Book Review: "Do You Believe in Magic?", by Paul A. Offit

Paul Offit’s new book, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine (HarperCollins, 2013) is a smoothly written, highly readable take on some important topics from the ever-changing complementary-and-alternative-medicine (CAM) territory. Offit’s primary theme is that treatments can harm as well as help—true of conventional medicine and its potential side effects, but even more true of unconventional treatments, with their untested effects. At several points in the book, Offit repeats the important dictum: there is really no such thing as “alternative” medicine, but only medicine that has been shown to work, effectively and safely,  and medicine that has not been shown to work or be safe. If it hasn’t been shown to be safe and effective, there’s no point in calling a treatment “medicine”.  

Offit begins the book with chapters considering two factors that help convince the public that an alternative treatment is a good idea: one is the belief that if a substance or procedure is part of an ancient tradition, it must be beneficial, and the other is the belief that whatever is “natural” is good for you.  (To these, I would add, by the way, the remnants of 19^th century Orientalism that suggest that whatever is done in Asia is a good idea.)

Obviously, these beliefs are unsupported by evidence. We read with horror of the devastation of the Black Death, of scurvy on sailing ships, of death and deformity from smallpox and polio. Strolling through a New England graveyard, we count infant deaths and note how many wives each man got through in those pre-divorce days. As for the goodness of the natural, we all must be aware of poisonous snakes and insects, of ergotism from contaminated grain, and of death cap mushrooms, deadly nightshade, oleander bushes, and the whole panoply of attractive toxins Ma Nature has put on the table. Yet, you can fool many of the people much of the time, and some of the people all of the time, if you just mention that shamans used to use a method or that a potion comes straight from nature’s bounty. Most curiously, a number of the foolees are quite convinced that they are cleverly avoiding the manipulations of the medical profession when they go for the old, the natural, the non-evidence-based. “Nobody can  fool me,” they think, and of course nobody needs to as long as they fool themselves.  

Most of Offit’s subsequent chapters recount sad stories of adults and children unhelped or even harmed by the treatments celebrities and “healers” sell to them. In the course of this discussion, Offit shows that snake oil proponents are not necessarily recycled used-car salesmen or preachers of the Elmer Gantry ilk. Stanislaw Burzynski, for example, is a Polish-trained physician who has been assistant professor at Baylor Medical College. He had a research Grant from the National Cancer Institute  and later FDA approval to test a cancer treatment, “antineoplastons”, extracted from that most natural substance, urine. The celebrity-expert, Suzanne Somers, says Burzynski is right about his treatment; unfortunately the evidence shows that despite his academic and research background, Burzynski’s claims are wrong.

Offit’s final chapter, “The Remarkable, Highly Underrated Placebo Response”, addresses the fact that people sometimes do get better when given alternative treatments. He refers briefly to several explanations of the placebo effect, including cognitive dissonance and regression to the mean. But what I’d hoped for from this chapter does not materialize. I would have liked to see some discussion of the effect of spending time with a patient and of personal interactions that may go a long way to explain the occasional effectiveness of implausible treatments.

When alternative practitioners say that their acupuncture or energy field methods have helped  people’s back pain (for example), it‘s not uncommon to hear conventional physicians say, “If I could spend an hour with each patient, I’d have more successes too”.  What happens during that hour of contact? It seems to me that this question, if answered carefully, could focus thinking on an important placebo factor, social and emotional interactions with another person.  

When researchers compare psychological interventions (alternative or conventional), they ideally design their studies so the targeted treatment is compared to another well-known treatment, rather than to no treatment at all. Unless the research question has to do with evaluating a brief method of treating a problem, as many features of the treatments as possible are matched, including the length of the treatment. Psychotherapies are aimed at making a person feel better, so all factors that could achieve this need to be taken into account. Although psychotherapists may employ different techniques, there are factors common to all these treatments that contribute a good deal to “feeling better”: the practitioner’s warmth, empathy, acceptance, and encouragement of risk taking. Presumably, the length of contact with each of these factors has an influence on patient changes.

Do those common factors also play a role in medical effectiveness? At one level, medical treatments  are aimed at creating physical changes that can be objectively measured--  lowering a fever, shrinking a tumor, bringing about weight gain or loss. But many medical treatments also deal with the “feeling better” aspect. If a person reports that he is still in pain or still hears ringing in his ears and does not “feel better”, presumably the entire medical task has not been accomplished.

Situations where the patient does not “feel better” in spite of treatment are situations that open the door to alternative practitioners. If the patient subsequently “feels better”, the alternative practitioner counts this as a success for his or her method and may report this or publish it in a journal dedicated to alternative medicine. But, in most comparisons of alternative and conventional treatments, the influential common factors go unconsidered. However difficult we might find it to assess warmth, empathy, and so on, it’s reasonable to say that less contact means less exposure to the common factors. Thus, research on alternative treatments, to be valid, needs not only to involve comparisons with conventional methods (rather than with “no treatment”), but to make sure that treatment plans equalize the contact time of patients and practitioners in the two groups.  Comparisons that indicate greater success for an unconventional treatment should not be accepted (by anyone) unless these rules are followed.  Otherwise, we are risking “believing in magic”.

   

Obedient Love: Prekopova, Hellinger, and Konrad Lorenz

The Czech psychotherapist Jirina Prekopova is a strong proponent of the use of physical restraint (“Holding Therapy”) for a range of childhood behavioral problems and even adult difficulties like marital conflict. As I’ve discussed elsewhere (http://thestudyofnonsense.blogspot.com/2012/12/jirina-prekopvas-holding-therapy.html), Prekopova recommends that all parents restrain children daily, face-to-face on the lap when small, or with the parent lying prone on a larger supine child. This period of restraint, accompanied by emotional expression both negative and positive, is thought by Prekopova to release feelings of love in both parent and child and to make children want to obey the beloved parent. Prekopova attributes serious problems like autism and severe oppositional behavior to the absence of loving communication and sees restraint as a corrective measure.

In the 1970s and ‘80s, Prekopova presented this method as scientifically based and published several articles claiming to demonstrate its effectiveness. She was able to claim a scientific foundation in part because of the support she received from the Nobel laureate Nikolaas Tinbergen. However, over time, Prekopova gradually dropped the emphasis on what remained a very shaky scientific foundation, and moved to an argument in terms of spiritual influences. Czech correspondents tell me that she presently claims that her method was taught to her by her husband, who learned it from an old peasant who was steeped in tradition. She also warns that civilization is being destroyed by lack of family love and traditional relationships. Prekopova is very concerned about the effects of technology on human life.

Toward the end of her “scientific” period, Prekopova became associated with the German therapist/spiritual cult leader Bert Hellinger, who calls his practice Family Constellations or systemic family therapy. (Hellinger’s use of the term Family Constellation should not be confused with this term as it was used in the 1960s by Walter Toman as he attempted to describe effects of parents’ and children’s birth order.)   Hellinger’s treatment mode appears to involve assigning identities of family members, who may be absent or even dead, to people who are present, in the belief that they will then convey the emotions of the absent ones and allow family conflicts of generations back to be resolved. An important concept in Hellinger’s approach is what he calls “orders of love”--- that there is a hierarchy in the family in terms of birth order; that parents give and children receive; that males have the highest position (but work in the service of the female) (http://curezone.com/Hellinger/).

Hellinger’s “orders of love” concept may be responsible for Prekopova’s changed presentation, from positioning herself as a scientist with evidence for the effectiveness of her treatment to her present packaging of Holding Therapy as created not by herself (although as an elderly person she should be near the top of the hierarchy), but instead by a man--  and not just any man, but an old man, a man who understood ancient tradition. This source for Holding Therapy gives Prekopova and her colleagues a spiritual authority that cannot be claimed by a scientific approach, and that in turn allows her to co-opt religious and nationalistic emotion as supporters of her methods.

Holding Therapy has a historical tradition of its own and can be traced back to exorcism and other  early efforts to treat mental illness. Certainly, for what it’s worth, Prekopova did not invent this technique. But what about the framework of “orders of love” and threats of disastrous social change? Did Prekopova and Hellinger invent this? No, like most things under the sun, these ideas are not new, and to explore them fully would be a lengthy proceeding.

However, it may be interesting to look at some similar beliefs expressed by one of Nikolaas Tinbergen’s co-Nobelists, Konrad Lorenz. Famous for his studies of imprinting and social behavior in geese, Lorenz was also willing to discuss human life in ethological terms, and did so in his 1974 book Civilized Man’s Eight Deadly Sins. In this volume, Lorenz presented a belief in the importance of tradition, in the power of early experiences,  in the hierarchical organization of human social life, and in the dangers of breaking innate rules for human behavior. He did not carry these ideas forward to make claims about treatment of mental illness, as Tinbergen did, but articulated some of the concepts  that were foundational for Hellinger and Prekopova.

Here are some examples of Lorenz’s thought:

“Lack of personal contact with the mother during earliest childhood produces—if not still worse effects—the inability to form social ties, with symptoms extremely similar to those of innate emotional deficiency” (p. 48).

“Much in our society-sustaining or society-destroying behavior is the blessing or curse of early infantile imprinting by more--  or by less—understanding, responsible, and, above all, emotionally sound parents” (p. 52). (Interestingly, this statement appears in the context of an argument against the belief that attitudes and behavior are “conditioned”, and of course Lorenz always presented imprinting as different from other forms of learning.)

“[M]other love, self-sacrifice in the interests of family and society” are destroyed by domestication, in animals and humans (p. 55).

     

Without the environmental pressures for selection that were part of the world in which humans evolved, our behavior may be undergoing “genetic decay” , which Lorenz says animals bred in captivity show. In fish, he says, “the genetic pattern of brood tending is so disturbed that, among dozens of fishes, one  barely finds a pair still capable of caring for their young” (p. 54). Although humans are “child-like” in their adult playfulness and curiosity, if “the progressive infantilism and the increasing juvenile delinquency are, as I fear, signs of genetic decay, humanity as such is in grave danger” (p. 58).

“The modern mother can hardly ever give her full time to her baby and this results, to a greater or lesser degree, in the phenomenon, called by René Spitz, [hospitalism]. Its worst symptom is a severe, irreversible lessening of the ability to make human contacts. All this contributes in a serious way to the decay of human compassion that I discussed earlier. … The contemporary ‘nuclear’ family lacks the rank-order structure that, under more natural conditions,made an old man a venerable figure. … Recognition of superiority in rank order is not incompatible with affection” (p. 71).

There’s lots more of Lorenz, but basically there you have it, the foundation on which Prekopova and Hellinger have based their views. The world is going to hell in a handbasket now that we no longer live “naturally”; nature and tradition will show us the right things to do; people get soft if things are too easy for them; maintaining a strong social hierarchy is the way to do things; and mothers will ruin everything if they don’t spend enough time with their babies.

Historians of psychology have downplayed Lorenz’s involvement with the Nazis, although the ideas stated in the last paragraph are obviously congruent with the Nazi philosophy (as well as with other authoritarian views, including “racial cleansing”). But there seems no doubt that he joined the Nazi party in 1938 and was willing to try for an academic position where the incumbent had been dismissed for reasons probably connected with his wife’s Jewish background.  Are Hellinger and Prekopova appealing to current fascistic mind-sets? This seems very possible, especially in light of Hellinger’s famous  forgiving “letter to Hitler” (www.seesproject.com/verplaatsing/?p=1283). Such possibilities raise concern about Prekopova and Hellinger above the level usual for non-evidence-based alternative treatments.  

   

  

Book Review: "The Nature and Nurture of Love", by Marga Vicedo

I first came across Marga Vicedo’s book The Nature and Nurture of Love: From Imprinting to Attachment in Cold War America (University of Chicago Press, 2013) when it was discussed in a book review in Science by Ben Harris (24 May 2013, p. 926). Harris noted that Vicedo, a historian of science, “accepts no component of attachment theory as empirically revealed, natural truth” (but wouldn’t we be startled and worried if she did so?). Harris also concludes that “put on the witness stand, instinctual attachment theory does not acquit itself well”, an accurate statement, but perhaps puzzling (was this what the book was about?) in light of Vicedo’s focus on the Cold War era and her interest in how  ideas remain lively in spite of contradictory information.  

I often read books on history of science and get a lot of enjoyment from them. When I don’t really know the scientific subject matter that is being treated historically, I sometimes persuade myself that I am learning the science too, with the historical part as the spoonful of sugar that helps the medicine go down. Because I already know a lot about attachment theory and research, I wanted to see what Vicedo had made of it, both scientifically and in its historical context.

The Nature and Nurture of Love provides a good introduction to the development of thinking about attachment, and describes in detail the lurching, ramshackle construction of the theory now presented as smooth and monolithic in child development textbooks and parenting magazines. It’s said that it’s better not to know how either sausages or legislation are made, and the same may be true for psychological theories, which make their way from an idea to a full-scale system in unpredictable fashions shaped by personalities and geopolitics as well as by observation and systematic research. For all the faults of attachment theory (and it has plenty), its developmental trajectory was probably no more awkward or problematic than those of other psychological theories.

Not surprisingly, The Nature and Nurture of Love (hereafter NNL) began as a doctoral dissertation, and it retains some of the flavor of that kind of work, at some points trudging through material that has been described as well or better many times before, and at others revealing connections that have received little attention. The “trudging” part is underlined by the author’s frequent citations to popular publications, while the “revealing” part comes from some primary sources that have rarelybeen accessed or even mentioned--  and I learned a lot from the latter. Readers who were not born until after comparative psychology died will be fascinated by the whole discussion of Daniel Lehrman’s work, although regrettably they will never have a chance to see him act out ringdove courtship (unless someone filmed this tour de force of columbomorphism).

Vicedo presents NNL as an effort to understand the development of attachment theory within the context of the Cold War years, from the 1950s into the 1970s, and this would certainly be an adequate problem for a dissertation. However, many readers with professional or personal interests in attachment theory are more interested in events of the present-day, and in a concluding chapter Vicedo attempts to discuss current views, including those of popular authors like William Sears of “attachment parenting” fame. Here matters become murky, as NNL omits (and indeed has no space for) the thousands of research publications examining attachment behavior, emotions, and thoughts. Neither does she mention more recent statements about the changing nature of attachment theory, like Michael Rutter’s discussion in 1995 and (dare I say it) my own in 2011. How do we understand the popular use of the attachment concept after 2000 without the context of this vast database and the theoretical refinements? Vicedo states herself that that history remains unwritten, so naturally she does not try to explain the position of Sears (e.g.)--  but why mention these popular, even “alternative” views at all, unless under editorial pressure to bring things “up to date”, I wonder? (Or possibly, like the late great Peg Bracken, she is simply cramming in the last few things before slamming the tailgate.) 

I noticed some omissions of material that I think might have clarified some historical events for readers who are newcomers to Bowlby’s attachment theory. For example, Vicedo naturally describes some pre-Bowlby ideas about attachment--  and this is essential, because differences between Freud’s and Bowlby’s views were instrumental in both slowing and refining the development of attachment theory. However, I saw no reference to the previous work of Ian Suttie, the British author whose early death prevented further development of his claims that human affections arose from innate social needs , or of Kenneth Craik, whose concept of the internal working model was adopted by Bowlby as a description of the mental events underlying attachment behavior.

NNL contains a few apparent errors, which while perhaps not significant in themselves do take away from the more general positive impression. John Bowlby, while in line to inherit his father’s baronetcy, was the second son, so was not in the usual sense heir to the title. This title eventually went to John Bowlby’s son (Sir Richard Bowlby, a former medical photographer) as nephew of the second baronet, who died without issue. In a second, more bothersome error, Vicedo states that “ ‘attachment disorder’ has entered the medical vocabulary and, although, not yet recognized by the American Medical Association, has its own criteria for diagnosis and therapy”—a claim that Vicedo cites to the work of a sociobiologist and a philosopher. There are several problems about this claim. One is that this terminology is not the province of the American Medical Association, but of the American Psychiatric Association, publishers of the Diagnostic and Statistical Manual of Mental Disorders, the much revered and much cursed DSM. DSM has included a diagnostic category, Reactive Attachment Disorder, since the 1980s, and you would think that Vicedo would have been aware of this even before 2005, when she finished her dissertation--  but perhaps the problem here is reliance on the secondary sources that can be deceptive.

  

To end with praise: Vicedo’s description of Harry Harlow’s charm and entertainment value does much to help explain the influence of his work and the wish of attachment theorists to include his findings as a foundation for their views. She even refers, although briefly, to some of the issues about Harlow’s choice of a particular type of monkey for his experiments--  an insight rare in the present climate of avoiding animal studies (and a topic I have discussed in more detail at http://childmyths.blogspot.com/2011/09/you-can-pick-your-friends-but-you-cant.html).

Tomatis Therapy is Not a Conventional Treatment

In the last several days, I have received several comments from an annoyed Anon at http://childmyths.blogspot.com/2013/04/got-rad-dsm-v-rethinks-diagnosis-maybe.html.    Among many other things, Anon says her granddaughter is receiving conventional treatments for her behavioral problems, including Tomatis therapy to improve brain functioning compromised by Fetal Alcohol Syndrome. When I stated that Tomatis therapy was not conventional treatment, Anon insisted that it was.

In fact, though, Tomatis therapy is an “alternative” treatment that is implausible in the context of established information about human development, and is without acceptable research evidence. Here is a discussion of Tomatis therapy and other “auditory integration therapies” from my forthcoming book Faith run mad:

Auditory Integration Therapy (AIT)

            AIT practitioners cause patients to be exposed to the sound of music, electronically filtered and altered. Disorders for which AIT may be used include attention-deficit/hyperactivity disorder (ADHD), autism, dyslexia, learning disorders, and depression (Jacobson, Mulick, & Foxx, 2005). Most patients are children or adolescents.

            One method of AIT was developed in the 1970s by the French otolaryngologist Guy Berard (1993). Berard’s technique involves auditory testing that looks for areas of hyperacuity, or sound frequencies to which the patient is unusually sensitive. Berard and his followers then present the patient with music filtered in such a way that the frequencies to which the patient is especially sensitive are less intense than others. This acoustically-modified music is played to the person for a total of 10 hours, in two ½ -hour sessions per day for 10 days. The popular music is played through devices like the Audiokinetron, Audio Tone Enhancer/Trainer, or EARS Education and Retraining System. These devices modulate the sounds by randomly clipping frequencies above or below 1000 Hz for random durations from .25 second to 2 seconds (Mudford & Cullen, 2005). (However, the United States Food and Drug Agency disallowed importation of the Audiokinetron in 1993, on the grounds that the greater than 130 dB sound it produces is greater than the intensity permitted by OSHA for exposure for an hour a day [Mudford & Cullen, 2005]).

            A second French otolaryngologist, Alfred Tomatis (1977/1991), created a similar method of exposing children to music with the intention of treating autism and other disorders. Tomatis used music played through a device called the Electronic Ear. This progressively filtered out low frequencies. As a next step, the intensity of the sound to the left ear was reduced in order to “promote dominance of the right ear”. Children in treatment also spoke and sang into a microphone to hear their own altered voices. They simultaneously played with toys that promoted tactile and vestibular stimulation (much as is done in SIT).

AIT: Plausibility and Evidence

            Neither Berard nor Tomatis attempted to develop a research-based theory for their treatments (Creaghead, 1999). One supporter of the Tomatis method has claimed that “auditory stimulation results in myelination of the auditory pathways… which improves the speed of processing” (Gerritsen, 2010, p. 50), an idea which he cites to a personal communication. In fact, hearing is already functional in utero, and myelination occurs as a result of maturational factors rather than being driven by stimulation. The system does show some plasticity (guidance of development by experience), but this is largely associated with functions like sound localization, which need to adjust as the baby’s head grows.

            Berard considered areas of hyperacute hearing to be “traumatizing frequencies”, an idea without congruence with conventional understanding of hearing. His metaphor for AIT was a comparison to physical therapy, in which a stiff joint might be gradually moved into a wider range of motion; Berard thought of reduction of intensity in the same way, but with little explanation of how or why improvement might occur. More recently, practitioners of AIT under the name Digital Auditory Aerobics (DAA) have suggested that the treatment exercises the muscles that control the ossicles in the middle ear (http://www.georgianainstitute.org/quest.htm), muscles that serve to damp movement in response to excessively intense sounds.

            Neither the Berard nor the Tomatis method has been supported by research evidence. The positive popular attitude toward AIT has been based primarily on a book written by the mother of a child Berard considered completely cured of autism (Mudford et al, 2000; Stehli, 1999). The enthusiasm of the autism researcher Bernard Rimland also played a role in bringing AIT to public attention. Rimland and Edelson (1994, 1995) reported “sufficiently promising” results from 445 autistic children whose parents paid $1000 each to bring the children to Oregon for treatment; no placebo-treated comparison group was included in the design. Mudford et al (2000) later failed to replicate Rimland and Edelson’s results, and three other failures to replicate were listed by Mudford & Cullen (2005).

            A meta-analysis of work  on the Tomatis treatment (Gilmor, 1999) concluded that there might be cautious support, but the study designs were generally weak. In a more recent series of case studies, 5 of 11 autistic children were said not to benefit significantly (Gerritsen, 2010).

As these comments show, Tomatis therapy is not a conventionally-accepted or used treatment for childhood mood or behavior disorders. Practitioners who recommend this treatment are likely to be unconventional in other aspects of their work as well and are best avoided by parents.

Conversion Therapy, Reparative Therapy, SOCE: Proposed New Jersey Legislation Prohibiting Efforts to Change Same-Sex Attraction Experienced by Minors

On June 13, 2013, a New Jersey Assembly committee heard testimony about the bill A3371 (An act concerning the protection of minors from attempts to change sexual orientation). The bill was released from committee, and if passed will prohibit licensed mental health professionals of all disciplines from carrying out treatment of minors with the intention of altering a child’s behavior and experience of attraction to members of his or her own sex. The bill can be read at http://legiscan.com/NJ/text/A3371, and a description of the hearing can be seen at http://s.nj.com/udvnK11. Testimony was heard from a range of witnesses, with support for the bill coming from individuals with relevant personal histories, psychologist, psychiatrists, and representatives of gay and Lesbian organizations. Some of those who testified against the bill also told personal stories, including some self-described ex-gays, one mental health professional who described some of his own methods of doing the treatment, and a pastor of the Assemblies of God who argued that the bill would infringe on religious liberties by removing a clergy member’s option of referring a child or adolescent for this treatment. Several of the witnesses referenced research on children and adolescents with minority sexual orientations, and they particularly pointed to the 2009 report of the American Psychological Association that recommended against use of “conversion” therapies (www.apa.org/pi/lgbt/resources/therapeutic-response.pdf).

I myself testified in support of the bill, and this was my statement:

 Good Morning,

I’d like to start my testimony by saying thank you to Chairman Conway and Assemblyman Tim Eustace for sponsoring this bill, and the rest of the committee for bringing this important matter to a hearing.

I am Dr. Jean Mercer, and I am a developmental psychologist, a retired professor of psychology, and an expert on unconventional psychotherapies for children. I have published several books and a dozen articles in professional journals that discuss the problems of using unconventional, non-evidence-based mental health interventions for children and adolescents.

            I support  the bill to prohibit the use of so-called “conversion therapies” for minors.  I would point out that these treatments lack the support of systematic outcome research. They have not been shown to be either effective or safe. They are implausible in that they disagree with established principles and research evidence about human development. These are problems with respect to the use of such treatments for adults, but are especially important when minors are concerned.

            The use of “conversion therapies_,” or sexual orientation change efforts (SOCE), with children and adolescents pose[s] particular ethical problems. Minors cannot effectively refuse or resist treatments wanted by their parents or other authorities, so the fiduciary responsibility of those who make decisions for the treatment of children and adolescents is great.  Adults making such decisions need accurate information, and in some cases need the help of the state to  assist in making the best decisions. An example is the requirement of the state that dairies test their herds for tuberculosis and thus assure parents that no milk they choose to buy will transmit this disease. If a dairy claimed that its cows where tuberculosis-free when this was not the case, parents would not be able to make informed choices about purchasing milk, and this is why New Jersey and other states have acted to make sure that parental decisions are healthy ones.

            Parents have the right to make decisions about their children’s medical and psychological treatment, but they can exercise this right only when they also enjoy the right of accurate information about the choices they make. Unfortunately, proponents of “conversion therapies” have not provided accurate information. They have claimed that their treatments effectively change minors’ sexual and/or gender orientation, when there is in fact no systematic evidence to show that such treatments for minors are either effective or safe, and when in fact a number of adverse events have been reported in connection with the treatments. Because publications supporting “conversion therapies” have been fraught with inaccuracies and omissions, the rights of both parents and children to give their informed consent to an intervention have been interfered with. Informed consent can be given only when a guardian has been given accurate information about the demonstrated effectiveness of a treatment, about risks connected with the treatment, and about alternative treatments that may be preferred for various reasons. When there is no evidence that a treatment has been shown to be effective for people like the proposed client, guardians must also be informed of this fact. If these types of information are not provided, parental rights to make appropriate decisions are violated, as are the rights of minors to understand and agree with their treatment.

            If  “conversion therapies” had been shown to be necessary, safe, and effective, discomfort associated with them might be acceptable, as we accept a certain amount of discomfort with medical treatments. Because they have not, we must consider whether in fact these treatments are abusive. When they include holding therapy or aversive methods, it is clear that the line defining abuse is quickly crossed if the treatment is ineffective. When no physical methods are used, “conversion therapies” nevertheless meet criteria for emotional abuse by employing rejection, a refusal to acknowledge the minor’s worth or needs, and terrorizing, including verbal assault, bullying, and creating an atmosphere of fear by threats of present or eternal punishment. These treatments also resemble the “intrusive parenting” that has been shown to have detrimental psychological effects. 

            I believe that passage of this bill will help to safeguard rights of both parents and children to be safe from the effects of deceptive commercial speech and to make decisions based on accurate information. Thank you.

In listening to other people’s testimony, both pro and con, I was struck by a number of issues that were occasionally queried by committee members but never completely answered or resolved. I hope that when the bill comes to be discussed in the Assembly, some of these matters will receive attention.

1.      Minors versus adults.  When research about one group of people is to be generalized to another group, it’s necessary to take into account how similar the groups are. There is very little research about attempts to change the sexual orientation of children and adolescents. The research that exists is primarily focused on adults, and not only men, but white men, and not only white men, but to a considerable extent white men of fundamentalist Christian beliefs. Claims that the treatments are safe and effective for these individuals, who have chosen to be treated, are difficult to apply to a mixed group of younger persons who in many cases appear to have been coerced into treatment. I have been unable to find any report of systematic outcome research on the use of these therapies with children and adolescents on Academic Search Complete, PsycInfo,or Medline.

2.      The suicide issue. Witnesses testifying on both sides referred to an increased rate of  suicide , suicide attempts or suicidal ideation among different groups of people. Witnesses in favor of the bill attributed this increase to attempts to change sexual orientation; witnesses opposed to the bill attributed it to the fact of having a minority sexual orientation. One committee member asked what group this relative increase used as a standard of comparison, but no clear answer was given.

 The bill itself cites an article by  Ryan, C.,Huebner, D., Diaz, R.M., and Sanchez, J. (2009. Family rejection as a predictor of negative health outcomes in white and Latino Lesbian, gay, and bisexual young adults. Pediatrics, 123, 346). The Ryan et al paper reports 8.4 times as many suicide attempts  (not completed suicides) among sexual minority young adults ages 21-25 whose reported that their families rejected them than among a similar group who reported that their families were accepting of their orientation.  The participants were recruited from community sites and clubs that serve LGB young adults, so the comparison was not to a sexual majority group.

An article by Mark Hatzenbuehler (The social environment and suicide attempts in Lesbian, gay, and bisexual youth. [2011]. Pediatrics, 127, 896) stated that  sexual minority youth were more likely to report that they had attempted suicide during the previous year if they lived in negative, nonsupportive environments. In this study, about 20% of sexual minority youth (11^th graders) reported that they had at least one suicide attempt during that time, as compared to only 4% for heterosexual youth.  

If either side is to argue their position about this bill on the basis of suicide statistics, it is important to be clear on whether the reference is to completed suicide, self- reported attempted suicide, self-reported suicidal thoughts, or medically-reported suicide attempts. Although all of these are of concern, if we are to avoid the apples-and-oranges problem, clarity is needed.  

3.      Reversed burden of proof.  Witnesses opposing the bill argued that there was no evidence that the “conversion” treatment was not safe or effective--  indeed, claimed that the absence of research evidence meant that the bill was at least premature. However, this argument reveals a common problem of critical thinking, the demand that an opponent show that something is not correct. Rules of critical thinking place the burden of proof on the claimant who holds that something is true. It is for proponents of “conversion” therapy to demonstrate that the treatment is a safe and effective way of changing sexual orientation, and to do this by the rules governing outcome studies of conventional treatments, including the existence of an independent replication of results. Thinking about how they could do this raises an interesting question: would they also claim that they could treat a heterosexual person in such a way as to convert the person’s orientation and cause attraction to people of the same sex?

4.      What do “conversion” therapists actually do? Much of yesterday’s discussion focused on why anyone would, should, or should not want to change a young person’s sexual orientation. Little attention was paid to what the therapists actually do, and whether or not such actions are appropriate at all, whether or not they are effective. One Christopher Doyle, a mental health professional who does “conversion” therapy, stated that it was just talk therapy and therefore could not hurt.

This statement raises two issues: first, is it “just talk therapy”? And, second, if it were “just talk therapy”, could it be harmful?

Richard Cohen’s 2007 book Coming Out Straight describes a form of “conversion” therapy and discusses the rationale behind it. Cohen’s methods may not be those of every “conversion” therapist, but clearly they are the methods used by some and they are not “just talk therapy”. Cohen speaks rapturously of the version of Holding Therapy presented by the American psychiatrist Martha Welch, who believes that physical restraint of one person by another, accompanied by a wide range of emotional communications while the restraint continues for an hour or more, causes emotional attachment to take place. Cohen, like many other half-educated mental health professionals, assumes that most emotional disorders (among which he includes homosexuality) are caused by problems of attachment, and therefore can be treated by methods that he assumes affect attachment. In addition to Holding Therapy, Cohen also considered it helpful to employ a range of “new age” methods, including psychodrama, inner-child healing, bioenergetics, and other techniques that are both implausible and lacking in an evidence basis.

These are not “just talk therapy”, but it is presumably possible for some “conversion” therapists to confine their interventions to talk. If they do, is it true that no harm can be done? Scott Lilienfeld, in a well-known 2007 paper, argued that there are methods that should be considered potentially harmful treatments (Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70). He included as examples of treatments that have done direct harm such “just talk” methods as critical incident stress debriefing. In addition to direct harm from “just talk”, it’s important to consider the possible impacts of “talk” that focuses on unchangeable characteristics (as sexual orientation most probably is) rather than on discomforts like depression or social or family concerns, which in fact can respond to intervention. Harm can be done by “just talk” that ignores the client’s actual emotional needs and focuses elsewhere as the therapist’s agenda dictates.

A3321 obviously requires a good deal more discussion before it is put to a vote, and I hope the discussion will deal with some of the issues I have just noted. In my opinion, however, legislation to prevent a variety of inappropriate treatments for children and adolescents is long overdue. It is a mistake to accept the assurances of all the “helping professions” that they will regulate their own members, as they have clearly not done so.

When Babies Need Comforting: Part II-- Older Babies

Yesterday I discussed some ideas about how young babies can be comforted when they are crying and fretting but don’t seem to “really need” obvious things like food or an adjustment of warmth or coolness. After a baby is more than 3 or 4 months old, he or she may still need some of the old stand-by help like rocking, but there may be more issues that need to be dealt with than is true for the youngest infants.

Older babies have probably already learned some self-regulating tricks like thumb-sucking or positioning in certain ways or holding a favorite blanket. If you know a baby well, you’ll recognize these as ways the baby can try to calm down. If you don’t know the baby well, you may not know what he or she is trying to do--  but you’d be wise to let the baby do what it seems to want. Don’t worry about the teeth or whether this child will still be dragging that blanket around when he goes to college! Developing ways to be calm and tolerate frustration is much more important than those future issues. Also, keep in mind that a baby’s ability to calm alone (or with a little help) does not take away from her attachment to you, from the quality of your relationship, or from your ability as a caregiver. The baby does not have to be completely dependent on you for emotional regulation, and in fact if you are a good caregiver you will help the baby gradually take over the task.

Here are some other important issues for babies from 4-5 months to about 12 months--  depending on the individuals, some may arrive at different times for different babies:

1. Older babies get frightened in a way that’s not possible for younger babies. Sudden loud noises, people moving fast, or things they can’t see, like garbage trucks outside, can all make them cry with fear. It does not matter that they have been hearing and seeing these things for many months without being frightened! When they reach the age when the “fear system” begins to work, babies spend some months being easily startled and scared. This is a matter of maturation and should be welcomed, even though it can feel difficult to caregivers. Unless there’s some other good evidence that the baby has been harmed, sudden fearfulness should not be attributed to traumatic experience if it begins between 6 and 12 months.
2. When older babies cry because they are frightened, they can be comforted by familiar people. They try to get close to someone they know and trust, or at least to be able to see them. An unfamiliar person may have a lot of trouble comforting an older baby, who gets more scared when a stranger approaches. But if you are a stranger and the only caregiver available, you can help by staying near but averting your eyes much of the time--  not staring at the baby, but sneaking a peek at her face now and then until she warms up and begins to look at you occasionally. You can gradually move from that point to being able to pick her up. (If you are a new foster or adoptive parent, don’t just assume that the frightened child is more comfortable when you go away. )
3. If a crying older baby averts his eyes when you approach to comfort him, he is telling you he doesn’t know you well enough to accept your care. Don’t take this personally and get offended, but use your understanding of this communication to modulate your approach. As described above, you can probably get the baby to warm up to you if you are patient, although some babies take longer than others.
4. When an older baby sees or hears anything unusual, he checks out the facial expression and voice tone of a trusted familiar person. The baby wants to know what the grown-up thinks about this strange event. If the grown-up looks happy, the baby usually decides that the unusual thing is not something to be scared of. If the grown-up looks cared or even expressionless, the baby may become frightened and cry---  even though the adult’s expression had to do with something entirely different.
5. Older babies look at adults’ faces a lot, both for play and to see whether the adult is worried about things that are happening. Most of the time, a caregiver will look back at the baby and will change expression one way or another, as well as speaking and moving in response. If a familiar grown-up stares expressionlessly and doesn’t respond to the baby’s bid for communication, the baby soon begins to cry and even becomes physically upset.   (What does this mean about talking a lot on the cellphone while around the baby? I don’t know, but it seems it should mean something…)  
6. Babies who have spent much of their time around depressed caregivers often look sad, cry easily, and are hard to get to play and interact. They need lots of playful interaction as well as comfort to get them to a more normal emotional state.

Not surprisingly, older babies still need lots of comfort from their caregivers--  but, as you see, their needs are not as simple as they were before.

When Babies Need Comforting: Part I-- Little Babies

Just like the rest of us, babies get upset sometimes. Unlike many of us adults, though, babies don’t have many things they can do to make themselves feel better. They can’t have a cup of coffee or a cold beer, telephone a friend, eat chocolates, or go for a long walk. They depend on us caregivers to help them out.

Of course, some adults don’t think it’s wise to try to comfort an upset, crying baby. They think it “spoils” the baby, or that the baby is crying “on purpose” and having fun manipulating an adult. Some, like the egregious William Emerson, believe that babies need to cry in order to discharge negative emotions acquired during birth, and that adults just slow that process when they try to offer comfort.

I, on the other hand, would argue that there are a number of reasons why we should try to comfort crying babies.

It’s to our own benefit to help a baby calm down. A constantly crying, cranky, crabby child is very stressful to be around. Although caregivers may be able to “stand it” when a baby cries a lot, they can’t do as good a job or feel as good themselves when they have to listen to crying. One of the best things we can do for children in our care is to be cheerful and playful--  and that’s hard to do when someone is crying constantly.

If there are other babies or young children around, they too will be disturbed by loud shrill crying. Constant noise makes it hard for them to eat, sleep, or just look and listen. Very young babies can learn a lot just from hearing you talk, but they can’t hear well when there’s a lot of background noise. Calming the criers is a help for other babies and children.

And, of course, the criers benefit if you help them. Every time we help a baby calm down, that baby learns a little bit about how to calm down alone--  to “self-regulate”—and to be able to ignore all the distracting little nuisances of life. When you hold a baby in a comforting way, she learns that you can feel better soon after you start feeling bad. She learns that things like moving around or looking at things or thumb-sucking can all help her relax and forget little problems. This means that she becomes able to pay attention longer and eventually do more things by herself. In the long run, comforting a baby pays big dividends in development and may be one of the best things we can do to get kids ready for school.

So, how do we go about it? There are going to be some different issues depending on whether we’re talking about an infant between birth and 3-4 months, or about an older baby. And of course there will be things one baby likes and another does not. However, it’s possible to list some ideas that may be of help.

For the younger babies, here are some things to keep in mind:

1.      Touch is the most important comfort technique for very young babies. Sometimes just your hand patting the baby will work, but they are more likely to like all-over touch, with their bodies pressed against yours. Some babies don’t like light touch, and it might seem as if they don’t want to be touched at all--  but you can try touching them more firmly rather than less, and see whether that works. And some don’t seem to like being belly-to-belly with an adult, but may like being held facing away.

2.      Movement is something little babies like but can’t give themselves. Most are comforted by rocking, walking, or gentle jiggling and bouncing.

3.      Quiet, rhythmic sounds like singing and talking can help a crying baby calm down.

4.      Having something to suck is one of the most comforting things for young babies. Very young ones may need help to handle a pacifier. Thumb and finger-sucking is fine and will not spoil their teeth unless they ttill do it when the permanent ones come in.

5.      The rhythm of what you do is as important as the thing you’re doing. You can often “override the baby’s tempo” and bring him to a quieter state by starting at a rapid pace and then slowing down. So, if you rock a crying baby, begin by rocking fast and then slow down gradually. You’ll probably find that the screams slow and quiet too.

6.      Remember that it may take time for your comforting method to do its job. Once a baby is thoroughly upset, she doesn’t relax quickly, even though she really likes what you’re doing.

7.      When one thing you try doesn’t seem to work, more than one comfort method can do the trick. Try combining patting with singing, or walking with close, firm touch.

8.      Remember that you are not the only thing near the baby that affects her. Babies can be stimulated by lights, people moving around and talking, or noises nearby, and these can make it too hard for the baby to relax, sleep, or even eat. Try to create a calm environment around a baby who tend to cry a lot.

9.      As a general rule, it’s a good idea to avoid doing too many things the baby doesn’t like at the same time. If you have a very young baby baby who cries about bathing, about dressing, about changing, etc., it’s awfully tempting to do all those things one after the other rather than dealing with separate crying jags. However, doing that makes it very hard for the baby to get better at calming down, so it’s better in the long run to give effective comfort after each upset rather than rushing through a long routine in the way nurses used to call “cluster care”.

Of course, although most often babies cry out of frustration and the inability to self-regulate, it’s possible that the crying indicates a serious problem. Babies do experience pain, even though the classic “diaper pin stick” is long gone. When you’re trying to comfort the baby, and it’s difficult, you may well wonder whether the baby is really sick or in serious pain. Is it possible to tell the difference?  Yes, there are some signals that may indicate that it’s time to seek medical help, and certainly not to try to let the baby “cry it out”. For example, a baby in real pain may not sleep for hours even though he ordinarily naps a lot. The baby’s facial expression may be a “screwed up” look of pain. A baby in pain can give a constant high-pitched cry rather than changing pitch and loudness in the usual way. He or she may thrash the limbs or tremble, and may keep the fingers and toes flexed rather than straight (young babies often do have their fists closed, but if they are not crying, this does not suggest a problem). Finally, the baby does not suck when something is offered, and none of the other tricks described above work either.

Adoption, Fostering, Child Care, Babysitting: Getting to Know a Baby

When we meet new adults, most of us have a whole routine we do in order to be friendly and find out whether we like each other. We ask questions of the right kinds, as convention dictates—where do you live? Do you have children? Are you interested in gardening? (et cetera--  but we save “do you come here often?” for other purposes). The new person may ask similar questions back, in a friendly way, or may not seem interested in us; either way, we find out something about them and begin to figure out what kind of relationship we have. If another adult likes or does the same kinds of things we do, that helps establish whether we’ll get along well or not.

But how do we get to know a baby who doesn’t talk at all or understand much speech? Adoptive and foster parents have this problem to deal with, and on a more limited scale so do child care providers and even new babysitters. Each of these adults needs to know “who the baby is”--  how he or she is unique, and how he or she resembles many other babies. It doesn’t necessarily work well to assume that a particular baby is a “generic baby” who can be cared for in a general “right” way; each baby has biological predispositions to behave in certain ways, and may already have had experiences that have created other personality characteristics. When adults fight against infants’ individual characteristics rather than working with them, the result is likely to be dissatisfaction for everyone involved

How do we identify those individual characteristics? Observation is our only option--  but what to observe? Where to begin? How do we find out what is unique about this baby, and what is like other babies we know?

Here are some questions you might want to ask about any baby you are trying to get to know:

1. Does the baby like to be held? Does the baby arch or stiffen his body when held? Does he or she push or pull away when held? Does the baby cry when held? Snuggle in when held? Calm down quickly when held? Act different with some people than with others?
2. Is the baby comfortable being moved? Does he or she get cranky when moved around in space, or when you change his or her body position? Does the baby cry or look fearful when moved? Does he or she tolerate or like being moved in a circle or held upside-down? Does bouncing around make the baby smile or giggle?
3. Does the baby like movement games or songs? Does the baby seem to look forward happily to someone playing games? Does he or she watch, or turn away when someone starts pat-a-cake or other games? Does he or she participate?
4. Does the baby try new ways to play? Does he or she like for you to play in new ways, or prefer familiar ones? Does the baby pay more attention to new toys or to old ones? Does he or she touch and explore toys, or turn away from them? Does the baby bang or manipulate toys?
5. Does the baby use the mouth for playing? Does he or she avoid mouthing toys or gag when putting a toy in the mouth? Stuff too many toys in the mouth? Chew on toys? Smile or laugh when mouthing toys?
6. Does the baby use the fingertips or the whole hand for play? Does he or she reach for and grab toys? Does the baby hold onto a toy for a minute or two? Does the baby cry when a toy is put into the hand or close the hand to avoid a toy?
7. Does the baby use both hands for play? Does he or she pass a toy from one hand to the other?  Does he  or she use one hand or the other but not put them together? Does he or she reach across the body for a toy or bang two toys together?
8. Does the baby eat strained or solid foods? If so, does he or she sometimes refuse to eat? Does he or she like different food textures, or cry or gag when new textures like lumpy foods are given? Does he or she have strong likes and dislikes about foods?
9. Does the baby seem to like having more than one form of stimulation going on? Does he or she seem to “tune out” if there is more than one form of stimulation, like a squeaky ball with a rough texture? Does he or she fall asleep or cry if too many things are going on?
10. Does the baby seem to like all kinds of stimulation—sights, sounds, and touches?  Does the baby avoid toys with certain textures? Does he or she seem to like to look at bright colors, or prefer to look at plain or quiet sights?
11. Does the baby go to sleep easily? Can he or she fall asleep in many different places? Does he or she need to be rocked, cuddled, or bounced for a long time before going to sleep?
12. Does the baby calm easily after an upset? Does he or she go on crying even though rocked and cuddled, and does the crying go on for an hour or more?

All these questions together will help an adult come to understand the unique individual personality of a baby. In addition, if you know the answers, you will have an idea of the baby’s normal “baseline”--  the ways he or she usually acts. Knowing that baseline will let you know whether  something unusual is going on and whether the baby is getting sick or is disturbed by some event. It also lets the adult caregiver understand that when a baby reacts negatively, this often has to do with the baby’s own personality and is not a judgment of the success or failure of the caregiver.

The answers to these questions don’t let us “prescribe” the right way of caring for a baby. However, they do let us avoid some things that cause negative reactions in the baby, and to seek out as much as possible things that lead to positive reactions. This does not mean that the baby will never in its life have to experience things it doesn’t like! It does mean, however, that we can choose as much as possible to make the baby happy and to make ourselves happy because the baby is happy—thus building the best possible emotional relationship between us.

More on Those Lying Little Liars:Maturing and Learning Until They Lie Well

A while ago, at http://childmyths.blogspot.com/2013/05/when-children-lie-evade-misrepresentor.html, I pointed out that it takes a good deal of cognitive ability for a child to tell a convincing lie. Lying is a skill that develops through a combination of maturation and learning. It is a real part of typical development and does not indicate that the child is emotionally disturbed. Naturally, parents would like their children not to evade or attempt to deceive them--  but equally naturally, they would like the children to tell appropriate social lies (“Oh, Grandma, I love these purple socks with sky-blue pink polka dots--  nobody else has anything like them!”). Lying has a conventional aspect as well as a cognitive one.

When we think about lying, it’s all too easy to confuse the cognitive skills involved in an effective lie with the moral development that forbids lies under some (but certainly not all) circumstances. When people lie, they may or not be breaking moral codes. Understanding when lying is immoral and when it is not is a complicated matter and takes experience and maturation to master. If I go to a dinner party and tell the hostess I like the salad when I actually find it disgusting, few would say that lie was an immoral one; they would be more likely to say that it was at least rude, perhaps even unnecessarily cruel (and therefore perhaps immoral), if I confessed what I really thought. On the other hand, if a friend of mine is arrested for theft, and I state that she was with me at the time even though she wasn’t, my lie, although kind to my friend, would be both illegal and immoral because it could lead to the conviction of an innocent person and other bad outcomes.  (This all just goes to show that the idea of “learning right from wrong” is an enormous over-simplification.)  

So, lying, or choosing not to lie , is partly a matter of cognitive skills that help a child decide what’s likely to be believed and what will happen if he or she is or is not believed. But development of those skills happens in parallel with the learning of conventions about lying and truth-telling and with the development of moral decision-making.

In an article in Child Development Perspectives, Kang Lee of the University of Toronto recently discussed the developmental trajectory of lying in typically-developing children (Little liars: Development of verbal deception in children. 2013, Vol. 7, pp. 85-90).  Among other things, Lee looked at existing evidence about children’s lies in two situations--  when they were caught after having done something wrong, and when they needed  to back up a lie they had already told. Only about 30% of 2-year-olds lied to cover their transgression, but by age 6 more than 80% of children did so.  When they had lied (in an experimental situation, where they had been told not to peek at a hidden toy), 2- and 3-year-olds often denied that they had peeked, but then blurted out “Barney!” (correctly) when asked what they thought the toy was. Older children got gradually better at covering up, but were initially clumsy; Lee reported that one 5-year-old said she didn’t look, but felt the toy, and it “felt purple” so she knew it was Barney.

Lee also described the nonverbal behavior of lying children, and noted that when they lie deliberately, they often mimic “truth-telling” behavior, by making direct eye contact in some situations, and by averting their eyes (as if trying to remember) in others.  These are behaviors that are likely to be much influenced by culture and convention, and Lee’s discussion emphasized the role of cultural expectations in determining how children use “white” or “social” lies. Preschoolers disapprove somewhat of social lies, but when they reach adolescence, after years of instruction and modeling by adults, they see such lies as a positive contribution to social interactions.

It’s obvious that most children lie and that skill in lying is evidence of continuing cognitive development. Paradoxically, although we say that lying is wrong and don’t like to have children do it, we may also need to think of some aspects of lying as positive signs of moral development and empathy. When lying is excessive or appears unnecessary or even foolish to adults, we need to examine the social context, the child’s understanding and intentions, and the child’s expectations based on family and cultural rules. There’s no need to jump to the conclusion that childhood lying is a symptom of mental illness or of character flaws greater than those most human beings display.

An interesting question that has not received much exploration is this: at what age do children know that we are lying to them? Does the subject make a difference?  When they discover that the story about Santa wasn’t true, and that the sick kitten did not go to live with its grandma, do they also come to suspect that other things we say are less than truthful? As is so often the case, it’s what we do rather than what we say that sets the standard.

Apples, Oranges, Red Herrings, and Russian Adoptees' Deaths

In the articles by Tina Traster that I commented on a few days ago, and in many other recent places like http://www.csmonitor.com/World/Europe/2013/0304/As-emotions-over-US-Russia-adoptions-intensify-a-rift-widens-into-a-chasm, writers have stated that the proportion of adopted children who have died of abuse or neglect in Russia is greater than the proportion of children adopted from Russia who have died similarly in the United States.

It’s very reasonable to compare those two proportions rather than simply looking at absolute numbers of deaths in the United States. It’s well understood, unfortunately, that there are some populations (like physically handicapped children) that are at greater risk for abuse or neglect than others. If we could identify Russian adoptees as such a population, we might be able to focus help and resources for their adopted families in ways that would help prevent abuse and neglect at all levels--  not just the amount that is likely to be fatal. This would be a good idea for both Russian and U.S. adoptive families.

But how do we make this comparison? First we have to decide whether a particular comparison would be looking at “apples and apples” or “apples and oranges”. This is not necessarily easy to do, and different comparisons can give us different answers.

One approach would be to look at how Russian adoptee deaths in the U.S. compare to mortality rates for all children in the U.S. There are records of adoptions from Russia to the United States , estimated at about 60,000 children over the last twenty years. Of these, 19 have been documented as dying under circumstances characterized as neglect or abuse. (I believe that it is simply sensationalism to describe such deaths as all having been “at the parents’ hands). The number of deaths considered to be from natural causes or as the result of accidental injury has not been publicized, but it is possible that in that number are “hidden” deaths that might have been more accurately assessed as due to neglect or abuse. I might point out, too, that the custom of changing adopted children’s birth certificates to show their adoptive parents as birth parents may prevent identification of a dead child as being Russian-born, and unless the parents disclose the circumstances, a child adopted as an infant may not have been known as an adoptee. In any case, given the documented cases alone, the rate appears to be about .33 deaths per 1000 adoptions. The mortality rate for children from birth to 19 years in the United States is about 18 deaths due to accident or homicide per 100,000 , or .18 per 1000 , a little over half the rate of deaths of Russian adoptees. For homicide alone, the rate is about .04 per 1000.  (The figures I am using here do not show deaths from neglect, but this is the best I can do, I think.) So, it does appear that Russian adoptees have died at a higher rate  from non-natural causes than all children in the U.S.

How about the comparison of Russian adoptee deaths in the United States to Russian adoptee deaths in Russia? Again and again, journalists have stated that 170,000 Russian children were adopted by Russian families in about the last twenty years, and that 1220 died from abuse or neglect. This would obviously be a high death rate and strikingly different from the death rate reported for Russian adoptees in the U.S. But the figure 1220 seems to have come from an erroneous or ambiguous reading of a document (http://www.usynovite.ru/f/experience/book/book.doc) that refers to records of a preliminary study on deaths of children and incidents of ill treatment of orphans, with 12 out of 1220 dying in situations where guardians or adopters were at fault. There were also 116 who were seriously harmed, with 23 of those suffering harm through the fault of their caregivers. But who were the 1220 we began with? It is far from clear whether they were a group who were all harmed in some way, or whether they were simply a population sample drawn in an attempt to understand rates of harm without investigating all 170,000 cases. Whichever it  may be, it’s clear that any calculation of rates based on these data is what we call a PFA number – Pulled From the Air. There’s no easy way to tell whether this number represents apples, oranges, or some other comparison fruit.

At the beginning of this post, I suggested that making appropriate comparisons could be a way of deciding whether groups of children were for some reason at unusually high risk for mistreatment or other problems when in adoptive families. Knowing that risk factors were present could enable us to channel extra help to those families and to perhaps to prevent some problems. But I don’t think the intentionl of various journalists has been to make comparisons in order to reach that goal. Rather than dealing with apples and oranges, I think most of this discussion has actually been about red herrings. Rather than considering why Russian adoptees have died of abuse and neglect in the United States, some journalists have done their best to distract from the real issue by concentrating on blaming the children, the orphanages, Russian adoptive families, the Magnitsky Act, etc.

Let’s get back to the actual problem. The deaths of Russian adoptees are only one facet of the problem of systematic maltreatment of children, whether adopted from abroad or from the U.S., or whether oppositional or in some other way displeasing to their parents. Such maltreatment can result from mistaken beliefs about early development like those espoused by Tina Traster. We need to stop apportioning blame and start examining with care the expectations that adoptive parents carry into their new relationships. Only in that way can we begin to prevent more family tragedies.