SIDS, Outcome Research, and Proxy Measures

I mentioned a few days ago that Ed Clint of Skeptic Ink had objected to my comments on the research evidence behind the Back to Sleep/Safe to Sleep campaign to have parents put young babies in the supine position for sleep. Without concluding that a particular position was safest for infant sleep, I had queried whether the epidemiological research available actually provided evidence that supine sleeping reduces the rate of Sudden Infant Death Syndrome, as has been claimed. Now Ed has posted his own take on the situation, at http://www.skepticink.com/health/2014/12/11/back-sleepsafe-sleep-saveschildrens-lives/.

In his post, Ed included a familiar graph that shows 1.4 SIDS deaths for every 1000 live births in 1988, a gradual decline to 1.2 SIDS deaths per 1000 in 1992, the first year of the American Academy of Pediatrics recommendation for supine sleeping position, a reduction to 1.03 per 1000 in 1994, the first year of the Back to Sleep campaign, and then a continuing gradual reduction to a rate of 0.55 per 1000 in 2006. The graph also indicates changes in proportions of parents using prone or supine sleeping positions for their infants. From 13 % sleeping supine in 1992, this figure gradually rises to 75% in 2006.

This graph looks pretty significant, doesn’t it? Ignoring the fact that the rate of SIDS deaths was already decreasing before any recommendations for supine sleeping occurred, we see that the increase in the proportion of babies sleeping supine is accompanied by a decrease in SIDS deaths. It’s easy to assume that one caused the other… but of course the graph doesn’t show everything that could be affecting the SIDS rate. What other factors should we be looking at?

There are quite a few factors other than sleeping position that are associated with a lower or higher SIDS rate. Let’s just look at one of them—a variable about which much research has been done : tobacco smoking. Maternal smoking during and after pregnancy is known to be associated with a higher risk of SIDS. So, what has been happening about smoking during this period when the SIDS rate has been dropping? You can see this on slide 7 at www.cdc.gov/winnablebattles/tobacco/ppt/tobacco_wb_presentation_-oct2014_rev_508compliant.pptx. For those readers who hate trying to read graphs, I’ll describe what it shows: Between 1990 and 2010, a period roughly equivalent to the time shown on the SIDS and sleeping position graph, there was a reduction in cigarette smoking in the United States, from 3000 cigarettes per capita per year in 1990, to about 1000 in 2010. If we were to draw a new graph showing the relationship between SIDS and smoking, it would look very much like the association between supine sleeping and SIDS (only reversed, so that less smoking goes with less SIDS, whereas less SIDS goes with more supine sleeping, less prone sleeping).

Assuming for the sake of argument that SIDS is caused primarily by one of these two factors (which might not be the case), we apparently need to ask which one it is. The graphic representation of the relationships between SIDS and each of the factors look just alike. If we are going to have a campaign to reduce the SIDS rate, and we are going to tell people to do just one thing, which will it be--  don’t smoke, or don’t have the baby sleep prone? The figures don’t, and indeed can’t, answer this question, and can’t even tell us whether our two candidate factors are the only important ones. The choice is made for other reasons, and this is why I said that this kind of policy is in fact not strictly speaking science-based.

But let’s look a bit at the issue of whether either smoking or sleeping position is actually at work in affecting the SIDS rate. The problem with epidemiological research is that the factors looked at may be only proxy measures that are markers for the existence of some other factor that is more difficult to measure. Take, for example, a study that looked at (among other things) the effect of socioeconomic status on SIDS rates (Gelb, Aerts, & Nunes (2006). Sleep practices and sudden infant death syndrome: A new proposal for scoring risk factors. Sleep, 29, 1288-1294). Rather than do an elaborate and intrusive investigation into a family’s income and property to decide SES, these authors used maternal education as a proxy measure for SES, assuming that high maternal education is more likely among affluent families. Low maternal education was associated with the use of a set of high-risk sleeping practices, including not only prone position but soft bedding and allowing the child’s head to be covered during sleep. Young mothers and smoking mothers were more likely to use high-risk sleep practices, as were mothers who had fewer prenatal doctor visits. The mothers’ practices and their other characteristics were confounded in such a way that it was difficult to know what factor caused any outcome.

Proxy measures can be useful shortcuts to measurements that are hard to do. However, it’s important to remember that any factor chosen may in fact be a proxy measure that is determined by some background factor that is unnamed.  When parents choose to comply with advice about supine sleeping, is the factor that influences SIDS sleeping position itself, or is this just a proxy marker for parental characteristics such as carefulness, compliance with rules, middle-class status, education, and affluence? As developmental psychologists have proposed with respect to other topics, it may be that “good things go together” and that we don’t know which “good thing" is at work.

Choosing one “good thing” to work on may allow a simple campaign to be developed, but, once again, that choice is not based on clear scientific evidence about SIDS.

N.B. The point here is not to advise about infant sleeping positions, but to discuss the complexities of extracting helpful advice out of the available information.

Mistaken Attachment Beliefs, Persuasion, and "Trojan Horses"

I’ve been trying to figure out a name for a persuasive technique. Here’s an example: at www.imt.ie/clinical/2014/12/attachment-disorder-children.html, the authors Arshad and FitzGerald provide a good deal of well-substantiated information about children’s emotional attachment to their parents. They describe different qualities of attachment and refer to stages of attachment as they occur in the course of early development.

But now the trouble begins. Forgetting or ignoring the fact that insecure attachment is perhaps not ideal, but is within the normal range rather than pathological, these authors make the following statements: “Reactive attachment disorder is a severe form of insecure attachment, with symptoms of emotional dysregulation, anger, guilt, impulsive [sic], disinhibition, aggression, hostility, reactive [sic], proactive [sic], impulsiveness, stealing, hypervigilance, aggressive, withdrawn, destructive, temper outbursts, demanding, clinging, sleep problems, enuresis, overfamiliarity with strangers, oppositional, fidgety, poor hygiene, learned helplessness, abnormal eating habits, lack of eye contact, can’t keep friends, blames others for mistakes, mistrustful, manipulative, lack of remorse, irritable, fussy, swears, diffuse boundaries, and jealousy.” Rather than being supported by systematic research evidence, or drawn from any of the DSM discussions of Reactive Attachment Disorder, this symptom list is characteristic of websites like www.reactiveattachmentdisordertreatment.com.

The same technique is evident at www.attachmentnetwork.com and at www.radzebra.org. The latter has separate pages, one with material from DSM-IV and the other with a list of “symptoms” that are certainly concerning (like “fascination with blood and gore”--  by the way, is gore different from blood?) but that are not associated with disorders of attachment. These notional symptoms seem to have been drawn from the non-evidence-based 1996 article by Keith Reber which I discussed recently on this blog.

In the pages and documents I just mentioned, we have several examples of a persuasive technique. Trying to persuade people is not in itself a problem--  that’s something I am doing here, and even a simple presentation of well-founded statements is an effort at persuasion. However, persuasive devices are problematic when the goal is to convince readers that claims are correct, when they are not. It does not really matter whether the persuader is a true believer, has financial goals that depend on persuasion, or sees persuasion as a path to glory. Getting people to think that something is true when it is not is never really the right thing to do. In “wars of propaganda”, like World War II there may be short-term goals of persuasion that can lead to improved long-term outcomes, but even that use of persuasive devices may be based only on a guess as to what a good outcome may be. (Jane Austen’s novel Persuasion gives a good example of the difficulties here).

But what is the particular persuasive device seen in the examples above? It mingles true and false statements, apparently setting up an appeal to the authority of the true statements in order to “spread” that authority to cover the false statements as well. As I have tried to find a name for this device, I’ve found nothing among lists of fallacies or errors of critical thinking that might lead to persuasion in this way. There is such a thing as the fallacy of composition, which is the mistake of assuming that something true of a part of a whole must also be true of the whole, but that doesn’t seem to be exactly what’s going on here. I have found references to the method under the rubric of “disinformation” or intentional spreading of confusion about facts and logic, but no specific label to describe this technique as opposed to other disinformative methods.

Can any reader provide me with a name for a method that mixes true and false claims with the purpose of gaining belief for the false ones? In the absence of any other name known to me, I’m going to call this a “Trojan horse” technique. Presenting the reader with some well-established information, the “Trojan horse” user suggests the verity of ill-founded statements that have the potential to harm those who accept them. That’s certainly what appears to be happening in the examples given earlier, where accepting mistaken beliefs about attachment can lead to mistaken--  in fact, dangerous--  choices about treatment of children.

More About "Back to Sleep": The Neglected "Tummy Time" Part

Yesterday I posted some comments on the complex causes of Sudden Infant Death Syndrome (SIDS) (http://childmyths.blogspot.com/2013/12/sids-sleeping-position-and-single.html). I pointed out that there are many factors that increase the risk of SIDS--  that supine sleeping is not the only one, even though it has received the greatest emphasis by far. I ended that post by referring to adverse events associated with supine sleeping.

One of these unwanted side effects, deformational plagiocephaly, I have written about at http://childmyths.blogspot.com/2014/05/flattened-skulls-helmets-not-much-use.html. Lying in the same position for long periods can flatten an infant’s still-soft skull, which gradually hardens into an asymmetrical shape. Once flattening has begun, the baby’s head naturally turns to place the flattened area down, increasing the extent of flattening. But although the resulting asymmetry can have an effect on ear positions, it does not damage the brain or otherwise cause problems. (As anthropologists have pointed out, there have been many cultures that intentionally bound or flattened baby’s heads to get an appearance that they considered highly attractive.) Still, most parents today would rather their babies did not have flattened or asymmetrical heads, so paying attention to babies’ head positions and varying them is probably a good idea when babies sleep supine.

A more complicated side effect of supine sleeping as currently practiced by many parents is that some early events in motor development are delayed (see Pin, T., Eldridge, B., & Galea,M.P. (2007). “A review of the effects of sleep position, play position, and  equipment use on motor development in infants.” Developmental Medicine & Child Neurology, 11, 856-867.) The review by Pin et al indicated that motor delays are due not simply to supine sleeping in itself, but result from the lack of experience of the prone position during waking time. Here are the conclusions of this review paper: “In healthy infants born at term, those who spent time in prone when awake achieved developmental milestones significantly earlier than those who did not or who spent limited time in prone when awake in the first 6 months of life… Those infants who slept in supine attained developmental milestones significantly slower than the norm… before 6months of age…. most of these healthy infants born at term walked independently or developed within normal age limits. … Low-risk preterm infants who slept in supine attained head control… and rolling between supine and side and bringing hands to midline significantly slower than infants sleeping in prone or non-supine positions. All these preterm born infants walked independently within normal age limits”  (p.865).

Why would experiences with supine or prone positions make a difference to motor development? It’s easy to think that motor development just “automatically” progresses from the top to the bottom of the body, just as we see physical growth proceed in the cephalocaudal direction. But motor development involves both maturation of the nervous system and practice which leads to muscle development. Full-term newborn babies lie in a flexed “fetal” position and need both maturation and appropriate exercise to be able to extend the body. When babies are in the prone position, they can be seen working on this from the first days of life, lifting the head awkwardly and turning it from one side to the other. With arms under them, they soon become able to lift the head briefly to look around. Within a few months they can extend the arms enough to get the shoulders up, then chest up with fully-extended arms. These achievements depend on strengthening the muscles of the neck and shoulders by exercise. Babies who spend most of their time in the supine position will eventually develop muscles and motor skills, but the supine does not provide the same opportunities and challenges for mastery of arm extension as prone does, and it forces the baby to work against the pull of gravity.

Is this phenomenon of motor delays a problem? In one sense, no, it is not. The evidence is that these babies walk and show other motor abilities within a normal age range. This is not very surprising, given evidence about other cultures that limit babies’ movement capacities. Margaret Mead reported in the 1930s that Balinese babies were never permitted to crawl, this being considered “animal-like” and incongruent with the babies’ recent arrival from the divine realms. Yet, the babies walked independently within a normal age range. Similarly, Geoffrey Gorer described the use of swaddling for babies up to a year of age in Russia, but found that the babies walked independently within a normal age range even though they had had very limited experiences of independent movement.

In another sense, though, motor delays may be a problem. A common and effective way of assessing early development involves comparing an infant’s motor skills to norms developed by observing large numbers of babies. But the norms we have now were developed at a time when almost all babies slept prone, so they do not necessarily give a good comparison for babies who sleep supine. These “outmoded” norms make it difficult to know whether a young baby’s development is progressing in a typical way. This may be especially important now that there are reports of slow motor development as a predictor of later communication problems in infants at risk for autism (see Bhat, A.N., Galloway, J.C., & Landa,R.J. [2012]. “Relation between early motor delay and later communication delay in infants at risk for autism.” Infant Behavior & Development, 35, 838-846). The diagnosis of genuine motor delays may be important in more ways than one.

Is there anything that parents can do to encourage good motor development in their supine-sleeping  babies? The first step would be to use “tummy time” regularly and to work with reluctant babies to tolerate and later enjoy the prone position. “Tummy time” may be awkward at first, but the baby’s motivation for mastery of the environment will soon help move the process forward, especially if parents have been given good information about what to do.

  

Is there evidence that “tummy time” or other techniques do any good for motor development? There has been an experimental study showing the effects of a program to encourage motor development (Lobo,M.A., & Galloway, J.C. [2012]. “Enhanced handling and positioning in early infancy advances development throughout the first year.” Child Development, 83, 1290-1302). These authors noted that the prone position is challenging to young infants and that most caregivers tend to avoid it. They taught caregivers in the experimental group to do the following for 15 minutes each day, beginning when the infants were two months old: “placing them on the floor or [on the] caregiver while encouraging them to push up to lift their head.. pulling them up [by the arms] and lowering them down while assisting them to keep the head in line with their body…supporting them in sitting and standing while encouraging them to weight bear and to reorient their body upright with respect to gravity, and… moving their hands to midline for play to encourage a shift from lateral to more midline arm placement” (p. 1292). Caregivers in the control group put their babies in the supine position and played face-to-face with them for 15 minutes a day. The caregivers in both groups continued their activities for three weeks.

The  babies in the experimental group were earlier than the control babies in their achievement of reaching for an object at the midline, transferring objects from one hand to the other, creeping on hands and knees, walking with support, and walking independently. This intervention apparently counteracted the motor delays associated with supine sleeping.

I think an important point about the success of the handling and positioning intervention is that caregivers were carefully taught what to do with the babies. They were provided with an illustrated manual and a diary to record their activities with the babies. In addition, activities were suggested other than simple prone positioning--  the prone position being especially feared by parents who know that SIDS risk is much higher when babies who are accustomed to supine sleep are placed in prone. The usual casual admonition to ”do tummy time” does not convey much information to caregivers, and new parents who delay prone positioning until their baby is three or four months old will probably find that the baby objects strongly to an unaccustomed position, a situation that further discourages anything but supine positioning.

Perhaps an appropriate change in the “back-to-sleep” mantra would be “Back to Sleep; Tummy to Be Played With”.  Young babies don’t exactly play by themselves, but as the song says they can remind us how to play, and our mutual enjoyment can encourage good motor development.

     

SIDS, Sleeping Position, and Single-factor Theories

I had a disagreement last week with www.skepticink.com. I had submitted, and a moderator had  posted, a piece discussing whether the research evidence actually supports the idea that the use of supine sleeping positions for young babies is the cause of a reduction in Sudden Infant Death Syndrome (SIDS) over the last 20 years. People at skepticink apparently thought it was dangerous to babies even to talk about this possibility, took down my post, and have been unwilling to discuss the issue with me. As for me, my opinion is that it is dangerous to refuse to discuss controversial questions. If I had proposed that parents switch babies used to supine sleep over to a prone sleep position, that would have been dangerous, as it increases the risk of SIDS dramatically (see “The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk” (2005), Pediatrics, 116, 1245-1255), but I did not do that, nor give any other recommendations about sleeping conditions.

My attention was  called back to this issue by an article in the New York Times (Saint Louis, C.,
“Federal study finds 55 percent of infants sleep with soft bedding, raising risk of death “, Dec. 1, 2014, p. A21 , reporting on a recent article in Pediatrics. The study used data from the 1993-2010 National Infants Sleep Position Study, which interviewed about 19,000 parents by telephone and examined changes in sleep practices year by year. The study reported that the use of soft bedding, blankets, and pillows, decreased by 23% between 1993 and 2000, but has not decreased much further, with 55% of infants in the United States still experiencing this known SIDS risk factor.

Could the problem here be that most of us, unless we try quite hard, tend to select one factor that we think causes an outcome, and to ignore all the other related factors? Few medical or developmental events have a single cause, so we are likely to be mistaken if we concentrate too hard on one factor. In addition, the great majority of developmental events are not only caused by more than one factor, they are also influenced by the ways those factors interact with each other--  the whole of the causes being rather more than the sum of their parts. Causes thus become too complex to lend themselves to easy solutions or slogans, but we tend to choose easy solutions anyway, even though that choice can make us neglect other important points.

From the earliest research on SIDS, it’s been clear that although prone sleeping position appears to play a role in sudden infant deaths, there is a list of further factors that have important effects. These are discussed in some detail in the 2005 Pediatrics article I mentioned earlier, so I will just list them: the use of soft bedding (an important point in the early New Zealand research on SIDS), exposure to tobacco smoke, failure to immunize, failure to breastfeed, failure to use pacifiers, overheating, premature birth and/or low birth weight.  Yet, as the recent study showed, the use of soft bedding continues; resistance to immunization is still present and even fostered by state laws supporting parental choice in medical care; smoking remains common in some populations, especially among the young mothers whose babies may have additional SIDS risk factors. As for the use of pacifiers, which would be an easy recommendation to make and carry out, there is still a sense of repugnance about them and a feeling that parents who give a pacifier have somehow failed.

Given this list of risk factors for SIDS, why is “Back to Sleep” the great recommendation to the public? The slogan sounds good (the baby will go back to sleep if she awakens in the night, it seems to imply) , and it provides a simple solution that appears to make it unnecessary to worry about stopping smoking or deciding to immunize. It’s hard to conceive a similar catchy slogan for avoiding soft bedding--  “Be Hard on Your Baby” doesn’t really work. Besides, once people have developed a single-factor belief about SIDS, another slogan will probably not catch on.

Please notice: I am not saying that I think babies should sleep in one or the other of the possible positions. I am saying that the claimed success for “Back to Sleep” (and there are reasons to question that success) may have occurred at the expense of forgetting about other SIDS risk factors.

I also want to comment on a nonfatal but problematic outcome of “Back to Sleep”. Parents who use the supine sleep position for their babies most often do not do the second part: “Tummy to Play”.  As a result, there have been considerable increases in the incidence of head shapes made asymmetrical by a baby’s constant lying position, and a tendency to delays in motor development milestones. I will be commenting on those issues in the next few days.

N.B. I now see that on Facebook Ed Clint of Healthy Skeptic has said that my statements about SIDS and sleeping position are comparable to someone without good evidence saying that all the statements of climate scientists are wrong. No, actually, what it's like is a student of the climate saying that more factors than human activity are responsible for global warming, and in order to understand the impact of human actions we must take into account what the other factors are and how they operate.   

5/20/15: For anyone who thinks I am way out of line to look at diagnostic categories as an issue here, you might have a look at https://eliminatechildabusefatalities_sites.usa.gov/files/2014/05/Transcript-Tampa-FINAL.pdf,  pp 11-12.

Children, Faith-healing, and Religious Exemptions

Do your state laws protect parents who allow their children to die without medical care because of their religious beliefs? Until recently I was not sure how this question should be answered for my own state--  and just as a reminder for readers  outside the U.S., the 50 states have differing laws on many topics, so knowing one state’s position does not tell you what happens in other states.

Ordinarily, a failure to provide medical care for a child when it is desperately needed would be considered a criminal matter of neglect and abuse. Civil suits against the parents might also be a possibility. But some states provide religious exemptions to parents who cite religious beliefs such as commitment to the power of prayer as justification for a failure to seek medical care for a child. As far as these parents are concerned, prayer or similar activities are the treatment they should give, and in fact to do otherwise indicates the weakness of their faith in God and endangers their souls and those of their children.

I’m indebted for information about this to CHILD, Inc. (www.childrenshealthcare.org), and to a map displaying the legal positions of the states at www.vocativ.com/culture/religion/faith-healing-deaths/?page=all . (This map is based on data drawn from childrenshealthcare.org.)

You can probably look at the map graphic yourself, but I am going to describe the similar positions taken by groups of states. By the way, as you will see, this does not play out geographically exactly as one might guess.

Let me point out first that six states allow no religious exemptions to either criminal or civil charges involving abuse and neglect. These forward-thinking states are the following: Hawaii, Oregon, Nebraska, North Carolina, Maryland, and Massachusetts. (Boo, New Jersey! I had expected better of you!)

Twelve states allow no criminal exemptions, but they do allow religious exemptions in the case of civil suits resulting from neglect or abuse of children. Exemptions in civil suits may discourage child protective services from pursuing a case at the civil level, which requires a less stringent proof than criminal cases do. The states that allow these religious exemptions to civil suits are these: New Mexico, Arizona, Montana, Wyoming, North Dakota, Michigan, Illinois, Kentucky, Pennsylvania, Connecticut, Vermont, and Florida. Parents who fail to provide medical care to very sick children for religious reasons are liable for criminal prosecution, which has a high standard of proof, but not for civil actions, with their lower standard.

Fourteen states allow religious exemptions only in criminal cases involving misdemeanors like a non-felony level of child endangerment, not in cases of murder or manslaughter. These states are: California, Nevada, Colorado, South Dakota, Kansas, Missouri, Mississippi, Alabama, Georgia, South Carolina, New York, New Hampshire, and Maine.  In those states, there are no religious exemptions for civil suits related to incidents of neglect or abuse.

Nine states allow religious exemptions to prosecution for felony crimes against children, in which sexual assaults are included, as are child endangerment and neglect. These states are: Washington, Utah, Texas, Oklahoma, Minnesota, Wisconsin, Illinois, Tennessee, West Virginia, New Jersey, and Rhode Island.

Finally, almost unbelievably, there are six states that allow religious exemptions to prosecution for negligent homicide, manslaughter, and even capital murder. These are: Idaho, Iowa, Arkansas, Louisiana, Ohio, and Indiana.

The reasons for the broad religious exemptions in this last group of states presumably have to do with the proportion of their populations who want to choose faith-healing over standard medical care, probably for themselves, but most relevantly for their children. The most obvious community for these people to belong to is Christian Science, but there are a wide variety of other faith-healing-oriented groups like Followers of Christ or Church of the First Born. Charismatic churches in general are committed to the principle that once “born again”, Christians can have access to the gifts of the Holy Spirit, including discernment (diagnosis) and exorcism or deliverance (expulsion of the demons responsible for both physical and mental illness). Like other people, these groups of believers are attracted to areas where there are many of their co-religionists, and as they increase in number move into a position where they can influence state laws. In addition, of course, once laws have created religious exemptions for child abuse and neglect, even more such believers will arrive. This process helps to establish the polarization responsible for the current “culture wars” in the U.S.

One more point: this blog usually focuses on issues that have to do with child development from a psychological viewpoint. Do religious exemptions to abuse and neglect charges play a role in those issues? I think they probably do, although child deaths are much less likely even in alternative psychotherapies than they are in cases of medical need. However, injuries short of fatality may still be considered abusive. Religious views seem implicated in the apparent use of Attachment Therapy at the Seventh Day Adventist school, Miracle Meadows, in West Virginia (see above, by the way). There is considerable overlap between the authoritarian views held by some religious groups and those held by practitioners of Attachment Therapy. If practitioners or parents claim that religious beliefs are the justification of child mistreatment as a psychotherapeutic or educational method , there are a number of states in which this reasoning will help them evade prosecution.

There was little discussion of these issues during the successful efforts to ban “conversion therapy” in California and New Jersey. This may have been because only mental health professionals are prohibited from doing this treatment, and then the ban involves minor clients only. Parents and clergypersons can go ahead and use “conversion therapy” if they want to--- but perhaps one day an affected minor will grow up able to prove that he or she was harmed, and we will see whether courts accept the religious exemption then.  

   

That Reber Paper, Attachment Therapy, and Darkening Counsel

Everybody is busy nowadays, and even mental health professionals who should know better sometimes skimp on careful reading of articles that they later quote or reference. Occasionally they make other hurried mistakes like drawing a bibliography from an article without carefully examining the papers that are included. There are worse things to do, you say? Yes, that is surely true – but unfortunately these careless practices can bring misinformation into the mainstream and encourage beliefs and actions that are indeed worse.

A case in point: an article from the 1990s that conveys dozens of erroneous statements about attachment, attachment disorders, and Attachment Therapy has been cited repeatedly, by authors and editors whose positions give them great influence. The article in question is by Keith Reber (1996), “Children at risk for reactive attachment disorder: Assessment, diagnosis,and treatment.” Progress: Family Systems Research and Therapy, 5, 83-98. (Progress was and perhaps still is a publication of the Phillips Graduate Institute in Encino, CA, one of the freestanding mental health training organizations, unaccredited outside the state,  that appeared in California in the 1970s.) Reber’s paper has been cited many times, and has even formed part of the training of lawyers who will serve as guardians as litem for children; a paper on mental health needs of dependent children references Reber (http://guardianadlitem.org/Practice_Manual_files/PDFs/Ch17_MENTAL_HEALTH_NEEDS_OF_DEPENDENT_CHILDREN.pdf).

Yet, almost everything Keith Reber said in that 1996 paper is wrong, and not just wrong, but wrong in ways that are potentially harmful to children and families. So what did he say? I’m going to quote and comment on a number of points, but I have to say that this paper, once easily found on the Internet, is now not to be found there. I have a copy and will forward it to readers who give me an e-mail address.

To begin at the beginning, Reber believed that the emotional attachment of a child to a parent begins before birth as a “connectedness in utero…Attachment begins before birth on a neurological and emotional level. “ In addition to the effects of neurochemicals and hormones on the child, Reber stated that the mother’s attitudes before birth affect the child’s attachment.( It is difficult to quote only a small part of these remarks without losing the effect of the logical jumps of the original, but Reber in a single sentence linked the claims of Verney that unborn children are conscious and aware with the statement of Fahlberg that attachment influences the sense of self. ) However, these statements by Reber are without empirical support in spite of the numerous unrelated citations he provides, and in fact all the evidence tells us that attachment—as discussed and defined by Bowlby and many others--  does not occur  until some months after birth, and develops as a result of social interactions. To assume that Reber’s statements were correct is to open the door to a host of unjustified fears on the part of adoptive families, and to suggest to them that harmful treatments like Attachment Therapy are necessary for them.

Naming some frequent forms of social interaction between parents and babies, Reber stated that when these are absent, infants “can lose interest in the world, become ‘insecure’ or ‘anxiously attached’, or even die”.  No doubt there is a little truth to this last claim, because social interactions so often occur in the context of daily care routines, and where there are few social interactions, the chances are that daily care activities are missing too. It’s also likely that in the absence of normal social interactions, infants may fail to engage with either people or objects. But how do these serious consequences parallel insecure or anxious attachment? Although these qualities of attachment are not ideal, they are nevertheless well within the normal range and are not related either to a disengaged, autistic style, or to unexplained death. Reber appears to have been determined to attribute all unwanted outcomes to attachment problems.

Now, I need to quote an entire paragraph from Reber’s paper (but I will omit citations to save space): “After birth there are several specific child behaviors and maternal responses that need to take place in order for the child to develop normal attachment… The child behaviors include crying, smiling, clinging, rooting, postural adjustment, and vocalization, and are exhibited by children a few days after birth… They are goal-oriented… and are the child’s way of making contact and encouraging the caregiver to respond to him. When a caregiver meets the expressed needs of a child, the child begins to experience trust. This process is often called the Trust Cycle. There is some disagreement, however, about whether or not these behaviors need to take place immediately after birth…”

Let’s examine the statements in this paragraph. First, Reber seems to have had some uncertainty about whether some necessary child behaviors occur a few days after birth, or whether they need to take place immediately after birth in order for attachment to occur. The basic problem here seems to be that Reber was not sure whether he was talking about bonding, the adult’s intense positive response to the baby (at one time erroneously thought to occur only within a brief sensitive period following birth), or about attachment, the baby’s gradually developing desire to maintain proximity to the familiar caregiver. The child behaviors described are certainly attractive to caregivers, and the caregiver’s responses both demonstrate adult bonding to the child and help to facilitate the gradual development of the child’s attachment to the adult. However, Reber was so concerned with early behavior that he barely mentioned the adult social responses that do indeed support the child’s attachment to a familiar person and which need to continue over many months before attachment is apparent. Instead, he seems to have attributed attachment (or trust--  which he seems to have thought to be the same thing) to gratification of needs, as in the old Freudian “cupboard love” principle. As for the proposed process “often” being called the Trust Cycle, I suggest that readers Google this term and let me know if they can find a single use of either Trust Cycle or Attachment Cycle outside the writings of Attachment Therapy proponents. (In fact, you will see that the great majority of references to this involve the National Trust and cycle paths.)

Reber continued his discussion with the statement that “Attachments run along a continuum between securely attached and unattached, with the normal child falling somewhere in the middle” ( as statement he references to the AT proponents Magid and McKelvey). Now, interestingly enough, there is an ongoing discussion among students  of attachment as to whether attachment behaviors can in fact be ranked on a continuum, and whether we might fruitfully regard secure attachment as “more of something” than insecure attachment of various kinds. However, most writers who discuss attachment assume that there is no continuum, but rather several attachment patterns that are qualitatively different from each other. This was the view taken by Mary Ainsworth in her studies during the 1970s, but she and more recent researchers have not usually considered either an “unattached” pattern or the “disorganized” pattern described by Mary Main and others. The three basic attachment patterns were all considered to be  aspects of typical development. In any case, Reber’s reference to a continuum from secure to unattached  with the normal child in the middle would seem to assign the “normal child” to an anxious or insecure position, which Reber earlier classed as a risk with disengagement and even death.

Are any readers still with me? This is a very trying task, isn’t it? But I’m afraid it’s all too much worth doing because of the role Reber’s paper has played in providing misinformation and obfuscation to people who want a quick read on attachment and Reactive Attachment Disorder. Still, I will just mention two other points about the paper.

Let me take one sentence from a paragraph on the third page of Reber’s paper. He says, “The tie in between abuse and attachment disorder is supported by the work of Cicchetti and Barnett (1991) who classify eighty percent of maltreated infants as having insecure/ambivalent attachment.” But---  one moment, please. How did we get from attachment disorder to insecure/ambivalent attachment? Insecure attachment is not ideal, but is one of the normal patterns of attachment originally described by Mary Ainsworth in her studies of normal populations. It is not an attachment disorder, and certainly not Reactive Attachment Disorder as defined by any version of DSM. Reber has conflated a normal attachment pattern with a psychiatric disorder and has thus provided a source for confused thinking about attachment issues, a source that will continue to function until mental health professionals have learned to dismiss his paper as worse than useless.

Now, a final point about the paper, before I go on to report some facts about its author. In spite of just having provided the then-current DSM description of Reactive Attachment Disorder, Reber gave a table that is supposed to guide diagnosis of RAD on completely different grounds than those referenced in DSM. Anyone who has read the writings of Attachment Therapy advocates will recognize the symptoms that Reber wants to have diagnosed as RAD. These include all the usual: superficially engaging, no eye contact, fights for control over everything, affectionate with strangers but not parents, cruel, hoards food,  fascinated with blood and gore, lacks cause and effect thinking, has abnormal speech patterns, etc.,etc. The actual sources of these items are probably to be found in a psychopathy scale created decades ago by Hare, but Reber attributes them to the files of the Family Attachment Center in Salt Lake City. But this is as far as his attribution goes. He does not deal with the obvious unanswered questions: how many children were seen at this center in total? How were the claimed symptoms assessed? What proportion of children had each symptom? And, rather importantly, what information was used to connect any of the symptoms to any attachment behavior or attachment history? In the absence of answers to these questions, it seems most likely that these claims were created more or less out of the whole cloth--  yet poorly trained mental health professionals and many journalists have happily accepted them, and like Reber have seen them as justification for the use of Holding Therapy..

Does Keith Reber still make the same claims? Who was or is he, anyway? As far as I know, he has never published another paper, but he seems to have kept the same belief system. Trained as a marriage and family therapist, he probably received little instruction on the actual development of attachment, but instead was easily convinced by the AT proponents he quotes in his paper. His continued use of Holding Therapy caused his professional license to be revoked in Oregon  (www.oregon.gov/oblpct/BoardAction/Reber.pdf). In 2003, the Utah Division of Professional Licensing asked a state judge to order Reber to cease practicing at a clinic that had been associated with the death of a child (www.deseretnews.com/article/1001664/Orem-therapist-lost-license-over-controversial-methods.html?pg=all). He would now seem to be a hearing aid salesman in Provo, UT.

Whether because of carelessness or genuine misunderstanding, Reber’s 1996 paper—which might have been expected never to be read--  has had an extraordinary  and highly negative impact on public understanding of Reactive Attachment Disorder. When I see this paper in any list of references, I immediately question whether the author of the citing material has any real knowledge of the subject. Sometimes people have apologized to me about citing Reber and have confessed that they simply copied someone else’s reference list. Others presumably actually believe Reber’s claims.

Parents, journalists, and mental health professionals, I ask you to recognize the Reber paper for what it is and to stop using it as a source. For the sake of children and families, let that publication die a well-deserved death and proceed to the obscurity that should have been its original fate!

Debunking Da Bunk: A Discussion of James Van Praagh and His Claims

I was greatly surprised a few weeks ago when I saw that my pre-retirement college, Richard Stockton College, was having an appearance in its Performing Arts Center of the “medium” James Van Praagh. Though I recognized the privileges of freedom of speech that belong to Van Praagh, Stockton, and everybody else in this country, I was disturbed and offended by the college’s allowing this performance without any analytical or contradictory discussion. Like many other colleges today, Stockton is emphasizing critical thinking skills, and it seemed to me that to have Van P’s show, and nothing else, was really a failure to model such skills for students.

I put out a message to college faculty and staff, stating my position and asking whether anyone wanted to have a panel, discussion, “teach-in”, whatever you might want to call it. Feelings about this appeared to run high, but with a wide range of opinions, from those who shared my concerns to those who thought it was silly or even puritanical to criticize what was advertised as a “fun afternoon”. Nevertheless, some people stepped forward as willing to speak in public about their opinions of Van P, mediumship, and spiritualism in general.

The programs for Van P’s performance made very strong claims for his ability to talk to the dead and to bring messages from the dead to the living. (The dead presumably do not need a return service.) According to the program, Van P “is known as a ‘survival evidence medium’, meaning that he provides evidential proof of life after death via detailed messages from the spiritual realms.” I don’t think you can make the claim more plainly than that, nor can you make claims more plainly than Van P’s announcement during the performance that he can see people’s auras and know if they are lying, and that each of us has a colored ribbon from the top of our heads all the way up to a star that has our name on it.

Van P’s performance is presented as evidence that all his statements are correct. He states that a spirit is near him and identifies the age and sex of that person or states a name or an initial letter that may have meaning for someone in the audience. When there is a response from an audience member, Van P then spins out and develops the message by using information the person provides. “He was a man who liked facts”—“Yes, he was a lawyer”--  “You still have some of his law books”—“Yes”—“One is tan with a red top to the pages”--  “Yes!”, et cetera. In one case, however, there was what appeared to be a remarkable “hit” on a fact, which led me to wonder to myself whether there were confederates in the audience. If you’d like to know more about what Van P does, there is a youtube piece about  this showman-shaman: https://www.youtube.com/watch?v=b_1TtZ1tNww.

What I actually want to talk about here is the discussion that followed the performance. I don’t suppose anything was said that has never been said before, but there were one or two points that I did not expect. A number of people from the audience followed us into the discussion room and demanded to know whether we would be “for” or “against”; when I said that was what we were going to talk about, they reversed course and were gone at once. Three people who were apparently believers in mediumship stayed for a short time and one spoke of a previous meeting she had had with Van P, as well as of her contacts with her recently-deceased mother. I appreciated her willingness to give this information. Most of the other participants were current or retired faculty of the college, or students, but Michael Cluff of the South Jersey Humanists was kind enough to come and address humanist concerns about exploitation of the bereaved by self-proclaimed mediums. Others talked about issues like the confirmation bias and poor judgment of probability that plague human thinking about spiritualistic practices.

A question that I did not expect came from a historian of religion, who asked us all why we need to debunk spiritualist beliefs, given, she said, that these must play some role in the culture’s functioning or they would not be there (a side argument almost started on that last bit). This excellent question forced many of us to think hard about the assumption that I and others made: that if it’s bunk, it should be debunked.

It took a while to focus on this issue, as we had all been too busy debunking to think about why we wanted to do it. The first reason was one that had already been mentioned several times--  that those who claim to talk to spirits and bring information to the living may be exploitative and drain the vulnerable of their resources. It was also suggested that for the bereaved to spend their time consulting mediums caused delays in the grief process; however, we did not really know if this was true or even if it had been studied systematically, and there was also some uncertainty as to whether grieving really has to follow the guidelines standardized for it in the Unites States in the last century.

After a while, people began to consider the “slippery slope” concern: that acceptance of an unfounded spiritualistic belief system might make it easier for individuals to accept without evidence other beliefs, leading to practical decisions that might be harmful. One participant pointed out the multimillion-dollar industry making homeopathic medicines--  drugs that are thought by their advocates to impart their “vibrations” to water, so that a highly diluted version is expected to have a more powerful effect than one that is undiluted (the opposite of the usual dose-response relationship). Drugstores stock these, and convinced parents treat their children and themselves with totally ineffectual homeopathic remedies rather than seeking real medical care, creating a potential for harm. Along the same line, I spoke about the issues familiar to some readers of this blog--  the conviction that mothers and unborn babies communicate by telepathy and that the mother’s thoughts of ambivalence about the pregnancy “mark” the baby psychologically, causing adopted children above all to be scarred in ways that cannot be treated with standard psychological or psychiatric care and must be “healed” by unconventional, potentially harmful, treatment.

We were thus able to find practical advantages to effective debunking (although we remained pessimistic about the possibility of actually achieving this with true believers). Still, I continue my commitment to my a priori position:

If it’s bunk, it should be debunked.

And it seems pretty clear to me that Van Praagh’s claims are bunk.   

  

"Her Brain Needs All the Stimulation It Can Get": The Death of Kianna Rudesill

In Illinois, a trial for murder is presently underway. Heather Lamie is accused of having caused the death in 2011 of her 4-year-old foster daughter, Kianna Rudesill (see www.pantagraph.com/news/local/crime-and-courts/live-tweets-from-the-heather-lamie-murder-trial/article_18c5d535-adc8-55a8-8890-fe3d5f3ea.html

and www.pantagraph.com/news/local/crime-and-courts/live-tweets-from-the-heather-lamie-murder-trial/articl_62bf4158-4fbb-5ff1-9900-7c7785c-16b76.html). Kianna died of head injuries that according to medical experts could not have been self-inflicted.

It appears that the defense will call as an expert witness the pediatric forensic pathologist Janice Ophoven. Ophoven has become known for her contributions to the defense of parents accused of killing children. Her testimony shown at www.yorknewstimes.com/news/contracted-doctor-takes-stand-for-defense/article_7a631db0-66b411e2-8a43-001a4bcf887a.html shows her arguments against a conclusion that a parent had nonaccidentally killed a child. She gave similar arguments in the Yhip case in California and the Trevor Smith case in Ontario, both to be found through Google. (The Yhip case is of particular interest if you want to look at this background.)

Until recently, prosecutors and forensic examiners investigating the causes of a child’s death had to work by reverse inference based on bruises and other evidence, to consider how injuries might have come about and what causes were most likely. The actual events leading up to the death, in the previous days and hours, were known only to the accused--  if indeed to them. But today there is a new source of information: the text messages sent and received by the accused during the run-up to the time of death. These may be of much importance in establishing what happened, and in the case of Kianna Rudesill’s death, they appear to say much.

Heather Lamie and her husband Joshua texted to each other about Kianna’s condition, expressing no sympathy about an injury the child appeared to have. The texts included the admonition to respond to Kianna’s being “out of control” by a simple expedient: “Beat her ___”.

Sad and telling as these texts may be, they open a number of important questions. Did these people not understand that their texts could be read later? Or, did they think that it was not important to hide what they said, because they believed they were doing the right thing? If they believed they were doing the right thing, why did they think so? Did they, like the adoptive parents implicated in the death of Nathaniel Craver in York, PA in 2009, have contacts with people who would advise them that they must unbendingly assert their authority over a foster child? Were they instructed that the child was intentionally defying them by failing to comply, and that all methods were acceptable in the fight to save her from herself?

I ask these—clearly speculative--  questions because of a specific text sent to her husband by Heather Lamie. Referring to putting Kianna into the shower, she texted: “Yes it is kind of cold but her brain needs as much stimulation as it can get.” This statement has many implications beyond the obvious message of cruelty.

I think it is quite possible that Heather’s treatment of Kianna was based on recommendations made by proponents of Attachment Therapy, either directly or as passed along by would-be helpful friends and neighbors. These recommendations often confuse social stimulation--  much needed by developing babies--  with sensory stimulation, and assume that intense sensory stimulation of all kinds serves to force brain development. Those making the recommendations also propose that all failures of children to satisfy parents’ wishes are results of poor brain development. The “logical” conclusion of these two assumptions is that sensory stimulation causes improved brain development, improved brain development causes compliance with parents’ wishes, and therefore sensory stimulation ranging from doing jumping jacks to cold showers is beneficial. There is certainly no evidence to this effect, although many occupational therapists and special educators persist in practices like skin brushing because of their commitment to the connection between sensory stimulation, brain changes, and improved behavior. (Interestingly, Jessica Beagley, of hot sauce fame, also put her adopted Russian son in a cold shower and videotaped this to send to “Dr. Phil”; she appears to have been surprised that she was charged with child abuse. She claimed that the boy had Reactive Attachment Disorder, suggesting that she might have been influenced by Attachment Therapy beliefs.)

Heather’s and Joshua’s attitudes toward Kianna, as shown in their texts, were also reminiscent of the views of Nancy Thomas, who has become a spokesperson for Foster Cline and others of the authoritarian Attachment Therapy school of thought. Thomas has recommended assuming that children are lying about injuries, or that they have deliberately hurt themselves in order to cause trouble for adult caregivers. When Kianna’s leg was injured at home, her preschool teachers carried her from place to place during the day. Joshua texted about this, ”If it hurts that bad she can go to bed.” Thomas and other Attachment Therapy authors like Keith Reber have attributed illnesses including vomiting to the intentional actions of children, and have argued that showing sympathy to sick or hurt children is simply allowing oneself to be manipulated and thereby making the children’s mental illness worse. The Lamies may or may not have taken this belief straight from Attachment Therapy, but instead may have shared it as part of the “old-fashioned” way of dealing with children  recounted in many memoirs, especially of those who grew up in the Middle West or West of the United States. Nevertheless, the possible association of their actions with Attachment Therapy needs to be explored, and I hope the prosecutors will realize this.

And what if the Lamies’ actions toward  Kianna did indeed come from a caseworker or therapist adherent of Attachment Therapy? The Lamies will have to take their own responsibility for their actions, but their advisor (if there was one) will not, unless a malpractice complaint is brought, and that is highly unlikely until NASW and other professional organizations face up to their obligations in matters of this kind.

Oct. 7, 2014: Heather Lamie has been convicted on two counts. No caseworker or therapist was charged.

  

A Survivor of Attachment Therapy Speaks

I don't know how to bring some very important comments to this page, so let me ask everyone interested in AT to go to http://childmyths.blogspot.com/2012/03/attachment-therapy-where-are.html, and look at the comments by McKenzie Schmitt.

The post originally asked for accounts of AT by people who had experienced it as children and who felt it had been helpful. There have been none.

Instead, here is an account that speaks volumes about the real nature of the treatment.
 .

Sensory Rooms and Gift Horses

Most people have heard the admonition “not to look a gift horse in the mouth” – in other words, not to query or criticize anything we are given for free. Well, it seems that an organization has provided to some Russian orphanages a small stable of gift horses in the form of “sensory rooms” (http://psypress.ru/psynews/d8484.shtml). Most Russians are not examining the value of these gifts carefully, so I will do it for them.

What are sensory rooms? They are rooms full of equipment that provides sensory stimulation through flashing lights, changing colors, and so on. Google the term and you will find that you can buy one on line for more than $20,000, and it will include the following: an infinity tube, a bubble tube, a LED fiber optic cascade, a projector wireless, color changer, and other bits including a bean bag chair. I don’t know what all those things do exactly, but they are said to change your room into a Multi-Sensory Environment (their caps).

What are sensory rooms for, and why would anyone want to have them? Basically, they are the same kind of thing as “snoezelen” (see http://childmyths.blogspot.com/2011/03/ja-das-ist-ein-snoezelen-bank-or-theres.html). These activity rooms were originally created in the ‘70s for fun, by graduate students in the Netherlands, and I would speculate were planned to make recreational drugs even more recreational. More recently, they have been used with dementia patients and with autistic children--  but without any evidentiary support for the helpfulness of this practice.

Now, the Russian orphanage managers and their donors are assuming that young children in institutional care will benefit in some way from periodic sessions in the sensory room. Once again, there is no empirical evidence to support this idea, so perhaps it would be a good idea to ask where anyone got this notion.

The basic belief behind sensory rooms (and similar treatment) is that human personality and intelligence are shaped by the impact of sensory experience—that infants are “blank slates” whose development and eventual characteristics derive from the sensory experiences they have had. This idea dates back to the French philosophe Condillac, who at the time of the French Revolution put this suggestion forward as relevant to creating good citizens in the post-revolutionary world. J.M.G. Itard, an admirer of Condillac, used this approach as he attempted (unsuccessfully) to work with the “wild boy of Aveyron”, an apparently feral, language-less boy who was about 12 when “caught”. Itard used a variety of sensory stimuli such as massage and the production of different sounds in his efforts to produce in the “wild boy” more normal levels of ability, which of course Itard assumed to develop in most people as a result of the sensory experiences of which the “wild boy” had been deprived. Similar approaches were taken later in the 19^th century as American educators tried to work with blind and deaf children. (This was the reason for the famous scene in the life of Helen Keller, when Annie Sullivan pumped water over her hand.) Some children responded well to social interaction and stimulation, but more generally it appeared that whatever the source of their cognitive and sensory limitations, they could not be cured just by additional sensory experience.

But--  here we are today, with sensory rooms for sale, and in use in institutions like the Russian orphanages, from which children often emerge with poor cognitive abilities and possibly with emotional disorders as well. If there is no evidence that sensory rooms provide effective treatment, why are people spending resources for them,  that might be used more helpfully in other ways? No doubt some of this is the “trailing edge” of Condillac’s thinking, but I believe there are some other misunderstandings at work here.

A primary problem with regard to the sensory room practice has to do with the confusion between social stimulation and sensory stimulation. Genuine deprivation of sensory stimulation in early life has been shown to result in later cognitive weaknesses in animals, and Jerome Bruner in the 1950s generalized this finding to human beings. Because some (but not all) aspects of sensory development are guided by sensory experience, it’s true that problems like poor depth perception can result from a lack of sensory experience. However, in the 1970s, Jerome Kagan, studying Mayan infants who were reared for the first year in darkened huts, found that although the children seemed cognitively slow at a year of age, they recovered over the next several years as they became involved with a stimulating outside environment.

In any case, children in institutions are not deprived of sensory stimulation, as has been done experimentally with animals and as has occurred for cultural reasons in some human situations. Institutional infants have plenty of illumination and things to look at, including other children, adult caregivers, windows, doors, and so on. (This may not seem like an interesting view to adults, but it is quite enough to support the growth of cortical sensory areas.) Institutions tend to be  noisy, with talk by caregivers and older children, crying of babies, and so on. There are also smells, tastes, and the experience of physical handling.  But just having these experiences--  or the experience of the sensory room--  is not enough to encourage good cognitive or emotional development in the very young.

What is missing, then? Institutional children are often deprived of social stimulation, for example of infant-directed speech with a pitch and tempo of interest to infants, or of the smiling, interested gaze of a caregiver. (Of course, these experiences may also be missing in foster homes or even in poorly-functioning families.) Social stimulation at its best encourages cognitive development by helping to guide infant attention to important sensory events and by regulating or buffering sensory experiences that may be overwhelming for an infant. But there is more to it than that.  A well-trained and engaged caregiver does not just speak in an infant-directed way—he or she changes the voice in an effort to get the infant’s attention, or softens speech if the infant seems over-stimulated by it. Such a caregiver smiles and gazes at a baby, but if the baby averts his or her gaze, the caregiver waits until the baby looks back before making other efforts to interact. Good caregivers recognize that in order for a baby to learn from sensory stimulation, the sensory experience must be neither too intense nor too weak, neither too rapid in tempo nor too slow.  They also realize that for infants and toddlers, much of their most important sensory experience occurs during care routines like feeding and diapering, and that these routines can provide an essential ”curriculum” for teaching young children.

In sum, sensory stimulation is not useful for early development unless adult caregivers actively engage in shaping the infant’s sensory world in ways that foster attention and learning. Unless caregivers are doing this job in sensory rooms, any stimulating properties the rooms have may simply overwhelm young children and minimize any learning effects that they might conceivably have.

Could the money contributed for the purchase of sensory rooms have been better spent? Yes, but to do so would involve ongoing commitment of dedicated amounts over a period of years. Real advantages for young children’s development do not come from “one shot” solutions like the gift of a sensory room, but they are a matter of hiring and training excellent and sufficient staff.  Help of especial importance is given by increasing staff salaries and living conditions so that turnover of employees is reduced and a stable social environment is provided. Without stability, caregivers cannot get to know the children, and unless they know the children well and read their communications of interest or aversion, the caregivers cannot buffer sensory experiences to provide the best levels of stimulation.  

Throughout human history, and all over the world, most babies have not had environments that looked or sounded interesting to adults, but they developed and learned well because they had plenty of social stimulation by engaged caregivers who modulated sensory experiences to suit the children’s needs. Living arrangements that fail to provide this help will not support good development whether they are orphanages with sensory rooms, foster homes, or the children’s biological families.

Before the Fringe: Do Today's Unconventional Beliefs Have Common Ancestors?

A member of a Facebook discussion group recently speculated on whether there was a connection between the concerns of Christian groups in the ‘80s and ‘90s about abortion, and the “Satanic panic” of the ‘90s, which featured stories about how devil-worshippers conducted unholy rituals that killed babies. I don’t know the answer to this problem, but the question itself points up the possibility of connections between unorthodox beliefs and other religious or political principles and practices. These connections could involve ideas whose popularity was high long ago—a sort of  ”trailing edge” phenomenon--  or current beliefs which either affect each other directly or which are brought about by a shared predecessor.

I understand that historians don’t like this kind of search for connections, and I can see how it might be thought of as cherry-picking. Nevertheless, I think it may be useful to see whether the predecessors of today’s unconventional beliefs were also the “fringe” of their own times, and how they connect with other “fringes”..

Some aspects of current unconventional thought may be the “trailing edge” of Transcendentalism, a philosophy of the mid- 19^th century that stressed the unity of physical and mental processes, the role of Nature in human life, and the importance of traditional Asian beliefs as guidance for Western thinkers.  Bronson Alcott (“Grandfather” of Little Women) was a Transcendentalist who tried to keep his family on a farm, “Fruitlands”, through a New England winter, living on oatmeal and apples and wearing only cotton and linen so as not to exploit animals; his wife finally persuaded him that the younger children needed milk as well, and after a while the family moved back to Concord.

This is simplifying a bit, but by the 1880s Transcendentalism had given rise to the New Thought, a system that emphasized the power of thought over physical events. The New Thought included approaches like Christian Science, a belief system that stressed physical health as it might be influenced by thought, and one which hangs on as a somewhat conventional, minimally evangelical religious group in the United States. The influence of the New Thought is still apparent in some current Internet and print  publications about Attachment Therapy, in which it is claimed that children can voluntarily vomit, defecate, or even die, out of their desire to disturb and humiliate their adult caregivers.

But although Transcendentalism and then the New Thought seem to be precursors of some alternative psychological beliefs, it’s difficult to bring those older beliefs into alignment with other “fringe” ideas--  especially those that have to do with physical facts and the history of the universe. In a 2012 book, The pseudoscience wars: Immanuel Velikovsky and the birth of the modern fringe, Michael Gordin discussed a number of beliefs that emerged between the 1940s and the 1970s and that seem to provide a foundation for more recent alternative beliefs. I want to summarize those and see if there is any evident connection between them and other unorthodox beliefs, whether about alternative psychotherapies or about Satanic ritual abuse.

Gordin concentrated on issues of pseudoscience and the demarcation problem of discriminating between science and pseudoscience. (This is a more difficult task in the physical sciences than in psychology or medicine, where the occurrence of injury as the result of an assumption provides a brighter demarcation line.) He organized this discussion around the 1950 publication of Worlds in Collision by Immanuel Velikovsky, a former psychoanalyst. Velikovsky’s book collated accounts of events in the Bible and other texts that could support the idea of planetary catastrophes having occurred within recorded history--  for example, the story of the sun having “stood still” for hours during an Old Testament battle. Using such examples, Velikovsky put forward the claim that changes in the planet and solar system have not been gradual and uniform as is assumed by geologists and astronomers. Instead, Velikovsky argued, a comet that later became the planet Venus brushed Earth with its tail, causing disasters but also creating the manna that fed the Jews in the desert (the explanation for this last bit was provided, but I really can’t get into it). The present form of the solar system was thus less than 5000 years old.

Worlds in Collision was published by Macmillan, the leading scientific textbook publisher of the time, after having been reviewed by someone who was only peripherally involved in astronomy. Its publication was followed by severe criticism of the publisher, not so much for having accepted the book at all, but for allowing it to be presented as if it were a scientific undertaking. (The author himself was at times quite willing to have it regarded as history.) Concerns about how the public might be deceived by Worlds were exacerbated by summaries and serializations of the book in the popular magazines Harper’s and Collier’s. Scientists who spoke critically of Worlds were, however, also concerned about the reality or appearance of censorship of scientific work; these worries were based on the current political witch-hunting of Senator Joseph McCarthy, and the recent history in the Soviet Union of suppression of modern genetic work in favor of the anti-Darwinian view of inheritance, Lysenkoism.

Velikovsky did not go away. He continued to write and developed a small but devoted following who by the 1970s became part of what Gordin called “counter-establishment science”. The counterculture, with its commitment to the Free Speech Movement of a few years before, helped establish several journals that gave serious consideration to Velikovsky’s proposals. As time went on, college courses examined his work as a breakthrough that went beyond the existing system of thought. Even quite recently, as Gordin pointed out, the whole 2012-Doomsday scenario included references to Worlds in Collision. Referencing Randolph Weldon, author of Doomsday 2012, Gordin noted: “Weldon supplements Velikovsky’s account with a mechanism that disturbed the solar system in antiquity, issuing the comet that became Venus… This hidden force was what the Mayas had calculated would return at the end of the Long Count, and a new force will soon terrorize and destroy Earth.” 

Where does this lead us with respect to alternative beliefs about psychology? Did such beliefs share ancestors with Velikovsky’s theory of the solar system? Except for the fact that Velikovsky had trained as a psychoanalyst, and psychoanalytic concepts of the unconscious and of repressed memory have been important parts of alternative psychologies and psychotherapies, it is difficult to see any direct connections—but there are commonalities between the psychological “fringe” and the physical science “fringe”. There are also unshared characteristics.

1. Do the physical and the psychological “fringes” both appeal to nonmaterial forces as explanations?... Velikovsky’s arguments were supportive of a “young earth” approach and therefore of creationism with its strong spiritual emphasis, and he drew evidence from sacred writings of various kinds, treating them as historical evidence. Nevertheless, his explanations were as entirely material as one sees in conventional science. Lysenkoism used a material explanation too. In alternative psychologies and psychotherapies, however, it is common to see appeals to supernatural phenomena like telepathy or to the effects of unknown energies.
2. Have physical and psychological “fringe” material been presented to the public in the same ways?... Velikovsky’s publication of Worlds in Collision with a well-known scientific publisher was something of a fluke. Most such material has been published by specialty presses and has not been widely advertised. The same has been true of psychological “fringe” material until the late 1990s and later, when there were publications of such material by the Child Welfare League of America, Academic Press, and Wiley. 
3. Have physical scientists and psychologists responded in the same ways to ‘fringe” materials?... Gordin’s book discussed the confused response of physicists and astronomers to Worlds in Collision. Physical scientists wanted to argue against Velikovsky without falling into the censorship trap; some focused their criticisms on the publisher, whose approval of the book seemed to imply that it should be included in their respected natural science list. Others ignored Velikovsky’s arguments, or, like Albert Einstein, were friendly but would not give the support Velikovsky wanted. Psychologists have on the whole ignored issues about alternative psychologies and psychotherapies; the American Psychological Association has even in recent years given continuing education credits for study of alternative treatments. A possible explanation of this indifference comes from a comment by Martin Gardner on the work of Wilhelm Reich, a direct predecessor of today’s alternative psychotherapies: “The reader may wonder why a competent scientist does not publish a detailed refutation of Reich’s absurd biological speculations. The answer is that the informed scientist doesn’t care, and would, in fact, damage his reputation by taking the time to undertake such a thankless task” (quoted by Gordin).
4. Have countercultures supported both physical and psychological “fringe” ideas over time?... The role of the ‘70s secular counterculture in popularizing and maintaining interest in Worlds in Collision--  even bringing it into college courses—is clear. The religious counterculture that supports creationism has also played a role. These countercultural phenomena were not just anti-science in a general way, but fought the authority of science by declaring their own sources of authority to be paramount. Aspects of the secular counterculture are also apparent as supports of some alternative psychologies and psychotherapies--  for instance, the countercultural appeal to “Asian tradition” as a source of knowledge shows up in the energy therapies of different kinds.  The idea of repressed memory is also fostered by the secular counterculture’s stress on emotion as a more trustworthy guide than thought. Religious countercultures like the charismatic movement have supported alternative approaches that focus on adoption issues or posited prenatal experiences of interaction with the mother; these concerns relate clearly to positions on abortion and extramarital sex.

It’s hard to come to any clear conclusion here. Alternative beliefs about the physical world and about psychological phenomena share some but not all concepts and histories. The one factor that seems to me to be most important in encouraging the “fringe” is the existence of countercultures that can increase their own power and prestige by advocating for a “fringe” belief. But perhaps an equally important point is the fact that as Martin Gardner said, “the informed scientist doesn’t care.”