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Concerned About Unconventional Mental Health Interventions?

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

Tuesday, March 25, 2014

Institutions versus Foster Homes for Parentless Children: Rich and Healthy, or Poor and Sick?

When I was a teenager, we used to think it very funny to ask people their opinions: “Is it better to be rich and healthy, or poor and sick?” This “joke” comes back to me nowadays when I think about discussion of the advantages and disadvantages for abandoned children’s development of being cared for in an institutional setting or in high quality foster homes.

Most discussion of this issue is based on the findings of the Bucharest Early Intervention Project (BEIP), a randomized controlled trial of the two care settings carried out almost ten years ago by Charles Zeanah and colleagues. Further publications and recommendations based on the BEIP finding that foster care had beneficial effects are appearing every day, and proposed legislation in the U.S., the Children in Families First Act (CHIFF) is based primarily on the BEIP reports.

A few months ago, the publication Zero to Three published an article, “A Matter of Timing” (Fox, N.A., Zeanah, C.H., & Nelson, C.A., Vol. 34 (3), pp. 4-9). The article repeated many of the conclusions of earlier reports of the BEIP, as well as focusing on alterations in brain development possibly associated with institutional care in the early years.

I responded to the article with a letter which was kindly published by the ZTT editor, Stefanie Powers, along with a response from Fox, Zeanah, and Nelson. In my letter, I expressed concern with possible biases from lack of blinding of evaluators--  an almost insurmountable problem of this type of research, but one that requires cautious interpretation of findings. I also queried the comparison between the “poor and sick” institution and the “rich and healthy” foster homes, and particularly the apparent blanket conclusion that all foster homes were superior to all institutions, a conclusion that appears to evade the fact that this randomized controlled trial did not in fact isolate or hold constant some relevant variables. In closing, I expressed concern about the emphasis on the BEIP in the proposed CHIFF legislation, and the fact that the practical outcomes of inappropriate interpretation of these research outcomes could be very serious indeed.

Fox, Nelson, and Zeanah  kindly replied to my comments in the  March 2014 issue of Zero to Three (pp. 4-5).They summarized some of the statements of the earlier article, and very reasonably emphasized the findings of the brain measurements as unbiased by expectations of researchers. They went on to note that every nonrandomized earlier study of institutional versus home care had the same findings—that home care was superior—which is hardly surprising because in those nonrandomized  studies selection biases would certainly have been at work. (And surely the BEIP, with all its difficulties and expense, would never have taken place if the nonrandomized studies had had different outcomes.)

In responding to my comment that comparisons of high-quality institutions to foster homes had not been done, Fox, Nelson, and Zeanah referred particularly to a 1975 publication by Tizard and Rees, comparing children in  high-quality institutions to a contrast group of which the children had been full-term, healthy babies, both parents were white, the father was employed and working-class, the mother was not employed outside the home, and there was no slightly older child in the home. The institutions studied by Tizard and Rees were certainly of very high quality compared to the Romanian orphanage of the BEIP, but there were some serious problems by today’s highest standards of care for infants and toddlers. Tizard and Rees noted that “Although staffing was generous, many different nurses handled the children. The average number of staff who had worked for at least a week with each child in the past 2 yr was 25.8, range 4-45. The major turnover was in untrained assistants and student nurses, but in all except two institutions the trained nurse in charge of the child’s group had changes at least once in the past 2 yr.” (p. 64). In addition, a number of the children had parents who visited from time to time. These institutions, although of high quality in various ways, did not meet the criterion of having assigned caregivers that I stated in my letter, nor the criterion of having low staff turnover that is usually considered developmentally important. The Tizard and Rees study thus did not do much to supply data comparing an excellent institution to foster care, as the institutions did not meet important criteria, and the contrast group were not in foster homes.

In their response to my letter, Fox, Nelson, and Zeanah concluded, “Our research provides the most definitive evidence to date that foster care is a more effective alternative than institutional care for abandoned infants and young children”. And, yes, I must agree with this, that it is “the most definitive evidence”. However, this does not mean that it is actually definitive, and it is regrettable that the CHIFF legislation confuses “most definitive… to date” with “definitive”.

Relevantly, the March-April 2014 issue of Infant Mental Health Journal contains several articles that contribute to this discussion. One of these “Psychopathology in young children in two types of foster care following institutional rearing” (Tibu, F., Humphreys, K.L., Fox, N.A., Nelson, C.A., & Zeanah, C., IMHJ, 35, 123-131), compared children from the BEIP who had been assigned to high-quality foster homes to a group that remained in institutional care for a time, then were placed in government-sponsored foster care (some of this group had already been adopted or returned to biological parents; the comparison group here were those who had not had those placements). The groups had thus spent different amounts of time in foster care. Information about the two groups also differed in  sources of bias, as there could have been biological or behavioral reasons why some were adopted or returned, and others not. Children in the high-quality foster homes had significantly fewer reports of ADHD. Girls in the high-quality group had significantly fewer internalizing problems--  an unusual finding, as girls are usually seen to be less sensitive to environmental factors than boys are. The authors pointed out the need for high-quality foster care to support good development.  (This comparison may have been one of “rich and healthy” care to “poor and healthy” care, rather than to the “poor and sick” care of the  low-quality institution.)

A second useful article from this issue of IMHJ  is by Victor Groza and Kelly Bunkers (“Adoption policy and evidence-based adoption practice: A comparison of Romania, Ukraine, India, Guatemala, and Ethiopia”, INHJ, 35, 160-171). This is a complex article reviewing a number of issues about adoption practices and needed policy, and I am going to choose a few comments from it that may be of particular interest to readers. (I don’t think I am “cherry-picking”, but no doubt someone will call me on it if I am.) Groza and Bunkers note that there is already a comprehensive legal framework on these issues, derived from the United Nations Convention on the Rights of the Child and emphasizing that decisions about adoption or other placements are always to be made with the goal of achieving the best interests of the child rather than furthering adult concerns of other kinds. They point out the need for careful record-keeping about domestic adoptions (a point well applied to intercountry adoption as well), and the difficulty of having a good evidence base without this—relevantly, they refer to traditions of secrecy about adoption that can interfere with the collection of information.

Groza and Bunkers looked at efforts to encourage domestic adoption in countries that were once much involved in intercountry adoption. These have generally been successful, but in the case of Ukraine a public relations campaign that emphasized how difficult it was for children to grow up in institutions may have stigmatized the children and alienated institution staff. Groza and Bunkers noted that it was not clear how these efforts had progressed after a change in government in 2010, and of course the current unrest in Ukraine in March 2014 makes it hard to predict what will happen next--  reminding us that there are many factors in any nation’s life that influence the number of abandoned children and the ways available to care for them.

An interesting point made by Groza and Bunkers compared situations in countries with many resources to those in the low-resource countries examined in this article. They commented, “Regardless of the [low-resource] country reviewed in this article, the main reason children entered the child protective system was abandonment.  The second reason was that a parent, usually the birth mother, relinquished the child, most often immediately or soon after birth. In contrast, most children in high-resource countries enter the child protection system because of a combination of neglect and abuse within their biological family. Often, parental rights are terminated involuntarily through the judicial system” (p. 167).  

Obviously, systematic investigation is revealing more and more about characteristics of abandoned children and their developmental outcomes in different settings. What is “most definitive… to date” may not be so at a later date. In any case, extreme care must be taken about generalization from events in low-resource countries to those in high-resource countries, and vice-versa. Research on the needs of parentless children is not yet ready to be depended on by legislation. If such legislation is baldly stated to be based on values or a priori assumptions, well and good; if it is claimed to be  based on the “scientifically proven”, that is a mistake. 

Tuesday, March 18, 2014

Psychozoology in the Courtroom: Dodo Birds, Woozles, Heffalumps, and Parenting

Extinct or imaginary creatures seem to make good shorthand for referring to issues in the field of psychology. Psychologists who talk about Dodo Birds are usually concerned with the claim that all forms of psychotherapy are equally effective--  as in the statement by the Dodo Bird in Alice that “all have won, and all shall have prizes”.

I have recently become acquainted with a new and important analogy-animal, thanks to Dr. Linda Nielsen of Wake Forest University, who kindly sent me her article, “Woozles: Their role in custody law reform, parenting plans, and family court.” (Psychology, Public Policy, and Law, 2014). Readers who have, or have been, children, may recognize the word “woozle” from A.A. Milne’s Winnie-the-Pooh stories (sorry, Disney, you may have gotten your hands on them, but you didn’t write ‘em!). The woozles who concerned Pooh and Piglet were fearsome imaginary animals, the evidence of whose existence was the many tracks Pooh and Piglet had left in the snow as they walked around and around looking for woozles. As Nielsen uses the term with respect to psychology, “a woozle is a belief or claim that is not supported – or is only partially or tentatively supported—by the empirical evidence. But because the claim has been repeatedly cited and presented in misleading ways, the public and policymakers come to believe it.” Nielsen applies the woozle concept to beliefs and assumptions about the potential harm of overnight visits for infants and toddlers to an estranged parent. To quote another bit of Lewis Carroll, she is concerned that “what I tell you three times” is taken to be true.

Nielsen kindly sent me a synopsis of the paper, which I give immediately below. She also says that people who would like a copy of the complete paper may contact her at

“What’s a woozle? And what role does it play in child custody decisions and custody law reform?
If you remember Winnie the Pooh, he and his friends become obsessed with the idea that they
are being stalked by a frightening beast they called a woozle. In fact, they are being deceived by
their own footprints as they walk around in circles. In social science a woozle is a belief or a
claim based on inaccurate, partial, or flawed data – data that have been repeatedly
misrepresented, misinterpreted or “woozled” in ways that end up influencing public opinion,
individuals’ decision making, and public policy.
This paper illustrates the woozling process that has contributed to the creation of a powerful
and damaging child custody woozle: After parents’ separate, infants and toddlers who spend
even one night a week in their father’s care are more irritable, distressed, inattentive, vigilant and
anxious with their mothers, and physically stressed. In short, up until the age of four children
should live exclusively, or nearly exclusively, with their mothers. The one study that has
frequently been proffered as evidence that overnighting has a “deleterious impact” on infants and
toddlers is an Australian study commissioned by the attorney general’s office (McIntosh, Smyth,
Kelelar & Wells, 2010, Post separation parenting plans: Outcomes for infants and children).
By examining the discrepancies between the actual data and the woozles that have arisen
from the study, this paper deconstructs the mythical woozles. For example, the “wheezing
woozle” claims that infant wheezing is a valid and reliable measure of stress – stress that is
caused by spending more than 3 nights a month in the father’s care. In reality, wheezing is
caused by many factors having nothing to do with stress – including mold, pets, cigarette smoke,
and carpet in the house. Moreover, the toddlers who frequently overnighted wheezed less than
those who rarely overnighted. Likewise, the “whining woozle” claims that overnighting causes
infants to be more irritable and to exhibit “severely distressed” behavior towards their mothers.
The woozle conveniently ignores the fact that the frequently overnighting infants had exactly the
same mean score on the irritability scale as the infants in intact families – and that infants who
frequently overnighted were no more irritable than infants who never overnighted. As for the
“severely distressed behavior” woozle, the overnighters’ scores on the behavioral problems test
were well within normal range – and 50% of the mothers in the nationwide survey reported these
same types of problems with their two to three year-olds: sometimes refusing to eat or gagging
on food, clinging to her when she tries to leave, getting angry with her, or hitting and biting her.
More disturbing still, the “anxiety/insecurity woozle” was based on three questions taken from
the Communication and Symbolic Behavior Scale which is designed to assess infants’ readiness
to begin talking. This novel “scale” was created solely for this study and had no established
validity or reliability as a measure of anxiety, stress, attachment or insecurity. Because the
overnighting infants tried to get their mother’s attention and gazed at her more often – which on
the Communication and Symbolic Behavior Scales is a positive sign of readiness to learn
language – these researchers concluded that the infants were more “watchful and wary” about
their mom’s whereabouts, indicating more anxiety and insecurity in their relationship with her.
How are woozles born and raised? And how can they be used to dupe judges, parents, and
policy makers into opposing shared overnight parenting plans for children under the age of four?
Woozling is a process where many factors work in conjunction to distort the data. Among these
woozling techniques are exaggerating, misrepresenting, and frequently reporting only the data
that support the woozles, while ignoring and failing to report the data that undermine them.
Another is downplaying or completely overlooking the limitations of the study – especially those
that make it in appropriate to generalize the findings to the general population. Discussions and
presentations about the Australian study seldom, if ever, mention its many limitations –
especially in reports to the media and presentations or articles that reach large audiences of
professionals involved in custody decisions. Among the limitations were that: 90% of the
infants’ parents had never been married to each other and many had never lived together; no
more than 20 infants were in the rarely overnighting group, and no reliability or validity was
reported for four of the six instruments. Then too, this study was predicated on a theory that is no
longer widely held by attachment theorists: the belief (woozle) that infants form a “primary”
attachment to only one parent – the one who provides most of their daily care - and that spending
time overnight away from this primary parent jeopardizes the security of their attachment. In
fact, however, empirical studies have shown that infants form attachments to both parents at
about the same time, and that one attachment is not more important than the other. When we peel
back the layers of the woozles based on this Australian study, the highly publicized and alarming
warnings against overnighting are unwarranted and grossly exaggerated. In short, the study is ill
suited for making any recommendations for or against overnighting for children under the age of
Unfortunately the woozles arising from this particular study have been repeated frequently in
the media, in academic journals, and at conferences – woozling judges, lawyers, legislators,
custody mediators and other professionals involved in custody decisions. And as is the case with
woozles, those studies that have found no ill effects and some positive effects for infants and
toddlers who overnight in their father’s care have been overlooked. How do we corral these
damaging woozles once they are on the loose? First, share the woozles article with people who
are involved in making custody decisions – especially with parents who are in the process of
designing parenting plans for their very young children. Second, make the media aware of how
this particular study has been woozled in ways that are depriving many infants and toddlers of
loving, attentive care from both parents. “  

Nielsen has a specific serious purpose in circulating this discussion of woozling as it may be influencing judicial decisions about child custody and shared parenting.  There is an additional, overarching serious purpose to alerting the public and policymakers to the woozling use of psychological ideas in all kinds of decision-making. But this article has made me think: have we identified all the analogy-animals that can interfere with appropriate use of psychological concepts ?

Woozles do not seem to be the exact animals at work in problem areas like the overuse of attachment concepts (and, recently, of the idea of trauma). Woozling convinces people that events exist, when the evidence does not support this idea. But there really is attachment, with thousands of well-done studies about its phenomena, and there really is trauma too. What animal analogy is at work when the focus is too strongly on attachment or on trauma, when other factors are ignored, and when the power of an event is much exaggerated? Going back to Pooh, I offer the term “heffalump” to describe this. The heffalump seen with such trepidation by Piglet was simply his friend Pooh with his head stuck in a honey pot--  a real creature, but not the fearful heffible horralump Piglet fled. Similarly, attachment (for example) is simply one of a number of factors that determine human developmental outcomes, and giving it the heffalump treatment leads people to ignore other important considerations. Curiously, this analogy even holds at the level of “heffalump traps”,  as we see measures of attachment used in an effort to grab the exaggerated factor and use it in custody decisions as it was never meant to be used (see, for example, an article by Isaacs et al., Journal of Child Custody, 2009).

The heffalumps may not seem to be on the same topic as Nielsen’s woozles/overnights paper, but I would speculate that these two imaginary animals may be  cooperating when there are conflicts about shared parenting. Why are some parents and some authors so adamant that overnights must be prohibited until a late age? Why are others seeking overnights so enthusiastically? No doubt some of this conflict is simply left over from a dysfunctional marriage, but…  what do these people believe about attachment? Is one parent convinced that the child will lose attachment to him/her if not put to bed by him/her? Does he or she believe that attachment is time-limited, and that less than ideal attachment conditions in early life would mean that the whole relationship would be ruined and never recover? What beliefs do judges and attorneys bring to these disagreements? My bet is that the heffalumps have been romping with the woozles to create an unnecessarily increased tension about attachment, between parents who are already in many cases beyond rational decision-making.

And, let’s not forget that increased tension can lead to some wealth and fame for some of those who manipulate it. Both the woozles and the heffalumps can be lucrative for those who herd them, while they trample the financial and emotional resources of families.

Tuesday, March 11, 2014

More on Overnights, Infants, and Toddlers

A few days ago, at, I commented on a recent article that had been sent to me by Dr. Richard Warshak. (The complete citation for the article is given in that post.) In that paper, Dr. Warshak had examined research that is relevant to the issue of having infants and toddlers pay overnight visits to the estranged parent with whom they do not live most of the time. “Overnights” are a hot-button issue for many divorcing parents with very young children, and for a variety of reasons such visits have become a contentious part of the development of post-divorce parenting plans. Although some psychologists have argued that it is unwise to permit overnight visits for infants, toddlers, and even preschoolers, Dr.Warshak states that the available research evidence does not support that position--  and he is supported in his claim by a great many “famous names” in developmental psychology.

Dr.Warshak would like to establish a general guideline for courts, stating that there is no evidence that young children in most divorcing families will suffer from overnight visits to a parent who does not live with them. In this preference, he opposes the several-decades-old principle of the “best interests of the child” as recommended by the authors Joseph Goldstein , Anna Freud, and Albert Solnit; one aspect of this principle includes the idea that a custodial parent should in fact have all the decision-making power about shared parenting and all other aspects of child care.

For myself, I am uneasy about the formation of a general rule in an area where there are so many individual and family differences. But I concede two points. One is that whether or not a general rule is formulated in an “official” way, courts will employ their own general rules, and past experience with “best interests of the child” suggests that these court-determined general rules may wander far from the information on which they purport to be based. The second point is that if there is going to be a general rule, it had better be based on research evidence rather than on values or traditions or other a priori assumptions.

Without yet being in a position to say what general rule about overnights I would like to see in place, I can point to some considerations that I think should be included in any thinking about this subject:

  1. Burden of proof.  In discourse that tries to apply rules of logic to an argument, it is considered that one who states that something exists must demonstrate that evidence supports that claim; he or she cannot challenge an opponent to show that it does not exist, and in fact it would be impossible to show this about anything. The burden of proof concept means, in the case of overnights, that those who argue that such visits are potentially harmful to young children have the burden of demonstrating that  harm has resulted in the past. So far, there has been no clear demonstration of harm.
  2. Generalizability. The search for research evidence for or against overnight visits is bound to be a frustrating one, because this kind of research is so difficult and the existing work is so weak in comparison to studies that can control variables. No one can be made to divorce for research purposes, so all studies of post-divorce events are full of the confounded variables related to personality, situational, economic, and other factors that played some part in causing the divorce which the couple “chose” for themselves. These factors also influence children’s developmental outcomes and their effects may be impossible to differentiate from the effects of divorce itself, of overnight visits, or of any other factor. In order to generalize from the results of research to the “real life” of individual families, we need to know that the families closely resemble the group from whom the  research evidence was collected--  but because there are so many variables involved, this may be quite difficult to determine.
      It’s especially important not to assume that research on middle-class, well-educated           divorcing couples can necessarily be generalized to high-risk families, ill-educated and      living in poverty--  or vice-versa. This reality can lead to problems because it is often    much easier to get middle-class people to participate in research than is the case for poor    people, who may feel threatened by the apparent nosiness or imagined disapproval of the             researcher. When a study looks at a group of parents of whom a high percentage are          under restraining orders (cf. Solomon & George, 1999), or who have some other unusual       characteristics, it is questionable whether the results of the study should be generalized to the rest of the population.
      In considering generalizability, it’s also critical to see what comparisons were made in       the research being considered. Do these comparisons reflect the differences we might be   interested in understanding? For example, Dr. Warshak’s paper examines with care the     famous study by Solomon and George which has been used to suggest that overnight  visits were problematic for toddlers. Solomon and George compared young children who were having overnight visits with a combined group who were either in an intact family    or were with a mother alone, but not having overnight visits. But surely the important      question for generalizing to the guidance of parenting plans is the difference between children of separated parents who were having overnight visits, and those who were not.

  1. Issues about attachment. One of the serious problems related to creating general guidelines about overnights for young children is the extreme popular focus on attachment and the assumption that attachment quality determines everything from childhood obedience to school performance to later success in marriage. Other motivations and developmental factors of childhood, such as exploration, are generally ignored outside developmental psychology. There are also some common misunderstandings about attachment that have become woven into thinking about parenting plans.
  1. Monotropy. The original theory of attachment formulated by John Bowlby made the assumption, based on studies of animal behavior, that infants’ and toddlers’ emotional attachment was to a single caregiver at a time (monotropy). As it became clear that this was not the case, there was a tendency to make only a slight change in the monotropy assumption by designating primary and secondary attachment figures.
      However, it seems clear now that several attachment figures can (and usually do) exist for young children, and attachment to one does not alter attachment to others, although a child may show preferences for one over another in certain circumstances. The obvious example is the maintenance of attachment to a parent in spite of many hours a week spent with a day care provider who is also an attachment figure. A reasonable conclusion is that overnight visits to a parent, if they facilitate attachment to that person, do not also destroy attachment to the live-in parent.

  1. Time limits. The original view of attachment was that there was a sensitive period during which attachment relationships had to develop, or else they would not be possible. As Everett Waters pointed out in his interview with Jennifer McIntosh in the 2011 Family Court Review issue, this does not appear to be the case. Attachment is a developing, changing aspect of motivation and personality, and does not have the time limits once assumed to hold. Understanding of this point can suggest, as Waters did, that early overnight visits are not required for eventual attachment to a nonresident parent, but on the other hand it does not particularly suggest that such visits will be beneficial.
  2. Security and order. Some discussions of parenting plans focus on security of attachment. However, insecure attachments are by no means outside the normal range or associated with psychopathology. Presumably it is not the purpose of a parenting plan to create the ideal of psychological development, but instead its purpose is to balance the needs of family members in a way that provides for “good enough” development of a child. “Insecurity” sounds unpleasant, and in popular thought is associated with neurotic behavior, but in fact insecure attachment is an orderly and adequate strategy for dealing with attachment and exploratory needs.
Much more serious outcomes are associated with disorganized/disordered attachment, a way of responding to caregivers in which young children may “freeze” on seeing the adult, or may use unusual approaches like backing up to the person or approaching while averting the eyes. Solomon and George’s 1999 paper reported that such behavior was more common among the children having overnight visits, and of course this is concerning. However, work like that of Mary Dozier has shown that this behavior is associated with the caregiver’s behaving in a frightened or frightening manner toward the child, and interventions like Dozier’s Attachment and Biobehavioral Catch-up can change the adult behavior and make the child’s attachment strategies more ordered and less disorganized. Unless it can be shown that indeed overnight visits cause adults to behave in frightened or frightening ways (which is not impossible), it is hard to see how shared parenting is directly causal for the child’s disorganized attachment quality.

  1. Results now, or later? As has been noted (e.g. by van IJzendoorn et al, 2005), immediate changes in disorganized attachment behavior can be considered a good measure of the effect of events on a young child. However, it is equally or more important to look at long-term outcomes before concluding that an overnight visit is harmful, or an intervention is helpful. Only a well-designed longitudinal study can show the real impact of overnight visits on development. Infants and toddlers, from about 8 to about 24 months, are well-known for their negative response to changes of any kind. Developing autonomy (“No!”) and neophobia are enough to cause young children to resist change and to display stress reactions when more than a minimum number of changes occurs; even ordinary transitions like getting dressed to go outdoors can be fraught with emotion. It would be surprising if children in this age group did not respond negatively to visit experiences, especially if they pick up cues from the adults that anyone is worried or frightened about what is happening. The question is, how do these experiences alter the trajectory of development and lead to more, or to less, desirable outcomes--  if indeed they do?    
  1. Gender differences. As this post is getting very long, I am going to be brief on a point that may be of interest. As it happens, girls are more likely than boys to be assessed as securely attached during the toddler period, and girls may be less vulnerable to developmental disruption due to environmental stress.
Men and women may also bring different relevant characteristics to shared parenting. Women with perinatal mood disorders are more likely to have children whose development is problematic, and it is conceivable that mood disorders can disturb a marital relationship to the point of divorce.

Men, on the other hand, may be more likely to bring antisocial behavior into the picture. In  a study that is only indirectly related to the issue of overnight visits (Jaffee, S.R.Moffitt, T.E.,  Caspi, A., & Taylor, A. [2003]. Life with [or without] father: The benefits of living with two biological parents depend on the father’s antisocial behavior. Child Development, 74, 109-126), the authors showed that the children they studied experienced what they called a “double whammy” of behavioral problems when they received both the father’s genetic material and experienced living with him; children with the genetic tendency to antisocial behavior did better when they did not live with antisocial fathers. Antisocial behavior on the father’s part may also disturb the marriage and lead to divorce; the issue may then be to what extent any contact with an antisocial father is beneficial.

All I have done here is to bring up various factors and research issues that I speculate may be related to the effects of overnight visits for infants and toddlers (although they are probably much less relevant for preschool children). These points make me hesitate to think in terms of any general guidelines about overnights--  although I am well aware that some guidelines will be applied in most cases, however questionable they may be. I would like to suggest that rather than offering guidelines for parenting plans, it would be more constructive to develop a protocol for assessing how well a given plan is going for a child, and for fine-tuning plans that are proving problematic--  for example, a plan for visits that is frequently disrupted by scheduling changes or by the influences of non-parent adults.

Monday, March 10, 2014

"Screen Time" for Infants and Toddlers

I don’t usually double-dip by putting the same post on different blogs, but I think this topic is so important that I’m putting on childmyths a version of a post that will be on the website of the Pennsylvania Association for Infant Mental Health ( This post is a summary of an important presentation by  Dr. Stacey Hoffman, child clinical psychologist at Children’s Hospital of Philadelphia, and the discussion following the presentation. Dr.Hoffman’s presentation title was “Screen time in early childhood: Promoting parent-child relationships in the digital age”.

Dr. Hoffman began her presentation with some concerning figures. The average age for beginning TV/screen watching in the United States is 5 months. Ninety percent of children under age 2 years watch TV. Half of the young children in the U.S. live in homes where the television is turned on more than 6 hours each day. Seventy percent of children have TV sets in their bedrooms. Watching TV is the most common activity (so to speak) for young children, after eating. The average number of hours watched per day is 4.4 in homes. 3.2 in center-based day care, and 5.5. in home-based day care.

But, as was noted several times during the presentation, one of the reasons for this heavy use is that parents generally believe they are doing the right thing by facilitating screen use. They think that this kind of screen exposure will make their children “smart”. This belief persists in spite of the recommendations made by the American Academy of Pediatrics in 1999 and again in 2011: that all forms of screen use are inappropriate for children under 2 – a position that, as several members of the audience noted, is somewhat weakened by the almost universal presence of TV screens in doctors’ offices.

When parents say they believe screen use is beneficial and makes kids “smart”—in contradiction to the AAP recommendation—where do they get this idea? A major source is the marketing of screen media, targeting parents of young children, who often depend on ages for use of media as suggested by marketers. Product packages may recommend media as appropriate for babies from 6 months. Parents become convinced that there are suitable media presentations for infants and toddlers, as claimed by the 24-hour “Baby TV” channel. Marketing materials call such media ”learning activities” and imply that a baby without access to these may be “left out” developmentally. They also state that media are intended to be used for the shared experience of parents and babies (although this is not usually what happens).

A report by the Kaiser Family Foundation in 2005 stated that 58% of the parents surveyed thought that available material was “educational” for babies. Most did not watch with the baby, but took the opportunity to do something else. They felt that the screen was calming for the baby and that intent watching for longer and longer periods indicated that the baby was developing a longer attention span and getting “smarter”. One mother was surprised that her baby seemed to have language delays even though he watched “Baby Einstein” every day.

Is there any support for the marketing claims? No, and in fact the highest levels of infant learning may be incompatible with screen use. The Campaign for Commercial-Free Childhood brought to the FTC a complaint of fraud against the leading marketer, the “Baby Einstein” company, and forced the manufacturers to back down to some extent. Refunds were given to purchasers who applied, but the company did not admit deceptive marketing and couched the issue in terms of “customer satisfaction”.

What problems are associated with infant screen use? Why does exposure to new information on the screen not “make babies smarter”? The researchers Anderson and Pempek (2005; see below for reference) used the term “video deficit effect” to describe the additional time needed for infants to learn material from a screen, as compared to learning from a live model. Part of the problem is that infants do not readily generalize from the two-dimensional screen image to the three-dimensional real world. Neither have they developed the ability for symbolic representation that lets them see the equivalence between the small, flat screen image and what they see around them (DeLoache & Chiong, 2009; see below).
Infants’ natural ways of learning involve not only the visual experience that is so crucial to adult learning,  but also movement and touch, often using the mouth as well as the hands. Despite the occasional chomps infants give to screen devices, this kind of exploration really not be done with a screen image.

Caregivers contribute to infant learning in ways that screen devices cannot imitate (so far, at least). A critical contribution is scaffolding, observing what is easy or difficult for the child and providing just enough support to enable the child to be successful with more difficult tasks. An everyday example is providing a spoon or finger food for a baby who wants to self-feed but cannot handle a fork. Scaffolding can involve hastening or slowing an activity in response to a child’s needs at the moment, or asking a series of questions to guide a sequence of tasks, as needed.

Some aspects of baby learning have to do with infants’ sensory and motor abilities, which facilitate active learning through real experience, but do not fit well with learning from a screen. As has been shown by Smith, Yu, and Pereira (2011; see below), sitting is a breakthrough to examination of objects and learning from them (and, notably, the average age for starting infant screen use is prior to the average age for sitting alone!). Linda Smith and her colleagues have talked about “good naming moments” when infants are likely to learn the names of objects. These are times when the sitting baby holds an object not far from her face  (because her arms are short) and has it in the center of her visual field. The holding position helps to stabilize the child’s head and give a clear view of the object. Object names experienced during these situations are learned more quickly than is the case when the object is being held by the mother. Pretend play is also encouraged by handling and looking at objects.

So, here we are: there is plenty of evidence that playing with real objects is better for learning than watching a screen, and that interacting with a real person involves experiences that can’t occur when watching someone on a screen. How, then, do we encourage young parents to abandon the screen use that has been sold to them by clever but deceptive marketing? Discussion at Dr. Hoffman’s presentation focused on the idea that it does not help merely to tell parents not to do something. A good substitute must be offered, whether it’s singing, talking, reading aloud, or playing games like pat-a-cake. Unfortunately, many young parents do not believe they can teach their children anything worthwhile, and they need help to see  how many important things they have taught and will teach in the future. A final and important point is that we need not try to get parents to go at one step from 24 screen hours a day to none at all. Anything that reduces screen use, and increases interactions with the real world, is a step in the right direction.

Anderson, D., & Pempek, T. (2005). American Behavioral Scientist, 48, 505-522.
DeLoache, J., & Chiong, C. (2009). Babies and baby media. American Behavioral Scientist, 52, 1115-1135.
Smith, L. Yu, C. & Pereira, A. (2011). Not your mother’s view: The dynamics of infant visual experience. Developmental Science, 14, 9-17.

Tuesday, March 4, 2014

Overnights, Divorce, and a New Article By Richard Warshak

I was not a little surprised and somewhat puzzled (yikes, does this mean people read this blog??) when I received in my inbox this morning a message from Dr. Richard Warshak, sending along a copy of his recent article about parenting plans and referring to my post from three years ago,

Dr. Warshak (whom some readers will recognize as the parental alienation man, and who has been working on issues strongly related to father custody since the beginning of his professional career) pointed out that the research I had cited was of questionable quality. His recent paper, “Social Science and Parenting Plans for Young Children: A Consensus Report” (Psychology, Public Policy, and Law, 20, 46-67) makes well-deserved hay of a number of research reports on matters relevant to overnight visits of young children to parents who do not share the households where the children live most of the time. It is all too true  that the research in this field is exceedingly weak and does not provide a good foundation for practical decisions made in the best interests of children. This statement is not a condemnation of  the researchers concerned, but just a recognition of the extreme difficulty of doing high-quality research when it is impossible to use a randomized design (not the random sample characteristic of some studies Warshak cites), when access to families is limited by their interest in cooperating (thus omitting from the studies a most interesting group of people), when there are no universally accepted assessment methods  available, and when the existing assessment methods were developed to use for research with large groups rather than for prediction of an individual outcome. As a result of these problems, there is no high-quality research to support either the idea that overnight visits for young children are advisable, or the idea that they are inadvisable.

To make a decision about overnights based on the existing research, theory, and other relevant information is a judgment call, and Dr. Warshak, with the agreement of over a hundred well-known researchers and theorists, has judged that the information supporting the advantages of overnight visits for young children is more compelling than the information showing their disadvantages. In my own 2011 references to some existing research, I did not make such a general judgment, but used the evidence for distressing effects of overnights on some children as an introduction to some thoughts about individualizing plans, anticipating problems, and fine-tuning visits as child responses are observed.  

 I am concerned that general recommendations about overnights, if adopted as guidelines by courts, could make it more difficult for divorcing parents to work on individualizing their parenting plans with respect to children’s ages, developmental stages, temperaments, special needs, and situational variables. I anticipate difficulty in periods or relationships of high conflict when one parent says “this isn’t working well” and the other replies “the judge said we have to do it this way”. Just as there were problems created when the courts accepted the idea of monotropy in attachment (that is, that one parent is always much more important than the other), problems will be created either if courts assume that overnights are never indicated for young children or that they are always indicated, and it would be my prediction that some attorneys and some judges would take one of those simplistic views if encouraged.

One section of Dr. Warshak’s paper caught my particular interest, and I am delighted to see it stated in print. He says, “our recommendations apply to children who have relationships with both parents. If a child has a relationship with one parent and no prior relationship with the other parent, or a peripheral, at best, relationship, different plans will serve the goal of building the relationship versus strengthening and maintaining an existing relationship” (p.60). In other words, methods that facilitate maintenance of an established parent-child connection are different than those that help create a relationship between a child and a person who, though biologically related, is essentially a stranger.

This comment is in my opinion one of the most critical in a paper that is likely to be very influential, and I hope that those who take guidelines from Dr. Warshak’s article will read it through to the end. I am thinking of the mistaken application of good rules about ordinary parenting to situations where a parent has had little contact with a child, or perhaps not even known that there was a pregnancy or a child born. For example, in a case known to me recently, a woman who found she was pregnant by her employer, whom she had come to distrust and even fear, went away to her parents in another state. The employer sought her out, and learning that she was pregnant, denied paternity. A later test showed that he was the biological father. At that time, he petitioned for full custody of the child. Because of evidence of violent behavior in the past, he was given supervised monthly visitation during the first year, then unsupervised visitation during which he took the child back to his home state for weekends and had him cared for by a nanny during those visits. The child appears to have responded with distress to the visiting schedule and events---  a schedule and events that (except for the nanny and some experiences that may have occurred) might have been perfectly appropriate if there had been an existing relationship. (I say this with complete awareness of the fact that toddlers can be stressed by many ordinary changes; this child’s response went beyond the ordinary level even for an irritable or low-threshold child.) I hope that the statement about building relationships made by Dr. Warshak, and supported by a large group’s consensus, will be given full consideration by courts dealing with cases of this type.