclusions, some not. I am going to try to pull out some points that may be of particular interest to readers.

An aspect of the monograph that will be of interest to many is the question raised in the title: whether there are psychological patterns that follow severe social and other deprivation in early life. The ERA investigated a group of characteristics that seemed more likely to occur in post-institutional children than in other adoptees. The following items were included:

1. Quasi-autism: A behavior pattern not identical with autism, but including rocking, self-injurious behavior like hair-pulling, unusual and exaggerated sensory responses, and tantrums in response to changes in routine, as reported in parent interviews (Gindis, B. [2008]. Institutional autism in children adopted internationally: Myth or reality? International Journal of Special Education, 23, 118-123).

2. Disinhibited attachment, as shown in unusual friendliness toward strangers and failure to show strong preferences for familiar people in threatening circumstance. The monograph describes disinhibited attachment as including “inappropriate approach to unfamiliar adults, a failure to check back with a caregiver in unfamiliar settings, and willingness to accompany a stranger and wander away from a familiar caregiver. It is often associated with a lack of appropriate physical boundaries, so that children may interact with strangers intrusively and even seek out physical contact… there is sometimes inappropriate affectionate behavior with strangers and undue physical closeness” ( Monograph, p. 58) .

3. Cognitive impairment, including problems with “mentalization” or the ability to understand what other people might believe or feel about a situation.

4. Inattention and overactivity similar to attention-hyperactivity disorders.

While by no means all children who had come from institutions displayed these problems, even those who had spent more than 6 months in a Romanian orphanage, the ERA group reported that over 90% of those who still showed the behaviors at age 15 had spent more than 6 months in severe deprivation. Those who persisted to age 15 with these problems had often improved (for example, become more likely to be helpful or comforting to others), but odd behaviors still occurred. Some children “annoyed other people but did not know why, and difficulties making or keeping friends were common… In a few cases, … inappropriate remarks included excessively outspoken sexualized use of language” ( Monograph, p. 86). Some children were reported as fascinated with collections, including those of “useless rubbish” like chocolate wrappers.

Can we generalize from the ERA children to other adoptees? While it’s useful for potential adoptive parents to have some idea of the types of problems they may see, it’s important to keep in mind some differences between the ERA group and many other adoptees. Members of the ERA group were aged 42 months or younger at the time of adoption, and most of them had gone to the institution shortly after birth. The Romanian orphanages were characterized by extremely severe deprivation, including confinement to cribs and bathing with water squirted from hoses, conditions unlike those in most other child-care institutions. Children with different histories may be quite different from the ERA group.

In addition to the possible effects of differences in background, the following facts are noted by the monograph: “A striking finding at all ages was the heterogeneity in outcome. Thus, even with the children who had the most prolonged experience of institutional care, there were some who at age 11 showed no indication of abnormal functioning on any of the domains we assessed. Conversely, there was a substantial proportion of children who showed impairments in multiple domains of functioning.” (p. 14). It would be a mistake for potential adoptive parents to assume that they can predict which outcome will belong to a given child.

Federici v. Mercer: The Story Behind the Lawsuit

A phone call this morning alerted me to the fact that the Virginia psychologist Ronald S. Federici is suing me and other critics in Fairfax, VA (CL10-16657, filed Nov. 24). As of today, I have not yet been served in this matter, but I assume that his complaint is that I have defamed him and interfered with his business, as he already brought such a suit in Small Claims Court and lost it, but is allowed to appeal.

What is behind this suit? The event that seems to have triggered it is that I published on my former Psychology Today blog a piece which I will present below. This piece, which I entitled “The Hungry Boy”, was based on a published opinion of the North Carolina Court of Appeals (, which discussed Federici’s involvement in an adoptive family situation that resulted in the incarceration of both parents for felony child abuse. The COA opinion quotes testimony Federici gave during the trial as well as the statements of the abused boy. (After writing “The Hungry Boy”, I obtained the transcript of the original trial, which does not counter in any way the statements in the COA opinion.)

Shortly after the publication of “The Hungry Boy”, Federici complained to and filed suit against me, Psychology Today, and other persons. Psychology Today took down “The Hungry Boy” and told me not to mention Federici’s name again. Although Psychology Today was served with a summons to appear in Fairfax, VA to answer the suit, and although I warned them that they should not default, they did not send a representative to appear in court and as a result a judgment for $5000 was given against them. I appeared and had a chance to see that Federici did not present evidence that he had been harmed by what I wrote nor that what I wrote was untrue (both necessary for a successful defamation case in the United States). As a result, the judge found for me.

Over the following several weeks, I did not mention Federici’s name on my blog, as instructed, but I did mention that I had been in court in a defamation case. Psychology Today responded to this by freezing my account on the grounds that I had broken an agreement with them, and I moved my blogging to

Having lost his case in Small Claims Court, Federici had the option of an appeal to a higher court, and he filed this appeal against me and some other people. (He apparently came to some agreement with Psychology Today.) However, after some weeks, he decided on a “non-suit”-- to drop the case for the time being but to keep the option of reviving it. This revival is what he has apparently done as of Nov. 24, 2010.

What did “The Hungry Boy” say that was so disturbing to Federici? I’ll show you by posting the piece below.

The Hungry Boy: An Adoption Story, With Comments

Is starvation the key to good discipline and loving relationships in adoptive families?

In several posts on this blog, and in print publications over the last ten years, I have alluded to the suggestion by unconventional therapists that withholding food from adopted children is an effective way to shape desirable attitudes and behavior. Today, I’d like to tell some of the story of adoptive parents who took this advice, the consequences for themselves and their adopted child--- and the absence of consequences for the therapist who acknowledged in court that he had provided the treatment plan. I draw my information about this case from a document of the North Carolina Court of Appeals, issued Jan.19, 2010, and available at , as well as from a document prepared for the defense in this appeal and available at

Here is the basic story. Paul and Leslie Salvetti adopted in the 1990s a little boy who had been born in Russia in 1993. Leslie later died, Paul re-married, and the new wife, Debbie, became mother to the boy, known as “Pesha”. At some point, the family’s functioning became less than ideal; “Pesha” reported to social services that Debbie had hit him with a frying pan and baseball bat, among other complaints, but it is not clear whether this was investigated.

According to the appeals court documents, Paul and Debbie felt that “Pesha” was “umanageable” by the time he was 13. In about February, 2007, the Salvettis consulted Ronald Federici, a clinical psychologist with a Psy.D. degree, licensed in Virginia, about their problems with “Pesha”. (The fee for this consultation was $5200 for three days of work.) Federici made a number of recommendations about appropriate treatment of “Pesha”, including the suggestion that ordinary meals should be contingent on improved behavior, but that “Pesha” should be provided with bologna sandwiches and fruit in any case.

The Salvettis also confined “Pesha” to his bedroom, where they covered the windows and removed most furniture , and these were the circumstances of his life for three months. “Pesha” later described himself as “cold and hungry” during this time. “Pesha” eventually escaped from the house and made his way to the authorities; at this time he was hospitalized for a week, during which time he gained 10 pounds. The Salvettis pled guilty to felony child abuse (intentionally inflicting physical injury, starvation) and in 2008 were sentenced to a period of imprisonment.

During the Salvettis’ trial, Ronald Federici testified on their behalf, and, unusually for a psychologist, commented on medical and genetic issues as well as psychological concerns; expert witnesses are generally expected to speak within their area of professional expertise. It is of particular interest that Federici testified to his belief that “Pesha” had not been substantially deprived of food. Federici and the defense attorney appear to have taken refuge in the ambiguity of the English language and to have interpreted the term “withheld food” to mean “withheld all food and liquid” rather than “reduced the amount and type of food available”. The defense argued that because some food had been provided, food had therefore not been withheld.

In addition, Federici testified to his opinion that children’s rage could cause them to lose weight, and that this, rather than food deprivation, was the cause of “Pesha”s” condition. (Although the implications of this statement were not discussed in the court documents that are available, I should point out that there is no known evidence to support Federici’s opinion.)
So, what can we conclude from this case? Is starvation the key to good discipline and loving relationships? If not, what are its consequences? In this case, the consequence for “Pesha” was a terrifying experience and the loss of the home he knew. For Paul and Debbie Salvetti, the consequence was a period of imprisonment. For Ronald Federici , the consequence of his many activities has been popularity with the media, including a recent interview with National Public Radio in which he commented on the latest Russian adoptee scandal. Others who give similar recommendations have also found them lucrative.

If you are a member of an adoptive family, please note that you are not one of the people likely to benefit from using the withholding of food as a child-rearing technique.

*** That’s the end of “The Hungry Boy”. If you’re not sure whether my statements were accurate, you can read the North Carolina Court of Appeals opinion on line. Incidentally, the appeal in this case had nothing to do with any facts about what had actually happened, or any discussion of the appropriateness of Federici’s advice to the parents. The appeal had to do with the type of plea made by the parents in order to avoid trial, and whether they had actually understood that they would go to prison.

Thursday, November 25, 2010

The Raising-a-Psychopath Blog

A reader asked me to comment on the blog “Raising a Psychopath” ( For those who haven’t seen it, this blog appears to be by the adoptive father of a child who was adopted at age 6 after many experiences of neglect, abuse, and change of caregiver, and who at age 11 is regarded with fear and anger by the parents and has been in residential treatment for periods of time. The blogger, whom I’ll call FRP (for Father Raising a Psychopath), as his blog title suggests, considers the child to be psychopathic as well as to have Reactive Attachment Disorder. Many of the posts present arguments that FRP has put forward to support his view of the child, “Lucas”.

I have some general comments about the material contained in this blog, but I need to emphasize that I have no reliable information about “Lucas’ or his parents. I have no way of knowing whether the statements on “Raising a Psychopath” are true, or whether there is omitted material that would put a different spin on the statements that are made. Even if I were sure about the veracity and completeness of the blog, I would not want either to praise or to criticize the actions of the parents, therapists, teachers, social workers, etc. It’s too easy to talk a game that you don’t have to walk, as we can see from many of the comments, both positive and negative, on FRP’s statements.

That said, here are some thoughts I had while reading “Raising a Psychopath”.

1. The psychopath thing:
It appears that from the beginning of the blog, FRP identified “Lucas”, who was then about 9, as a psychopath-- he chose this title for the blog, and in one of his posts predicted a timeline of more and more serious misbehavior. Whether or not this was a self-fulfilling prophesy is difficult to say with the information we have. We can ask, however, why FRP was so quick and so sure about this diagnosis. What are the advantages of labeling a boy “psychopath” rather than staying with more ordinary childhood problems like Conduct Disorder or Oppositional and Defiant Disorder? The advantages would seem to be the possibility of declaring the child beyond help and incapable of living in the family home, removing any responsibility the adoptive parents might have, as well as the possibility of focusing all blame or negative evaluation on the child himself.

Many of FRP’s posts describe his thoughts about the evaluation of “Lucas” with Robert Hare’s PCL-YV (Psychopathy Check List-- Youth Version). FRP discusses each of the check list items in detail, and, not surprisingly, concludes that he has a genuine psychopath on his hands. But although he mentions the limitations of the PCL-YV briefly, he evidently has not taken them seriously.

The first limitation is that the check list is not intended for the use of parents. It is to be given by an experienced clinician who can compare an adolescent to many other adolescents seen previously, and who will ideally use an objective approach in which both positive and negative evidence is carefully assembled and combined before a decision is made. No parent can be genuinely objective about their own child-- indeed, if they were, it would be a cause for concern. In addition, FRP already decided that “Lucas” was a psychopath some time ago, so it would be surprising if he did not seek evidence to confirm this belief.

The second limitation of the PCL-YV is that it has been standardized on and is intended to be used with adolescents from 12 to 18 years old. “Lucas” was 11 or less at the time of FRP’s assessment efforts. Yes, of course, 11 is almost 12, but it is not 12-- and at a period when the rapid changes of puberty begin, a few months may make enormous differences in an individual’s abilities and motivations. FRP judges “Lucas” to have unstable personal relationships based on the adoptive mother’s report that “girlfriends” “break up” with him quickly-- at 11 years of age, a period when the more advanced reproductive maturity of girls makes relations between boys and girls labile to say the least.

On this “psychopath” thing, by the way, there are several general points to be made. One is that there are not very many psychopaths, so the validation of a brief check list is a difficult matter. Individual differences in a small group make it hard to establish a general set of criteria. In addition, there seems to be a common confusion between individuals who are sadists and take pleasure, often sexual, in the pain of others, and the psychopath or sociopath who does not care about causing pain, but does so only when it’s convenient--- for example, if a bystander to a robbery might identify the perpetrator and therefore “must” be killed. Finally, the frequent identification of violent offenders with individuals who are sensation-seekers is paradoxical; a reader’s comment on “Raising a Psychopath” says that a psychopath lacks empathy, but enjoys the sensation when another person is hurt, which for me raises the question, if he has no empathy, how does he enjoy the other person’s distress?

Reactive Attachment Disorder
Early in the blog’s appearance, a reader advised FRP that “Lucas” must have Reactive Attachment Disorder because his behavior was problematic and he had a history of separation, neglect, and abuse. FRP immediately fell for the view of Walter Buenning and others, that this disorder can be diagnosed easily by use of a check list (conveniently on line), and that its symptoms include failure to make eye contact, “crazy lying”, preoccupation with blood and gore, etc., etc., all of which, untreated, will culminate in serial killing by boys and prostitution by girls (but apparently not the other way around).

This check list is neither standardized for age differences nor validated against any other method of diagnosing Reactive Attachment Disorder. Examination of the criteria for Reactive Attachment Disorder in the Diagnostic and Statistical Manual of the American Psychiatric Association shows no overlap between the established criteria and the check list used by Buenning and others.

FRP’s discussion of “Lucas’s” history suggests that while “Lucas” may be quite insecure after his confused and painful beginnings, he is not without attachment or the capacity for attachment. For example, when FRP and his wife had their first meeting with “Lucas”, while he was in a foster home, they noticed that he was not eager to socialize with them. When they took him back to the foster home, they felt he was much happier to be with the foster parents than with them (FRP and wife), and commented that the foster parents were more like grandparents-- while FRP did not explain this statement, I would guess that it meant affectionate and easy-going. “Lucas” showed a preference for those foster parents and appeared more comfortable with them than when away from them; in other words, he exhibited emotional attachment which he had developed over some months in a nurturing foster home. Whatever his difficulties, they are not due to an inability to develop a positive relationship with a caregiver.

Plain old ignorance
FRP’s description of their decision to adopt “Lucas”, and of their feelings as the adoption date approached, suggests to me that these parents share with many others a serious lack of understanding of early development and of the role of relationships in children’s lives. Like many participants in the Zero-to-Three/Civitas Benchmark Study, FRP and Mrs.FRP seem to have been especially ignorant about emotional development. I say this because, like all too many adoptive parents, they felt they could save themselves a lot of trouble--- diapers, night feedings, and all that-- by staying out of the picture until a child was 5 or 6 years old. Then, they thought, they would walk in and adopt, and that adopted child would be EXACTLY like their friends’ children who had been loved and cared for from birth to age 6. FRP and Mrs. FRP could do everything they liked to do, just as they did before, but there would be living in their house an attractive, sociable, charming, and self-reliant child who would play with them when they felt like it.

I’m sorry, but this was idiotic. It was not even realistic from the viewpoint of thinking what their friends’ children are actually like.

FRP’s comments on the blog also suggest that he and his wife did not think it was a problem to bring into their home a child whom they did not actively want or feel sure about. They seem to have been na├»ve about their own emotions, not to speak about the impact on the child of having his lot cast with caregivers who were unclear about what they were doing. And with respect to this, I must also point out the ignorance or indifference shown by caseworkers who did not pursue this couple’s hesitation and make sure all was clear before proceeding. Was it not understood that the couple did not know important things about early development? Or, is it possible that the caseworkers didn’t know those things either?

Well. That’s about enough for now. Just let me repeat (to myself as well as to readers) that for all I know, nothing on “Raising a Psychopath” is true, or just as likely, it’s true but so are a lot of other things.

Wednesday, November 24, 2010

Toddler Meltdown, the Ever-Popular Thanksgiving Side Dish

Got a toddler or preschooler? Planning to celebrate Thanksgiving tomorrow? Be prepared for your little person to lack all aplomb as he or she encounters the feast that even grown-ups often dread.

The best you can hope for is that your child copes pretty well, cries only a little bit, eats a bite or two from the carefully-prepared menu, and delays tantrums until late in the day. Like some other major holidays, Thanksgiving contains many of the elements most disturbing to young children, and its family focus ensures that there will be plenty of adults and older kids who try awkwardly to cheer the little guys up, or scold them for their crankiness. This combination easily produces tears, resistance, clinginess, the biting of cousins, loud statements that the stuffing is yucky, and everything else that exhausts and humiliates parents.

What is it, anyway, that makes toddlers and holidays like Thanksgiving such a lethal mixture? Here’s a list of reasons:

1. Toddlers are creatures of habit. They eat when it’s the time they usually eat. If it’s too early or too late to eat, they don’t want to eat-- and of course we usually have the Thanksgiving meal later than lunch time and earlier than supper time, so what do we expect?

2. More habit, plus neophobia: Toddlers eat what they’re used to eating. They don’t eat new things until they’ve become familiar with them by seeing them a number of times. Even if their own family eats green beans and turkey, toddlers will instantly detect that what someone else cooked is not the right kind; it doesn’t look exactly the same and it doesn’t taste exactly the same, so the fact that it’s a green bean cuts no ice with the two-year-old. Even a turkey cooked at the toddler’s own house may not be acceptable, because Mom and Dad have done their best to make it interesting and appetizing for older people, i.e., different from what the child is used to. This problem, plus the timing of the meal, may mean that the child is hungry but can’t manage to eat.

3. Toddlers don’t manage well when they’re tired, and a holiday like Thanksgiving usually makes them tired. They may have been up late the night before while Mom and Dad were rushing around trying to get organized. In the morning, they may have had a long drive (in the course of which they fell asleep, messing up their usual sleep schedule), or there may have been a lot of commotion at their own house as someone tried to put a turkey in the oven while keeping the child from touching the hot oven door. Either at home or elsewhere, nap time was probably disrupted.

4. There are too many people to cope with. Toddlers are disorganized by large groups of large people, many of whom may be talking and laughing loudly, or alternatively starting to yell at each other. Just imagine yourself in a roomful of rambunctious 12-foot-tall people, if you want to see what the toddler experience may be like.

5. Ordinarily, toddlers depend on contact with familiar caregivers to get them through difficult situations. They make eye contact, or call out, or hold onto a parental leg until they calm down. But holidays like Thanksgiving make this difficult. There may be too much of a crowd for ordinary contact to be easy to make, and what’s more parents are likely to be distracted with cooking or with the demands of other adults for attention.

6. Toddlers pick up their parents’ feelings and are distressed when the parents are distressed. (This doesn’t mean that the child will behave differently in order to keep from upsetting a parent, though!) Parents often have reason to be anxious about family-focused holidays, and they are especially vulnerable to criticism or disapproval of their children’s behavior. This produces a vicious circle in which the fussy child draws criticism that disturbs the parent, who then becomes increasingly distressed, disturbing the child and becoming less capable of handling the disturbance. Scolding or spanking do no good at all when everyone is already in a tailspin.

All of these problems together pretty well insure that toddlers are going to behave less well on a day like Thanksgiving than they usually do. Unfortunately, most of these items are part and parcel of the holiday. It might be possible to get the dinner scheduled at something closer to toddler mealtimes, or to bring familiar food from home, and those changes might help a bit. But you won’t be able to change most of what happens.

Nothing is going to change a toddler into an adult for the day, but adults may be able to plan ahead and make sure that they themselves are as adult-like as possible. It would be an especially good idea for parents of toddlers to remind themselves that the child does not exist to make them, the parents, look good. Indirect criticism of the parents, by way of disapproval of the child, is uncomfortable to feel, but can be ignored, for the day at least.

Yes, this too shall pass. Just remind yourself that 20 years from now that toddler is going to ask why you can’t make the stuffing the way Grandma or Aunt Carol always did, completely forgetting how he used to shriek when coaxed to eat it!

Monday, November 22, 2010

Fearlessness, Empathy, and Preschoolers: That Report

The Internet is currently full of references to a doctoral dissertation done at the University of Haifa by Inbal Kivenson Bar-On, a student of the well-known child development researcher Ofra Mayseless. Bar-On reported that when she investigated the abilities and behavior of 80 preschool children, the “fearless” ones showed differences from the “fearful” (for example, at

Whether the children were relatively fearful or fearless was ascertained by looking at their reactions to common events like separation from parents or the sound of a vacuum cleaner, or surprising objects like a jack-in-the-box. The operative word here is “relatively”-- it does not appear that Bar-On sought out children who were unusually fearful or fearless.( I ought to note that I have not seen the dissertation, and it looks as if everyone commenting has drawn their information from the University of Haifa press release which is on their web site; what we all say about it is very much subject to revision when we see the details.)

Pamela Paul, writing in the New York Times Sunday style section of all things, implied that the fearfulness-fearfulness dimension measured by Bar-On is equivalent to the aspect of temperament often called approach-withdrawal. Temperament is an aspect of personality that is thought to be “constitutional”, or biologically determined, and which stays basically the same from infancy through adulthood (although it naturally is expressed through different behaviors at different ages). There are half a dozen or more factors in temperament, but approach-withdrawal is a pretty obvious one, especially for children at the extremes. The approaching child tries new foods easily, goes up to the strange dog, behaves in a friendly way to strangers, and so on; the withdrawing child needs a long time to adapt to new things and avoids them as much as possible. It probably makes sense to think of approach and withdrawal as substantially related to fearlessness and fearfulness. Bar-On’s report that the fearless children were friendly also supports this view.

According to Bar-On’s study, the children who were evaluated as fearless were quite good at recognizing when other children had facial expressions of anger, surprise, happiness, or sadness, but they did not readily recognize an expression of fear. The fearful children did a better job at recognizing fear. The fearless children were also more likely to take advantage of other children, and less likely to be remorseful when they had done wrong. Bar-On reported that these differences were like constitutional differences in temperament-- they resulted from genetic variations, not from parenting effects.

However, it’s difficult to determine that normal behaviors in 3- and 4-year-olds are purely constitutional in nature. Much behavioral development is transactional in nature; whatever the basic characteristics of parent and child, they influence each other and each shapes the behavior of the other. As a relevant example, let’s look at how infants make use of fearful facial expressions shown by other people. From 8 or 9 months, babies are able to avoid a lot of trial-and-error involvement with potentially dangerous things. When they encounter a new or unusual person or thing, infants try “social referencing”-- they look at the face of a nearby familiar adult. If that person looks (or sounds) frightened, the baby backs off and avoids the strange event. If the adult looks happy, the baby gradually moves to explore. This is why well-cared-for babies don’t have nearly as many accidents as they might. The mother’s frightened face as the baby crawls toward the unguarded stairs or starts to reach for the candle flame warns most babies very effectively.

But what would happen if a particular baby were not very good at recognizing a fear-face? He or she would not back off in response to the parent’s fear. The caregiver would have to move to keep the baby safe, perhaps swooping down and grabbing the baby away from danger, or even smacking his hands in an effort to get the lesson across. The baby might then associate another person’s expression of fear with the baby’s experience of aggression. Rather than an empathic response to the other’s fear, the baby might be angered by seeing another person look fearful, and by preschool age this could be shown in instrumental aggression toward other kids and a sense that this is justified.

Of course, this is all complete speculation on my part-- I have no idea how this would really happen-- but when we put together the transactional aspect of development, the infant use of “social referencing”, and the vigorous efforts made by attentive caregivers to find ways to keep babies safe, the scenario I’ve given is not an impossible one. In addition, it’s a scenario that would be complete by the preschool period, and would not necessarily be detectable unless longitudinal research followed each child from infancy. These events would be a mechanism that combined the child’s constitutional characteristics with the effects of experience, and would suggest that it’s possible for the child to learn to behave differently. Interestingly, this possibility shows that acceptable, appropriate, even admirable parent behavior might have an effect on some children that would increase undesirable child behaviors like aggressiveness. In this, there is a resemblance to the work of Graziela Kochanska on more fearful children, showing that very ordinary levels of punishment may be so overwhelming for some children that little learning about behavior is produced.

In Pamela Paul’s Times piece, she quotes the comments of the SUNY at Buffalo developmental psychologist Jamie Ostrov on the Bar-On report ( I must say that these comments were the first thing to catch my eye in Paul’s column, and they raised my eyebrows instantly. Ostrov was quoted as saying that the fearless children “may be charming, but they’re also highly manipulative and skilled at getting their way-- even at age 3 or 4”. I must question what Ostrov was talking about, and the extent to which this view (so characteristic of some unconventional child psychotherapies with which I would not expect Ostrov to be involved ) is actually supported by empirical work. None of Bar-On’s material which is available to me says the fearless children were charming, although it does say they were friendly; the idea of “psychopathic charm” is one which has been pushed hard by “attachment therapists”. Ostrov’s statement that fearless preschoolers are highly manipulative and skilled at getting their way (also a tenet of “attachment therapy”) is at odds with what is known about the development of Theory of Mind, a set of abilities by which we understand what other people know, think, and want. Three-year-olds may want very much to manipulate people, but they do a poor job because they do not understand how deception works. Four-year-olds are much better and can sometimes tell a convincing lie, but they have nothing like adult skills (very fortunately for all of us parents and teachers). Why did Ostrov take this opportunity to pass on some poorly-substantiated ideas about personality and mental health in childhood? Was he simply misquoted, or was a longer explanation omitted? I really don’t know, but I’d like to have an explanation from someone.

Sunday, November 14, 2010

"Robbed of Your Child's Childhood"

A recent article in the New York Times ( commented on the difficulties of locating children who had been abducted by one of their parents. Noting that abducting parents may later claim tax exemptions for children, but that the IRS does not provide information on the whereabouts of the missing children, the Times article estimated that there are about 200,000 such abductions in the United States each year. (Obviously, not all of them are permanent or even long-term.) The reporter, David Kocieniewski, wrote sympathetically of the anguish of the bereft parents, and quoted one as saying, “… when you’re the parent who is left behind, it is devastating… you’re being robbed of your son’s or daughter’s childhood.”

Astonishingly and discouragingly, however, the article failed completely to mention the impact of their experience on the abducted children. Their abrupt separation from a familiar caregiver may in many cases be as traumatic as the death of a parent or as kidnapping by a stranger, however good the intentions of the abducting parent may be. As seems to have been the situation for so many recent reports of disrupted adoptions, though, discussion of parental abductions has often focused on the needs and rights of the adults. "Robbery" of the children seems to be of little interest.

I have to wonder whether the media’s failure to consider the effects of these experiences on the abducted children has any influence on the abductors themselves. Without public statements deploring the impact of parental abduction, do the abductors feel free to imagine that they are doing something acceptable-- even that their action is “in the best interests of the child”?

It is difficult to imagine any scenario in which abduction by a parent would be without negative effect on a child. In the case of older children who are capable of asking questions, the abducting parent has few choices except to offer distressing explanations. Refusing to answer questions at all establishes an atmosphere of implied threat and fear. Promising future contact with the other parent-- but not following through--- adds mistrust to fearfulness. Lying about the situation can be devastating. “Your mother is dead” or “Dad told me he doesn’t want you any more”-- how can the abducting parent offer the comfort that is needed for children who have received this kind of “news”? And speaking the truth (“Your father wants you back, but I’m not going to let him find out where you are”) creates concerns about the bereft parent, as well as destroying the cherished fantasy of children of divorce, that the parents will be together or at least cooperate in some way.

For children too young to ask questions or understand answers, abduction and abrupt loss of contact with a familiar parent will be equivalent in impact to the sudden death of that parent. In the best case, the abducting parent will have been in close contact with the child and will be familiar with the child’s routine as well as with ways to offer comfort. But even in that case, the sudden absence of a familiar home and caregiver will result in the child’s grieving over the loss. A young child’s grief for loss of a familiar person includes disturbances of sleep and eating, social withdrawal, reluctance to play, and sadness and irritability, and these may be very challenging for an abductor, even one who knows the child well. By the way, far from being “too young to know what’s happening”, older infants and toddlers will be most intensely affected of all by an experience like abduction.

An unfamiliar parent abductor of a young child will find himself or herself in an even more difficult position than one who knows the child better. Imagine, for example, a parent who has never actually lived with the child, but who for his or her own reasons (perhaps to punish the other parent) has decided to abduct. The young child placed in these circumstances has all the problems of grief mentioned earlier, as well as fear of an abductor who although genetically related is in practical terms a complete stranger. In addition, the child is in the hands of a person who may have little skill or knowledge about child-rearing, and who in anxiety or stress may respond with punishment to the child’s grief.

I don’t know whether parent abductors usually give much thought to the outcome of their taking the child. In one case described in the Times article, the abductor had obviously planned the abduction carefully over months, but whether he had considered the child’s reaction is not known. If anyone is making such a plan, I would beg him or her to think over carefully what the experience of abduction will mean to the child, and to consider how appropriate goals might be met by acting within the law. I do recognize that there are circumstances in which fear for a child’s safety, and the apparent failure of courts to consider existing threats, may motivate a parent to take a child and run. All I am suggesting is serious consideration of the outcome of abduction.

In a less obvious way, the same kind of consideration might be advised for parents who are seeking custody of children who have for whatever reason not been available to them for some time. I talked a while ago with a father whose former wife had taken their children to a distant state, re-married, and brought what were apparently baseless accusations of sexual molestation against her former husband. His contact with the children had been very limited for some years, but an investigation had shown no evidence of wrong-doing on his part, and he was now asking for full custody of the children, who were approaching their teens. This father planned that as soon as he had custody he would immediately take all the children a couple of thousand miles away (although they said they wanted to stay at their old schools) and set up a new home where their mother could not easily influence them. While adults will sympathize with a person who may have suffered a good deal under serious accusations, and who may have had good reason to despise the influence of his former wife, we can easily predict the anguish of the children being forced to give up their familiar lives, schools, and friends at the behest of a father whom they barely knew. If he had received custody, the father would have had the right to do this, but I would argue strongly that he would have been in the wrong if he had followed the plans he had made. As a matter of fact, custody remained with the mother, and in spite of her apparently problematic behavior, I believe that this was probably the right decision.

Sunday, November 7, 2010

Reforming Adoption: Some Incomplete Thoughts

I’ve heard a lot recently about the need to reform adoption laws, and I strongly agree that it’s time to do this. There are a number of circumstances in which the rights of children and the rights of adult parents or caregivers are in conflict, and adoption, as we now manage it, appears to be one of the situations in which this problem is most evident.

As Ellen Herman shows at, it’s only since about 1850 that adoption laws and practices in the United States have focused on the needs and rights of children, and it’s much more recently that family relationships have become a matter of concern (as in some aspects of “the best interests of the child”). If we go back farther in time, we see that on the whole adoption practices were oriented toward assuring transmission of property and hereditary titles, or toward improving the adoptive parents’ income. Guardianship often hinged on this issue-- as in the frequent use by Gilbert and Sullivan of the concept of “wards in chancery”, heiresses whose guardians had the job of preventing them from being married for their money (though some of those guardians had the idea of marrying the girls themselves). Among poorer people, caring for “someone else’s child” often had the goal of rearing some farm help or collecting fees from the parish for doing this job.

As a result of this connection with property, much of adoption law was created in parallel with property laws. This parallel included absolute rights of possession; just as a car cannot belong simultaneously to the buyer and to the seller; an adopted child cannot legally speaking be simultaneously the child of the birth parents and the adoptive parents.

The equation of adoption with property rights may have worked well enough for its original purpose, which was property-oriented. Such laws may also have been adequate when adoption most often took place within a limited geographical area and within a limited group of people, although even then there were concerns about what was owed to an adopted child (see Jane Austen’s “Mansfield Park”, where there is discussion of the possible unfairness of bringing up a niece “as a lady” when she will not be able to inherit --- but, reader, she married him, so it was okay). However, we can hardly expect the same laws to be adequate for adoptions from thousands of miles away, from different cultures and language groups, with the mediation of government agencies rather than private contacts and decisions. Nor can we expect the same laws to work when most people expect caring for a child to cost them a good deal of money, rather than helping them accumulate property. In addition, I have no doubt that many readers will say those laws have had horrible effects, and no doubt they sometimes have-- I’m just trying to get at general reasons why, if once adequate, they are not adequate now.

It’s time to re-formulate the reasons for adoption and the ways law should protect all human rights as well as possible. Providing ways to mediate when rights of family members are in conflict would be part of this. I am by no means ready to suggest how this reformulation should be done, and I know that it will take a long time to do when it happens.

However, I would like to suggest a few things that could be accomplished without actual legislative changes, and which I think would be advantageous to adoptees, birth parents, and adoptive parents. I believe that it would be possible to make some of these improvements without legislation, but through education of judges, attorneys, and social workers, as well as potential and actual adoptive parents.

The first issue I have in mind has to do with large adoptive families and with circumstances in which adoptive parents accept more children from an institution than they had intended to adopt. “Mega-families”, especially those that include numerous at-risk children, are becoming known for an unusual frequency of child abuse and neglect. While there are a few adults who have the training and financial resources to take good care of a dozen or more children, some of whom have special needs, most of us cannot do this effectively. Yet these enormous groups are sentimentalized and romanticized by the press and by some caseworkers, whose attitudes influence adoptive parents. I do not suggest that legislation should forbid adoption of more than some small number of children, but I do suggest that social workers, adoption agencies, and child protective services staff should be extremely vigilant about insuring the health and safety of mega-adoptions. The idea that rearing children is “cheaper by the dozen” does not necessarily mean that it is safer by the dozen. Part of the task would involve caution about responses to whistleblowers (a visiting nurse who reported serious abuse in a Tennessee mega-family a few years ago was the focus of a lawsuit that was financially and personally potentially crippling).

A related second issue is increased caution by authorities about informal changes of adoptive homes and about the use of respite care. While normal family life in the United States can involve sleepovers of various kinds, or going to stay with a relative or friends for a few days or even weeks, there are adoptive families who go beyond the usual expectations by “dropping off” a child with others for convenience, perhaps to go on vacation or simply because they are tired of coping with the adoptee. In the case of the Tennessee family mentioned above, there were “dropped off” children living in the home whose legal guardians were unknown and for whom no legal transition had been made. A similar problem has to do with the use of “respite families”, often recommended by attachment therapists, to whom children are sent for the purpose of experiencing an austere and demanding environment that will motivate them to co-operate and be allowed to stay in the adoptive home. Respite care is certainly very legitimate when provided for handicapped children, for example by organizations like United Cerebral Palsy, which train people to do a few hours of care for children whose parents could not otherwise find qualified caregivers to use suction or monitor the eating of a child with oral problems. This is a very different matter from the “respite home” which is claimed to have a therapeutic goal, but which is not monitored in any usual sense. In these situations, adopted children and their families need the help of well-educated judges, attorneys, CPS workers, and caseworkers.

A third issue has to do with transfers of custody from one set of adoptive parents to another. More caution is needed in this area, and it would not require legislation to encourage it. In a case I was recently involved with, a child had been adopted from Russia at age 4. Her adoptive parents did not feel happy with her, sought unconventional therapy, and sent her to a respite home for periods of time. Eventually the respite family, in discussion with the adoptive parents and the therapists, decided that it would be better to have her adopted by the respite family-- and they did this, against the wishes of the child, who was 8 years old by that time. I’m talking here about legal adoption, not about an informal arrangement, so social workers and at least one judge were presumably in the picture. If this child had been with her birth parents, and they had relinquished her for adoption, essentially abandoning her, there would have been an impact in terms of their custody of other children in the home as well. In this case, there was no apparent investigation of the motives for this change or of the rest of the family situation. Once again, appropriate training and education of people involved in these decisions could make a great difference.

Finally, I want to make one simple suggestion, one that would contribute to the dignity and sense of continuity to be felt by adoptees. I suggest that we need a change in attitude about name changes connected with adoption. If a baby is only a few months old, a new given name might be selected, but I would propose one or both birth parent family names as middle names, with the adoptive family name added. If a child is old enough to recognize his or her given name (perhaps 6 months of age, ordinarily), the given name should not be changed, and family names should be kept if known. Certainly more than one change is out of the question, but the girl I mentioned in the last paragraph had her name changed both on her first adoption, at 4, and again by the second set of adoptive parents, at 8. I don’t argue against nick-names, but simply that children and adolescents who are establishing a sense of identity can benefit from knowing that the self at least has a consistent name. No one needs to wait for legislation to do this-- it’s a matter of individual attitudes and what they convey to the children and to others.

Yes, the laws need to change, but everyday practices can change much more quickly.

Friday, November 5, 2010

Updated CV, In Case You're Interested



Richard Stockton College
Pomona, NJ 08240

*Name was legally changed from Gene Alice Lester, 1977

Mt. Holyoke College, 1959-1961
Occidental College. 1961-63; A.B. in Psychology, 1963
Brandeis University, 1963-67; Ph.D. in Psychology, Feb. 1968

Assistant Professor, Wheaton College, Norton,MA. 9/67-6/69
Assistant Professor, State University College, Buffalo, NY 9/69-6/71
Assistant Professor, Richard Stockton College, Pomona, NJ 9/74-9/77
Associate Professor, Professor, Richard Stockton College, Pomona NJ 9/77-2/81
Professor of Psychology, Richard Stockton College, Pomona, NJ 2/81-2006
Professor Emerita of Psychology, Richard Stockton College, 2006--

Consulting reader, Infants and Young Children,1992-
Editor, The Phoenix (NJAIMH Quarterly Newsletter), 1994-1999; Editor,
Nurture Notes (NJAIMH Newsletter), 2000-2001.
Vice President, New Jersey Association for Infant Mental Health, 1996-2000
President, New Jersey Association for Infant Mental Health, 2000-2005
Past president, ex officio Board of Directors member, NJAIMH, 2005-
Member, Prevention and Early Intervention Committee, New Jersey Community
Mental Health Board, 2000-
Consulting editor, Scientific Review of Mental Health Practice, 2002-
Member, New Jersey Better Baby Care Campaign Advisory Committee,
2002- 2003

Fellow, Council for Scientific Medicine and Mental Health, 2003-
Faculty member, Youth Consultation Services Institute for Infant and Preschool Mental Health, 2003-
Chair, Board of Professional Advisors, Advocates for Children in Therapy, 2003--
Expert witness, Utah Division of Occupational and Professional Licensing, 2005
(license revocation matter)
Expert witness, Middlesex NJ Family Court, 2005 (best interest hearing)
Member, "Critical Pathways" teleconference on training and credentials (formed after ZTT/Mailman Foundation Infant Mental Health Systems Development Summit Conference, September 2005)
Expert witness, Thibault vs. Thibault, Pasco County, Florida, 2006 (child custody and discipline matter)
Expert witness, California vs. Sylvia Jovanna Vasquez, Santa Barbara County, CA, 2007 (child abuse matter)
Reviewer, American Journal of Orthopsychiatry, 2008.
Testimony, Robertson vs. Mannion, Montgomery County, PA, 2008 (child custody matter)
Founding member, Institute for Science in Medicine, 2009—
Reviewer, Choice: Current Reviews for Academic Libraries, 2009-
Board of Directors, Delaware Valley Group of WAIMH, 2010—


Lester, G., & Morant, R. (1967). Sound localization during labyrinthian stimulation.
Proceedings of the 75th Annual Convention of the American Psychological
Association, 1,19-20.
Lester, G. (1968). The case for efferent change during prism adaptation. Journal of
Psychology, 68, 9-13.
Lester, G. (1968). The rod-and-frame test: Some comments on methodology. Perceptual
and Motor Skills, 26, 1307-1314.
Lester, G. (1969). Comparison of five methods of presenting the rod-and-frame test.
Perceptual and Motor Skills, 29, 147-151.
Lester, G. (1969). The role of the felt position of the head in the audiogyral illusion. Acta
Psychologica, 31, 375-384.
Lester, G. (1969). Disconfirmation of an hypothesis about the Mueller-Lyer illusion.
Perceptual and Motor Skills, 29, 369-370.
Lester, D., & Lester, G. (1970). The problem of the less intelligent student in the introductory psychology course. The Clinical Psychologist, 23(4), 11-12.
Lester, G., & Lester, D. (1970). The fear of death, the fear of dying, and threshold differences for death words and neutral words. Omega,1, 175-180.
Lester, G. (1970). Haidinger’s brushes and the perception of polarization. Acta
Psychologica, 34, 107-114.
Lester, G., & Morant, R. (1970). Apparent sound displacement during vestibular stimulation. American Journal of Psychology, 83, 554-566.
Lester, G. (1971). Vestibular stimulation and auditory thresholds. Journal of General
Psychology, 85, 103-105.
Lester, G. (1971). Subjects’ assumptions and scores on the rod-and-frame test.
Perceptual and Motor Skills, 32, 205-206.
Lester, G., & Lester, D. (1971). Suicide: The gamble with death. Englewood Cliffs, NJ:
Lester, D., & Lester, G. (1975). Crime of passion: Murder and the murderer. Chicago:
Lester, G., & Rando, H. (1975). No correlation between rod-and-frame and visual
normalization scores. Perceptual and Motor Skills, 40, 846.

Lester, G., Bierbrauer, B., Selfridge, B., & Gomeringer, D. (1976). Distractibility,
intensity of reaction, and nonnutritive sucking. Psychological Reports, 39, 1212-1214.
Lester, G. (1977). Size constancy scaling and the apparent thickness of the shaft in the
Mueller-Lyer illusion. Journal of General Psychology, 97, 307-398.
Mercer, J. (1979). Small people: How children develop and what you can do about it.
Chicago: Nelson-Hall.
Mercer, J. (1979). Personality development and the principle of reciprocal interweaving.
Perceptual and Motor Skills, 48, 186.
Mercer, J. (1979). Guided observations in child development. Washington, D.C.: University Press of America.
Mercer, J., & Russ, R. (1980). Variables affecting time between childbirth and the establishment of lactation. Journal of General Psychology, 102, 155-156.
Mercer, J., & McMurphy, C. (1985). A stereotyped following behavior in young children.
Journal of General Psychology, 112, 261-265.
Mercer, J. (1991). To everything there is a season: Development in the context of the
lifespan. Lanham, MD: University Press of America.
Mercer, J.,& Gonsalves, S. (1992). Parental experience during treatment of very small
preterm infants: Implications for mourning and for parent-infant relationships.
Illness, Crisis, and Loss, 2, 70-73.
Gonsalves, S., & Mercer, J. (1993). Physiological correlates of painful stimulation in preterm infants. Clinical Journal of Pain, 9, 88-93.
Mercer, J. (1998). Infant development: A multidisciplinary introduction. Belmont, CA:
Mercer, J. (1999). ‘Psychological parenting” explained (letter). New Jersey Lawyer, July 12, 7.
Mercer, J. (2000/2001). Letter.Zero to Three, 21(3), 39.
Mercer, J. (2001). Warning: Are you aware of “holding therapy?” (letter). Pediatrics, 107, 1498.
Mercer, J. (2001). “Attachment therapy” using deliberate restraint: An object lesson on the identification of unvalidated treatments. Journal of Child and Adolescent
Psychiatric Nursing, 14(3), 105-114. This paper is posted at
with permission of the publisher to the Child and Adolescent Bipolar
Mercer, J. (2002). Surrogate motherhood. In N. Salkind (Ed.), Child Development
(pp. 399). New York: Macmillan Reference USA.
Mercer, J. (2002). Child psychotherapy involving physical restraint: Techniques used in four approaches. Child and Adolescent Social Work Journal, 19(4), 303-314.
Kennedy, S.S., Mercer, J., Mohr, W., & Huffine, C.W. (2002). Snake oil, ethics, and the First Amendment: What’s a profession to do? American Journal of
Orthopsychiatry, 72(1), 5-15.
Mercer, J. (2002). Attachment therapy: A treatment without empirical support. Scientific
Review of Mental Health Practice, 1(2), 9-16. Reprinted in S.O. Lilienfeld, J. Ruscio, & S.J. Lynn (Eds.), Navigating the mindfield: A user’s guide to distinguishing science from pseudoscience (pp. 435-453). Amherst, NY: Prometheus Books.
Mercer, J. (2002). The difficulties of double blinding (letter). Science,297, 2208.
Mercer, J. (2002) Attachment therapy. In M.Shermer (Ed.), The Skeptic Encyclopedia of
Pseudoscience (pp. 43-47) .Santa Barbara, CA: ABC-CLIO.
Mercer, J., & Rosa, L. (2002). Letter on Attachment Therapy. New Jersey School
Psychologist, 24 (8), 16-18.
Mercer, J., Sarner, L., & Rosa, L. (2003). Attachment therapy on trial: The torture
and death of Candace Newmaker. Westport, CT: Praeger. (see also reviews in Scientific American, PsycCritique, Scientific Review of Mental Health Practice).
Mercer, J. (2003). Letter to the editor. APSAC Advisor,15(3), 19.
Mercer, J. (2003) Attachment therapy and adopted children: A caution. Readers’
Forum. Contemporary Pediatrics, 20(10), 41.
Mercer, J. (2003). Violent therapies: The rationale behind a potentially harmful child psychotherapy and its acceptance by parents. Scientific Review of Mental Health
Practice, 2(1), 27-37.
Mercer, J. (2003). Media Watch: Radio and television programs approve of Coercive Restraint Therapies. Scientific Review of Mental Health Practice, 2(2).(see also letters in subsequent issues)
Mercer, J. (2004). The dangers of Attachment Therapy: Parent education needed.
Brown University Child and Adolescent Behavior Letter, 20(10), 1, 6-7.
Mercer, J. (2005). Bubbles, bottles, baby talk, and basketty. Early Childhood Health Link
(Newsletter of Healthy Child Care New Jersey), 4(1), 1-2.
Mercer, J. (2005). Coercive Restraint Therapies: A dangerous alternative mental health intervention. Medscape General Medicine, 7(3). (see also letters in subsequent issue).
Mercer, J. (2006). Understanding attachment: Parenthood, child care, and emotional development. Westport, CT: Praeger.
Mercer, J. (2006). IEPs and Reactive Attachment Disorder: Recognizing and addressing misinformation. Scope (Newsletter of the Washington State Association of School Psychologists), 28(3), 2-6.
Mercer, J., Misbach, A., Pennington, R., & Rosa, L. (2006). Letter to the editor (age regression definition). Child Maltreatment, 11, 378.
Mercer, J. (2007). Behaving yourself: Moral development in the secular family. In D..McGowan (Ed.), Parenting beyond belief (pp. 104-112). New York: Amacom Books.
Mercer, J., & Pignotti, M. (2007). Letter to the editor (neurofeedback research critique). International Journal of Behavioral and Consultation therapy, 3 (2), 324-325 ( ).

Pignotti, M., & Mercer, J. (2007). Holding Therapy and Dyadic Developmental Psychotherapy are not supported, acceptable social work interventions: A systematic research synthesis revisited. Research on Social Work Practice, 17 (4), 513-519.

Mercer, J. (2007). Systematic child maltreatment: Connections with unconventional parent and professional education. Society for Child and Family Policy and Practice Advocate (Division 37 of APA), 30 (2), pp.5-6.

Mercer, J. ( 2007).Media Watch: Wikipedia and "open source" mental health information. Scientific Review of Mental Health Practice. 5(1), 88-92.

Mercer, J. (2007) Destructive trends in alternative infant mental health approaches. Scientific Review of Mental Health Practice, 5(2), 44-58.

Mercer, J., & Pignotti, M. (2007). Shortcuts cause errors in Systematic Research Syntheses: Rethinking evaluation of mental health interventions. Scientific Review of Mental Health Practice, 5(2), 59-77.

Mercer, J. (2008). Minding controls in curriculum study (letter). Science, 319, 1184.

Mercer, J. (2009).Child Development: Myths and Misunderstandings.Los Angeles,CA: Sage.

Mercer, J., Pennington, R.S., Pignotti, M., & Rosa, L. (2009). Dyadic Developmental Psychotherapy is not "evidence-based": Comments in response to Becker-Weidman and Hughes (2009). Child and Family Social Work, 15, 1-5. . DOI:10.1111/j.1365-2206.2009.00609.x.

Mercer, J. (2009). Child custody evaluations, attachment theory, and an attachment measure: The science remains limited. Scientific Review of Mental Health Practice, 7(1), 37-54.

Mercer, J. (2011). Attachment theory and its vicissitudes: Toward an updated theory. Theory and Psychology, 21, 25-45.

Mercer, J. (2010). Themes and variations in development: Can nanny-bots act like human caregivers? Interaction Studies, 11(2), 233-237.

Mercer, J. (in press). Reply to Sudbery, Shardlow, and Huntington: Holding therapy. British Journal of Social Work.

Mercer, J. (in press). The concept of psychological regression: Metaphors, mapping, Queen Square, and tavistock Square. History of Psychology.

Lester, G. (1968). Some investigations of the audiogyral illusion. Unpublished Ph.D. thesis, Brandeis University.
Mercer, J. (1993) The successful single parent. Unpublished book-length ms.
Mercer, J. The developing child in
changing times: Infancy through adolescence Unpublished book-length ms.
Invited comments on the New Jersey Children’s Initiative proposal (March 10, 2000);
with Gerard Costa and Elaine Herzog.
Invited comments on the U.S. Bright Futures children’s mental health proposal (July 5, 2000); with Gerard Costa.
Mercer, J. (2000). Notes on Attachment Therapy: Relevant Research and Theory. Prepared for use by the prosecution in the trial of Connell Watkins, Colorado, Aril 2001.
Sarner, L., & Mercer, J. (2003). Statement to Human Resources Subcommittee of House Ways and Means Committee.
Mercer, J. (January, 2005). Expert witness report. State of Utah Division of Occupational and Professional Licensing. Case number 2002-223.
Mercer, J. (April, 2005). Expert witness report. Child custody case, Middlesex Family Court, New Brunswick, NJ.
Mercer, J. (October, 2006). Expert witness report. Child custody case, Pasco County, Florida.

BLOGS: (June 2009-June 2010)

Various presentations on child development and parenting issues to parent groups and
training workshops, including CASA.
“Law, policy, and attachment issues”; presentation at the Second Annual Conference on Attachment of the New Jersey Psychological Association. June 9, 2000, Newark, NJ.
“Custody changes and their effect on children’s development”; presentation at New Jersey State Child Placement Advisory Council conference, April, 2001.
“Bad language: How the professions confuse each other with words,” welcoming address at conference on Attachment, New Jersey Association for Infant Mental Health,
Piscataway, NJ, April, 2002.
“That cranky, crying baby”; presentation at National Association for Education of Young Children Conference on Health in Child Care, Princeton, NJ, May, 2002; repeated May, 2003, May, 2004.
“Warning Signals: When parents consider unusual mental health treatments for their children”; presentation at Third Annual Multicultural Health Conference, Richard Stockton College, Pomona, NJ, Sept. 2002.
“Misuse and abuse of attachment theory”; keynote speech at 2002 Annual Meeting, New Jersey Association for Infant Mental Health, Piscataway, NJ, Nov. 2002.
“Attachment Therapy: Science adversaries appeal to scientific evidence.” Institute of Contemporary British History conference, “Science, Its Advocates and Adversaries”, London, July 7-9, 2003.
“Analyzing Attachment Therapy”, at “Right From the Start: Supporting the Earliest Relationships and their Impact on Later Years,” professional conference presented by Youth Consultation Services Institute for Infant and Preschool Mental Health, Newark, Sept. 24-25, 2003 (continuing professional education credit-bearing).
“Principles of Infant Mental Health”, at “What Does Infant Mental Health Mean to Me?”, professional conference sponsored by New Jersey Association for Infant Mental Health, Gateway Maternal-Child Health Consortium, Northwest Maternal-Child Health Consortium, Piscataway, NJ, Nov. 13, 2003 (continuing professional education credit-bearing).
“Attachment and Attachment Therapy: The Good, the Bad, and the Ugly”, at annual meeting, Gateway Maternal-Child Health Consortium. East Orange, NJ, March 25, 2004 (Continuing professional education credit).
“Attachment.” Annual conference of New Jersey Association for Education of Young Children, East Brunswick, NJ, Oct. 16, 2004 (continuing professional education
Discussion of Attachment Therapy. “All in the Mind”, Australian Broadcasting Company, Dec. 18, 2004. Transcript available at
“Attachment: Social and Emotional Development from Birth to Preschool.” Conference of Coalition of Infant and Toddler Educators, East Brunswick, NJ, March 18, 2005.
“Attachment Therapy: Concerns on Unvalidated Treatments.” Institute for Infant and Preschool Mental Health Didactic Series, Youth Consultation Service, East Orange, NJ, May 12, 2005.
"Violent therapies with children: History and theory.” 9th International Family Violence Research Conference, Portsmouth, NH, July 11, 2005.
Invited state delegate and New Jersey presenter, Infant Mental Health Systems Development Summit conference, sponsored by Mailman Foundation/Zero to Three. Washington DC, Sept. 22-24, 2005.

New Jersey Perinatal Mood Disorders training program presentations, 2005-2006.

“Dangerous therapies”, with Alan Misbach. LCSW. Independent Educational Consultants Association conference, Philadelphia, Nov. 14, 2005.

"Attachment Therapy". Institute for Infant and Preschool Mental Health Didactic Series, Youth Consultation Service, East Orange, NJ, April 27, 2006.

"Attachment Therapy" comments, Paula Zahn show, CNN, Nov. 14, 2006.

"Attachment Therapy" comments, Court TV, Nov. 27, 2006.

"Understanding attachment." Delaware Valley Group, WAIMH. Dec. 1, 2006.

"Strategies for picky eaters." Jan 31, 2007, NJ WIC training, Ewing, NJ.

"Just the facts, ma'am: Asking and answering the right questions about evidence-based treatment." May 17, 2007. Florida Association for Infant Mental Health, Ft. Lauderdale.

Panel on secular parenting, moderated by Dale McGowan. Atheist Alliance International,
annual conference, Arlington, VA, Sept. 29, 2007.

"Circumstantial Evidence: Evaluating Design and Details of Outcome Research" (poster presentation). Dec. 1, 2007. Zero to Three National Training Institute, Orlando, Florida.

"Theory of Mind: A New Approach to Attachment." Conference of Coalition of Infant and Toddler Educators, New Brunswick, NJ, March 14, 2008.

"Novel Unsupported Therapies: Pseudoscientific and Cult-like". With Monica Pignotti and James Herbert. International Cultic Studies Association conference, Philadelphia, June 27, 2008.

"Attachment Theory, Evidence-based Practice, and Rogue Therapies: Using and Misusing the Concept of Attachment." With R.S. Pennington, L. Rosa, and L. Sarner. Wisconsin School Psychologists Association conference, LaCrosse, WI, Oct. 29, 2008.

"Are There Research-based Child Custody Evaluations? An Ongoing Case and an Ongoing Discussion." Annual Conference, New Jersey Association for Infant Mental Health, Dec. 12, 2008, North Brunswick, NJ.

“A Problematic Parenting Pattern Associated With Child Deaths.” Eastern Psychological Association, March 7, 2009, Pittsburgh, PA.

“Personalities and Power Struggles: Discipline, Temperament, and Attachment.” Coalition of Infant and Toddler Educators Annual Conference, March 14, 2009, Somerset, NJ.

“Don’t Be So [Un]critical! Using Critical Thinking to Foster Mastery of Child development Concepts.” Developmental Science Teaching Institute, Society for Research in Child Development, April 1, 2009, Denver, CO.

“Psychological Concepts and Measures in the Family Court”. Judicial Orientation, Essex Vicinage (NJ). Princeton, NJ, Oct. 2, 2009. (With Michelle DeKlyen, Ph.D.)

“Are There Research-Based Child Custody Evaluations?”. Conference on Infants and Children in the Courts, sponsored by Youth Consultation Service and NJAIMH; Clara Maass Medical Center, Belleville, NJ, March 19, 2010.

Wednesday, November 3, 2010

Symbiosis, Intersubjectivity, and Early Relationships

When people concerned about adoption discuss relationships between babies and mothers, they sometimes refer to a period of symbiosis, in which the identities or “selves” of mother and child are somehow fused, so the baby cannot tell the self from the mother effectively. As I’ve pointed out before, this idea is derived from the work of Margaret Mahler and other psychoanalytically-oriented thinkers, who considered this symbiotic period to last from about the second month to the seventh month or so. It’s important to note that Mahler herself did not think the symbiotic period included the first weeks of life or that the events of that period would have any effect on babies who were separated early from their birth mothers and adopted into different families.

Daniel Stern, in The Interpersonal World of the Infant, refers to symbiosis and discusses the concept in detail, but points out that modern research on early development has revealed a number of phenomena that contradict the possibility of early symbiosis as “fusion”. I want to review a number of facts that suggest that babies have an early concept of “self” versus “other” that makes a sense of fusion unlikely for the baby (although mothers may feel that their “selves” include their babies). This sense has been referred to as “primary intersubjectivity”.

One thing that suggests that young babies already “know” (or act as if they know) the difference between the self and another is that shortly after birth they will imitate the facial expressions of others, opening their mouths, even sticking out their tongues (Meltzoff, A., & Moore, A. [1989]. Imitation in newborn infants: Exploring the range of gestures imitated and the underlying mechanisms. Developmental Psychology, 25, 954-962). It is difficult to imagine that a baby would imitate itself (which brings to mind some infinite progression of mirrors), so the great majority of developmental psychologists today would interpret imitation as some primitive awareness that there are other people “out there”. Incidentally, this newborn imitation is not confined to the mother’s facial expressions as we might expect if the birth mother already had overwhelming importance for the infant.

Another point contradicting the possibility of “fusion” and symbiosis is the infant’s response to the so-called “still-face” situation. In this situation, an adult (the mother or someone else) faces a baby, but does not make eye contact and maintains a blank and unresponsive demeanor (this is not easy to do when the baby is signaling that it wants attention, by the way). From a few months of age, babies are distressed by this and become disorganized in their behavior, whimpering, averting the gaze, looking at their hands, even hiccupping. Babies who are in the developmental period where symbiosis had been thought to occur change their behavior in response to the still-face rather than accepting the unresponsiveness as a part of the “fused selves”.

At the same time, though, mothers or other primary caregivers continue to act as if they feel fused with their young babies. They interpret baby sounds, looks, and gestures as if they (the mothers) know the babies’ intentions. They talk to the baby about his or her needs and feelings. When talking to other adults, they may “speak for the baby”, voicing what they feel to be the babies’ opinions and answering questions or comments made to the baby by other adults. Sometimes they begin their baby remarks by saying “Say” in a lower voice, then switching to a high voice for the words the baby is supposed to mean to say (“Yes, I’m sleepy, Grandma”). As so often occurs, the mothers’ feelings and behavior are parallel to and supportive of the babies’ actions, but are by no means the same.

It’s notable that mothers’ sense of fusion fosters good infant development at the same time that it is not actually in line with reality. The mother who interprets her infant’s signals fairly accurately is encouraging the development of communication, followed by speech and eventually by other cognitive abilities. If she felt “unfused”, was convinced that the baby did not intend to communicate or that she could not understand, and did not try to respond, the mother would not do such a good job and the baby’s development might well be slowed. Problems are likely to occur when the mother is too depressed, tired, or sick to be responsive, or when there are too many young children to care for at once (as in low-quality group care for infants).

Even infants of a few months notice differences in adult emotional facial expressions, but they don’t respond with concern for the worried or frightened adult. By 8 or 9 months, they are interested in the meaning the adult’s emotions have for the child (is there something to be afraid of?). But it’s not until 12 months or so that they begin to have “theory of mind”-- the assumption that other people have their own separate feelings and knowledge, and that those adult facial expressions indicate feelings inside the adult. Without theory of mind, infants can hardly feel a sense of intimacy, much less symbiotic emotional fusion, with adults.

It’s a problem to assume that mothers’ and babies’ feelings about each other are mutual, with each a mirror of the other. We can’t make good guesses about infant abilities just from knowing how adults function. Research on infant abilities tells us that no matter what mothers may feel, babies don’t experience symbiosis. However much adoption reform is needed, it would not be wise to make reforms based on the assumption that mothers and young infants are in symbiotic relationships.

Tuesday, November 2, 2010

Symbiosis: More Fun with Metaphors

There was annoyance expressed by a reader last week when I was perceived as saying that something was “just a metaphor”. I didn’t say that, and I plan to not say it again today. In the study of mental health and other aspects of psychology, metaphors are extraordinarily important because they can guide our thinking into useful-- or useless—channels. A useful metaphor is one in which the psychological event can accurately be “mapped” onto the better-understood event we’re comparing it to, so a lot of things about the psychological event are like aspects of the comparison event. A useless or even harmful metaphor is one where the reality of the psychological event is very different from the reality of the comparison event.

Why am I bringing this up? I’m interested in the metaphor of symbiosis, so much bandied about in discussions of adoption. I believe this is a useless, even a harmful, metaphor. It was used by the psychoanalytically-oriented infant-toddler expert Margaret Mahler, and later by Daniel Stern as well as by others. They used the term symbiosis to describe a period of early life, beginning not at birth but at a few months of age, and going on until about the time that attachment behavior begins. For these authors, the word “symbiosis” was chosen to express the deep intimacy, physical and emotional, that often prevails between mothers and babies at this time in the baby’s life.

The word symbiosis, literally “a living together”, deceives us by looking as if it might be a good word to describe the best mother-infant relationships between about 2 and perhaps 6 or 7 months. But it’s not a word that was invented for this purpose. It describes another, more easily understood phenomenon, and because of this introduces a metaphorical usage into the discussion. Symbionts, or animals that live in symbiosis, are not uncommon in the natural world. They belong to different species but live near each other and behave in ways that are mutually beneficial. For example, pilot fish and sharks benefit each other and contribute to each other’s survival, as the fish eat the parasites that can infest the shark’s skin.

Real symbiosis does not provide a good metaphor for any stage of the mother-child relationship, because mothers and babies are not mutually beneficial to each other’s survival, either before or after birth. Mothers take care of babies; babies do not take care of mothers. On the contrary, aspects of motherhood are so potentially damaging to the mother that we have to look to evolutionary advantages for the species before we see any survival-related reason for having children. (I’m not talking about love, fun, or cultural pressures here, just plain survival of the kind that symbiosis aids.) Aside from a few possibilities like reduction in breast cancer caused by breastfeeding, we see virtually all the benefits of the relationship going to the baby, while the mother serves as an auxiliary immune system as well as an auxiliary ego.

What would be a more suitable metaphor, drawn from the natural world, to guide our thinking about young babies and their mothers? If we’re going to choose a comparison to animals living together, a better choice than symbiosis would be parasitism. A parasite, like a tapeworm living in a human gut, takes what it needs from the host, but usually does only slight damage, as it benefits from the host’s continuing life. Unborn babies function like parasites to a considerable extent, sometimes endangering or even killing their host[ess]. During the first year, or even longer, the long slow maturation of human beings makes them require constant care which they are completely incapable of reciprocating and keeps them in a parasitic relationship to adults.

Well, this is really an ugly metaphor, isn’t it? Babies as tapeworms is a pretty disgusting idea. But they’re not pilot fish either, and look at the problems we get into with the symbiosis metaphor. That way of thinking leads us to believe that the early mother-baby relationship is mutual, a two-way street in which the feelings and needs of one partner reflect the feelings and needs of the other one. We can make a lot of mistakes with that metaphor. One is to assume that anguish of a mother separated from her baby is necessarily mirrored by the anguish of a young baby separated from the mother, though observation of babies of a few months tells us this assumption is false. Another is to confuse the mother’s and child’s feelings as attachment develops and to think of “bonding-and-attachment” as if they meant the same thing. The parasite metaphor actually works much better as a description of the early mother-child relationship because it protects us from making mistakes about mutuality.

Of course, one of the difficulties of choosing a good metaphor for mother-baby relationships is that, like other aspects of development, those relationships don’t follow the same rules throughout life. Babies function in different ways at different points in their development, and within the second year will become less parasitic and more capable of reciprocating care and affection in a faintly adult-like way. Mothers, too, operate differently at different times in their own and their babies’ lives. As time passes, new metaphors need to be chosen to help us understand social and emotional development. It’s possible that symbiosis could be a good metaphor for some kinds of adult relationships, but I doubt that it ever works well for relationships between parents and their children of any age.

Autism Treatments: Science, CAM, or None of the Above?

There are plenty of non-evidence-based treatments aimed at ameliorating autism. Holding therapy was once used for this purpose, and may still be used by some practitioners. Chelation therapy is known to be not only ineffective but potentially harmful to the child. But what about the most famous treatment, Applied Behavior Analysis (ABA)? And what about the new treatment on the block, Developmental, Individual-difference, Relationship-based therapy (DIR), or Floor Time, based on the approach of the late Dr. Stanley Greenspan? ABA is often stated to be scientifically supported, even “proven”. DIR, on the other hand, has been included as a complementary and alternative treatment by Lisa Kurtz in her book Understanding controversial therapies for children with autism, attention deficit disorder, and other learning disabilities (Jessica Kingsley Publishers, 2007). The CAM designation generally means that a treatment lacks rigorous research support, and may indicate that the treatment is not plausible in terms of orthodox thinking about psychology or medicine.

ABA is based on behavioristic views of learning, which are well substantiated for both human and animal learning, and for all periods in the human lifespan. This treatment is related to operant conditioning, a method that involves reward or reinforcement of desired behaviors like talking, and the prevention of reinforcement of undesired behaviors like the autistic child’s tendency to flap hands or to become fascinated with objects. (At one time, ABA used punishment as well, but as this seemed ineffective it has been dropped from the method.) Operant conditioning is well-known to change behaviors effectively when the behavior chosen occurs from time to time and when a suitable reinforcer can be identified. It is less easy, but possible, for ABA to encourage a behavior which rarely or never occurs in the desired form; in order to do this, ABA specialists use a method called “shaping” in which they initially reinforce related behaviors (like making sounds with the mouth) and gradually limit reinforcement to the desired behavior (for instance, saying a word). ABA thus has a foundation that is plausible in terms of conventional understanding of human functioning.

There’s plenty of evidence that operant conditioning can alter behavior according to well-understood rules. But is there strong evidence that ABA successfully moves autistic children toward significantly more age-typical behavior? Some years ago, Morton Ann Gernsbacher discussed this issue in some detail (Gernsbacher, M.A.[2003]. Is one style of early behavioral treatment for autistic children “scientifically proven”? Journal of Developmental and Learning Disorders, 7, 19-25). In her article, Gernsbacher pointed out that the 1987 work of Ivar Lovaas, the developer of ABA, which reported a significant effect of the treatment, in fact failed to use a design that is needed for the highest category of research support for an intervention. Lovaas’ study did not assign participants randomly to an ABA treatment group or to another type of treatment. Instead, assignment to groups depended on the availability of a therapist, a method which brings in unknown confounding variables like the effect of holidays. The few similarly-designed, good-quality studies also had assignment to groups determined by practical factors rather than true random assignment. As a result, the strong effects those researchers reported need to be interpreted cautiously. A study in 2000 randomized participants, but reported much weaker positive effects than had come from the non-randomized studies (Smith, T., Groen,A.D., & Wynn, J.W. [2000]. Randomized trial of intensive early intervention for children with pervasive developmental disorder. American Journal of Mental Retardation, 105, 269-285).

As a result of these facts, we can conclude that although it may be appropriate to say that ABA is the best-supported method for treatment of autism, it is not appropriate to speak of it as “scientifically proven” or even as evidence-based at the highest level. To the best of my knowledge, no adverse events attributable to ABA have been reported, so this treatment does not belong in the “potentially harmful” or “of concern” category.

What about DIR? Unlike ABA, DIR is not based primarily on principles derived from empirical research, but instead has its foundations in a theory derived by Stanley Greenspan from a variety of sources: psychoanalysis, Piagetian theory of learning, the sensory integration theory of Jean Ayres, and studies of language development. DIR emphasizes an essential connection between emotional development and motivation to communicate with other people, and the capacity for language, thought, and problem-solving. This method focuses on the normal sequence of developmental change, on the formation of social relationships, and on individual differences between children. DIR is thus plausible in terms of commonly accepted ideas about developmental change, although its greater complexity of sources makes it less likely to have the type of support that is foundational for the simpler ABA approach.

Like practitioners of many other treatments for young children, DIR advocates have done little so far to test the efficacy of their preferred intervention. Devin Casenhiser, a psycholinguist in Toronto, has been carrying out a randomized trial study of DIR, but has apparently not yet published it. A number of doctoral dissertations have examined various effects of DIR, including attitudes of parents and of teachers about its use, but have not systematically investigated child outcomes.

It would be impossible to conclude that DIR is evidence-based when so little has been done to examine the outcomes of the treatment. As usual, however, we have no way of knowing whether there are unpublished studies with negative results, or even with the conclusion that DIR had a worse effect than another treatment used as a comparison. Like ABA, DIR appears to have been without reported adverse events.

Should we, then, agree with Lisa Kurtz and describe DIR as a complementary and alternative treatment? I confess that I was shocked to see this classification, as so much of the background of the treatment is highly plausible and conventional in nature. I would see DIR as an little-examined intervention of a conventional type-- a genuinely “experimental” treatment-- as opposed to CAM treatments that are not only without a basis in evidence, but are implausible and incongruent with existing information about development. It may be that plausibility is as important as empirical evidence in determining whether a treatment belongs to the CAM group, but in many ways plausibility is more difficult to determine than evidence, as it requires close examination of the premises and reasoning foundational to a treatment, rather than the simpler analysis of research designs and statistics.

It seems that neither statement about these methods for treating autism is clearly substantiated. ABA has much weaker scientific support than is often claimed. DIR, which makes few claims for research support, may not be correctly designated as complementary and alternative in nature, but I wish DIR proponents would comment on the inclusion of their method in the Kurtz book. I’d like to know whether they too accept the CAM categorization.

Friday, October 29, 2010

When is a Five-Year-Old Older Than Another Five-Year-Old?: Interesting News About ADHD

It wouldn’t surprise most of us if a baby of 6 months acted a lot different from a one-year-old, and a one-year-old a lot different from a two-year-old. Those age differences eventually smooth out, of course, so someone who is 23 probably doesn’t behave much differently from someone who is 22. But when does that smoothing-out occur? We usually treat school-age children as if their grade level is more significant than their actual age in years and months, but this may be a mistake. A recent health economics research article suggests that it may be wrong to assume too early that exact age is irrelevant ( Elder, T. [2010]. The importance of relative standards in ADHD diagnosis: Evidence based on exact birth dates. Journal of Health Economics, 29, 641-656.

Elder’s work used a group of almost 12,000 children and examined the proportion of children diagnosed with attention deficit/hyperactivity disorder (ADHD) in groups that were the oldest in their grades or the youngest in their grades. Because public schools have an age/ birthday cut-off for school entrance and enforce this strictly, looking at a child’s birth date tells us whether he or she entered public school soon after the required birthday and thus was among the youngest in a class, or did not enter until almost a year after that birthday and was among the oldest in the class. If the cut-off date was September 1, children with August birthdays would enter kindergarten at no more than 5 years and one month, but a September birthday would mean that the child waited a year for school entry and came in at no less than 5 years and 11 months of age. Both August and September-born children would be 5 years of age, but the oldest children would be nearly 20% older (and more developed) than the youngest children.

Elder’s study showed that in fact the nearly-20% age difference had significant effects on the children’s ability to cope with the demands of school. About 10% of the “youngest” children (with birthdays shortly before school entrance) were diagnosed as having ADHD, compared to only 4.5% of the “oldest” children (birthdays almost a year before school entrance). In addition, there are long-term consequences of this diagnosis, and by fifth grade almost twice as many of the “youngest” children were taking stimulant medications intended to treat their attention problems.

This pattern was the same for states with a late-summer cut-off as they were for states that set their cut-off later. In all cases, younger children within a group were more likely to be diagnosed and treated for attention problems than older children were. Looking at teachers’ and parents’ assessments of children, Elder found that teachers were very likely to evaluate younger children as having more attention problems, as they compared them to other children in their class; parents were less likely to do this.

Elder’s work suggests that evaluation of attention problems in kindergarteners is influenced by the child’s maturity relative to that of other children in a group. An accurate diagnosis for a child of this age requires comparison to others who are close in age, not to those who are 10, 15, even almost 20% older than the child in question. A child who is 5 years and one month old is as much less mature than one who is 5 years and 11 months old, as a 13-year-old is in comparison to a 15-year-old. Teachers need to be aware of these facts, as their recommendations and evaluations can play a major role in diagnosis of children.

Elder’s work is of great importance in understanding diagnosis of ADHD, one of the most common mental health diagnoses for children ( It is also relevant to the frequent use of medications that have the potential for adverse side effects, and to the creation of adverse expectations in adults who are aware of a child’s diagnosis-- both situations that may worsen the child’s developmental outcome.

The demonstration of relative-age factors for ADHD should also serve as a red flag with respect to various on-line checklists offered for diagnosis of other problems. For example, at, a checklist is presented, purporting to be appropriate for children from age 5 through teen-age. It includes the item “has frequent or intense angry outbursts” without noting that what is “frequent” or “intense” for a 5-year-old may be quite different from what is defined in those terms for a teen-ager.

When making decisions about what a child needs, the question “how old is the child?” is always of primary importance. School systems show that they understand something about this by setting age cut-offs for school entry, but teachers, parents, and professionals need to remember that the details of age can make a big difference in a child’s needs and abilities. One 5-year-old can be a lot older than another 5-year-old.