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Concerned About Unconventional Mental Health Interventions?

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

Thursday, July 31, 2014

You Can't Tell a Book by Its Cover, But Sometimes You Can Tell by Author, Editor, or Publisher

Nowadays, we tell each other all the time to be cautious about accepting information offered on the Internet. People may not actually follow that advice (especially if they find statements that they want to believe), but they think it’s accurate enough to pass on to others. And there is a general understanding that some kinds of websites, like .gov and .org, are often more accurate in their statements than .com sites may be.

But what about actual printed books? Traditionally, non-fiction book publishers have been rather careful about the manuscripts they accept. Part of their concern has been whether a book would sell, that’s true, but they were also concerned that if a book turned out to contain misinformation, this would reflect badly on the publishers, good authors would not want to work with them, and both reputation and business would go downhill quickly. Traditional publishers have usually sought outside reviews of manuscripts before they were accepted, and have asked authors to correct any inaccuracies or other problems found by reviewer.

Times have changed, though. Enter first vanity publishing (sometimes daintily called “boutique publishing”) and then self-publishing. These publishing methods are ideal for non-fiction authors and editors who want publication without review or criticism, a quick turn-around and ads swiftly  up on Amazon, in exchange for a fee. They are also excellent for lightweight publishers who “troll” for equally lightweight authors in order to put together a publication that will sell and provide the authors with bragging rights. The result? A book that is fine on the outside, but that does not necessarily contain reliable information. Unlike the Yankee farmer’s blind horse that “pulls good, just don’t LOOK so good”, these books appear to be the reliable things we learned to respect in grade school, but they may be quite otherwise.

I have these issues on my mind today for two reasons. One is a message I received from Marianne Milton, alerting me to some potential authors who are looking for material to put a book together.  The would-be authors are Gregory Keck and Lynda Gianforte, and here’s what they have to say:

"Dr. Keck and Lynda Gianforte are writing a book whose working title is Keeping Families Strong after Adoption. They want to include success stories written by parents and children. The stories will be edited and returned to people for their approval. People can respond to the questions below. Contributors may send the stories to Gregory Keck, PhD at

• Did you do anything special to make your adoption successful?
• Are there any parenting strategies that were particularly effective for you?
• Is there anything you did that didn't work?
• Did you get therapy for your child? If so, what kind?
• Did you get therapy or any specialized training to help you parent your adopted child more effectively?
• Do you have any suggestions for new adoptive parents that you'd like to share?
• What did your parents do that made you feel good about being adopted?
• If you could talk to new adoptive parents, what advice would you give them about raising their kids?
• When you're a grown-up, do you think you'll ever adopt a child?"

The potential publisher of this book is not named, so I don’t know whether this is to be self-published or simply go to a printer-ready press that will handle distribution. However, some information about the authors is available. Gianforte, writing under the name Lynda Gianforte Mansfield, is an adoptive mother who has since at least 1994 been collaborating on books with attachment therapists. One such book was published by Pinon Press, a small publisher in Evergreen, Colorado; Evergreen was home of a version of holding therapy, and Pinon Press specialized in related work, at least prior to the 2000 death of Candace Newmaker at the hands of two holding therapists. Gianforte was also strongly associated with “Love & Logic”, the commercial parenting program run by Foster Cline, one of the most influential proponents of holding therapy.

Gregory Keck is a licensed clinical psychologist in Ohio, but his educational background is ambiguous. He received a doctoral degree from the intermittently-accredited Union Institute, an institution that allows students to name the discipline that they believe their dissertation topic belongs to. Keck chose criminology for his discipline. Keck’s book Parenting the Hurt Child, co-authored by the social worker Regina Kupecky, recommends holding therapy. Of a group of psychologists writing for a special issue of the journal Attachment & Human Development in 2003, Keck  (along with Helen Minnis) was the only one whose article failed to reject the use of holding therapy (curiously, it was also the only article that appeared in the form of a dialogue rather than a normal scholarly paper format, so I assume it was accepted only because Minnis has some influence).

What, then, can we expect from a book produced by Gianforte and Keck? Is it likely to agree with expert views on holding therapy and on attachment disorders like those stated by the American Professional Society on Abuse of Children in 2006? Somehow… I doubt it. But will naïve readers be aware of that? Somehow I doubt this too.

All right, one more example of the untrustworthy book issue. I recently received from Nova Publishers an e-mail inviting me as follows:   

“Dear Dr. Mercer,

We have learned of your published research on theory of mind and would like to invite you to participate in our publishing program. A number of possibilities are available for our cooperation.

In particular, we welcome two possible avenues of collaboration (you can select one or both and let us know by return email):

1. Your authorship or editorship of a monograph or edited collection on a topic of your choice.

The format (monograph or edited collection), approach and the manuscript submission date would be at your discretion. Our Publication Idea Form might be of use to you in this regard and is attached to this email. If you are interested, please fill it in and return it to my attention at If your book proposal is accepted for publication, we will send our agreement for your evaluation and signature. Your book will be published in printed and electronic formats simultaneously.

2. Your submission of one or more original research or review chapter(s) for our upcoming hardcover edited collection (by selected invitation only) tentatively entitled:
Theory of Mind: Development in Children, Brain Mechanisms and Social Implications

Related Nova publication:
Autism Spectrum Disorders: New Research

The deadline for the abstract is August 25, 2014 and for the completed chapter November 25, 2014. Please send the abstract and the chapter to
We also welcome proposals to serve as the editor of this volume. If you are interested, please send your latest CV to [\"\"] Proposals to serve as the editor are welcome up to the abstract deadline.

The contributions for this edited book are intended to range from 4,000 to 35,000 words (chapters over 10,000 words can be updated by the author for the e-version of their chapter for a period of 2 years at intervals of 6 months, 12 months and 24 months after publication). If you are interested in participating, please consult the Notes for Contributors at the bottom of this letter. Should your schedule not allow a full contribution at this time, we would welcome either a Commentary or Short Communication of 1,000-4,000 words.

The book will be published in about 6-9 months after the close of the volume. As soon as a book is listed on our Website ([\"\"], the codes in the status field will indicate the production stages through publication cycle.

Select one:

Peer review to be arranged by author ...................................

Review at Nova ................................... “

Let me state, to begin with, that I have never done any empirical research whatsoever on Theory of Mind, and although I could “mug it up” and write something about other people’s work, it would be quite deceptive to present me to readers as a researcher in that area. Let me point out, too, that the last couple of lines tell us a lot: I, the author (if I were going to do this), could decide whether a review of the work should be done by someone at Nova, who is not likely to know much about the topic, or by a reviewer I asked to do it--  potentially, my friend or even my student.

This contact on the part of Nova explains to me part of the story behind the only Nova book I ever bought—New Developments in Child Abuse Research, edited by one Stanley Sturt, apparently a graduate student at the time. This volume contains a publication by Arthur Becker-Weidman in which he claims to have demonstrated the efficacy of Dyadic Developmental Psychotherapy, but includes much information suggesting that the treatment actually involved holding therapy. Now I understand what I suspected before--- that Becker-Weidman’s paper was never reviewed by anyone who knew the field, and that was why it was published, to its author’s presumable benefit. (I had queried Nova on these points years ago, but got no answer.)

Not to belabor this issue any longer, but skeptical caution obviously needs to be brought to information in print as well as on the Internet. As Pogo once suggested, it may not be the truth even though it’s more interesting.

Tuesday, July 29, 2014

Robert F. Kennedy Jr. Is Badly Mistaken About Vaccines and Autism

A recent article by Keith Kloor in the Washington Post Magazine discussed the position taken by Robert F. Kennedy Jr., who has edited a new book claiming that the preservative thimerosal, used in some vaccines, is responsible for a large proportion of neurodevelopmental disorders, including autism ( Kennedy is untrained in any of the scientific disciplines that would enable him to critique the evidence for such a claim. One of his co-authors, the physician Mark Hyman, is a purveyor of diets and alternative medicine as preventative of common disorders and as guides to “UltraWellness”.

According to the Kloor article, the book, Thimerosal--  Let the Science Speak, was published without some of the draft chapters, as even Kennedy’s co-authors felt they were too “combustible” (for which I read, “impossible to support with empirical evidence”). Nevertheless, the book makes strong claims about  the dangers of the mercury-containing preservative, and attacks the Centers for Disease Control and other federal agencies for their unwillingness to remove thimerosal from all vaccines. Kennedy and his co-authors interpret the fact that thimerosal was removed from vaccines for childhood diseases years ago as an admission of evidence of toxicity, rather than as what it was: a policy decision taken to counteract the mistaken thinking of some parents, who wanted to avoid vaccination because they thought the procedure could cause autism. They reason (?) from this assumption that CDC and other agencies know they are in the wrong about thimerosal, but for unknown motives continue to maintain their mistaken position.

There are three basic ideas in all of the anti-vax, anti-thimerosal arguments, and all three are problematic. One  idea is that because mercury in some forms and quantities is known to cause brain damage, all forms and quantities must have the same effect. Because people who ate fish contaminated by high levels of methylmercury effluents developed Minamata disease, with sensory disturbances, movement problems, and tremor caused by the mercury neurotoxicity, it is argued that occasional exposure to small quantities of other forms of mercury can have devastating effects.  This is similar to arguing that because a person can drown in the ocean, salt-water nasal sprays are also dangerous. In fact, in spite of homeopaths’ claims to the contrary, minimal exposures can be harmless even though greater exposures to a toxic substance can be fatal. 

The second idea depended on by Kennedy, Hyman, and others is that autism and other neurodevelopmental disorders are caused entirely by environmental factors.  However, there is strong evidence that genetic factors are largely responsible for autism and most other such disorders. This can be difficult for concerned parents to accept, because they imagine that all genetic problems follow a simple dominant-recessive pattern as some eye colors do; when their child is diagnosed as autistic, the parents say “it can’t be genetic, because no one in our families ever had such a thing”. However, genetic problems may involve a number of genes and be evident only when all the required genes are present together. They may also emerge from mutations or other changes which occurred in previous generations but were not apparent until the present one. Of course, the importance of genetic factors does not mean that there must have been no environmental factor at work, but it might well mean that only persons with certain genetic make-ups are vulnerable to the effects of certain environmental events (as discussed by Beaudet in a Science article in 2012).  

The third problematic idea is that there is an epidemic of autism. It is certainly true that many more children in the United States are diagnosed as autistic than was true in the past, but this is far from the same thing as an epidemic. What I am going to say about the frequency of autism diagnoses in the U.S. today has been said many times, but apparently it needs saying again: the number of cases of any disorder diagnosed depends on two different things--  the number there actually are, and the method of diagnosis. Before Leo Kanner proposed the diagnosis of autism, no children were diagnosed as autistic, but this is not likely to have been because there were no autistic children before the 1940s. Kanner did not “invent” autism or autistic individuals, but just called attention to an existing condition that had been confused with other speech problems and  with mental retardation. Definitions, symptom lists, and ways of diagnosing autism have altered over the years, and the present approach to autism includes both serious disorders and many mild problems that received other labels in years gone by. Unless some dramatic changes occur, combining mild and serious disorders will obviously result in having a larger number of people assigned the combined diagnosis than would have been the case for each previous diagnosis separately.  (Incidentally, this problem of categorizing and counting also applies to statistics about Sudden Infant Death Syndrome; while deaths attributed to SIDS have been reduced in number in recent years, there has been an increase in infant deaths whose causes are unidentified—the same number of deaths, but placed into different categories.)  Categorization is one source of the “epidemic”; another is increased awareness (not to say frantic anxiety) among parents, and haste in seeking diagnosis of peculiarities which in the past were often dismissed as trivial individual differences. This haste can lead to early diagnoses of autism in children who are later identified as typical in development.

Kennedy and his co-authors are thus wrong about the existence of an epidemic of autism, about environmental causes of the disorder, and about the actual effects of exposure to small doses of the form of mercury in thimerosal. By continuing to press these mistaken points, they discourage parents from immunization in general (even though thimerosal has long been removed from vaccines for common childhood diseases), and from flu vaccines in particular, as these continue to contain the preservative.  Kennedy’s celebrity status enables him to publish and push as scientifically based a position contrary to what scientific investigation actually shows, and to use this position to argue against all common sense that the Centers for Disease Control are deliberately working against public health needs.


Sunday, July 13, 2014

The Randolph Attachment Disorder Questionnaire: When a Psychological Test Is Not a Test

On several occasions over the last couple of years, I’ve referred on this blog to the case of a mother whose children’s fates seem to be under the control of one Forrest Lien, LCSW, of the Institute for Attachment and  Child Development in Colorado (for instance,

As recently pointed out by my colleague Linda Rosa, it turns out that Lien was working under a “stipulation” by his licensing board for some years, beginning in 2009, following an unstated problem in his work. This stipulation, as noted at
required him to be supervised  and mentored by another social worker for two years--  a requirement that must have been rather galling for someone who had years of experience and who was accustomed to supervising others. In addition to the supervision, Lien was required to take 30 hours per year of approved continuing education courses dealing with assessment and diagnosis, ethics, dual relationships, clinical supervision, and recordkeeping.
All of these continuing education requirements give us some idea about the problems that got Lien into trouble in the first place, but the one that needs the most discussion is the requirement for study of assessment and diagnosis techniques. This topic is of interest because of Lien’s past advocacy of tests and diagnoses without acceptable evidence bases. His IACD website, (under previous guises), had been engaged with inventive but unsubstantiated diagnostic approaches in the past, then had stopped mentioning them.

But the IACD site is once again making claims that are unsupported and selling a test that has never been demonstrated to be valid or reliable: the Randolph Attachment Disorder Questionnaire (RADQ, not to be confused with another test with the same acronym developed some years ago by Helen Minnis). The RADQ was developed and marketed by Elizabeth Randolph, a practitioner who had lost her license in California and moved to Colorado.

What do I mean when I say that a test has not been shown to be either reliable or valid? Some readers will know this, and others may remember it vaguely from Intro to Psych, so I think I’d better clarify.

Psychological tests have two jobs to do. One is to identify problems quickly and easily, without having to wait years to see how development goes, or having to commit months of time to tedious observations. The other is to help decide whether a treatment has had the effect it was intended to have, and thus whether it should be used again.

In order to do these jobs, a test must be reliable and give the same results each time it is given to a person, unless something like a treatment has acted to change the underlying condition. In addition, the test must be valid--  it must test what it is supposed to test.

 To find out whether a test is reliable, several methods can be used. Sometimes there are two or more test administrations to a group of people, and the results are examined mathematically to see whether they are sufficiently similar. Sometimes the test results for a group are “split” so that the results from one half of the test questions are compared with the results from the other half, and the comparison is examined as before. Reliability is very important when a test is used to determine whether a treatment is effective; if the test does not ordinarily give the same results each time, it can hardly be used to detect whether the treatment changed patients’ characteristics.

However, validity is even more basic to the usefulness of a test. If a test does not give information about the issues it purports to examine, it adds confusion instead of clarity to assessment. But how do we know whether the test is valid? We have to find out whether the test results give us information about people that are similar to the information we could get in some other, more difficult, more time-consuming way. For example, we might give a test to a group of children, then wait until they grew up and see whether the test had done a good job of predicting their adult characteristics. Or, we could give the test and compare it with the results from some other well-validated but expensive or cumbersome test we wanted to replace. Or, if there was agreement among clinicians about how to diagnose a problem, we could give the test, and compare its results to the diagnoses given by clinicians who did not know anything about the test or its results and who were not involved in the test administration.

Let’s look at the RADQ in terms of validity. First, Elizabeth Randolph herself says in her test manual that this is not a test of Reactive Attachment Disorder, but of some other “unofficial” disorder she calls Attachment Disorder. Confusingly, although many people shorten Reactive Attachment Disorder to RAD, the R in RADQ is for Randolph, not Reactive. What is Attachment Disorder, then? According to the IACD website, it is a term that covers a number of dissimilar problems, each with different symptoms as described in DSM or ICD: Reactive Attachment Disorder, Oppositional and Defiant Disorder, Post-Traumatic Stress Disorder, childhood trauma effects, and Pervasive Developmental Disorders (now usually called Autistic Spectrum Disorder). Whatever AD is, it can begin before birth when baby and mother do not bond prenatally (whatever this means) or can occur later. Its symptoms, or perhaps I should say the symptoms of all the diagnoses mentioned earlier in this paragraph, are said to include the usual list used by attachment therapists, including cruelty, provocative behavior, lying, and superficial charm, none of which are actual symptoms of most of the diagnoses named as making up AD.

Evidently, there are problems here. The RADQ is presented as a way to diagnose a number of dissimilar difficulties of behavior and mood. Yet it consists of a fairly small number of questions. Are the answers used to detect a pattern of behavior that is characteristic of each of the diagnoses? No, the total number of answers is supposed to measure the notional Attachment Disorder that somehow shares the sometimes-contradictory characteristics of a whole set of different diagnoses. There is no clear definition of the problem to be assessed, so it is impossible to work out whether the RADQ is a valid assessment of … something.

There’s more to deal with here. Randolph says she can diagnose AD; one of her methods is to see whether the child is able to crawl backward on command. [I’m just reporting the news, you understand.] So, she can identify AD, and she will validate her test by seeing whether she and the test come to the same decision about each child. In order to do this, of course, what she needed to do was to have someone else administer the test, and to look at the mathematical relationship between the test results and her assessments of a group of children. But, no. That was not what happened. Not only did Randolph administer the test herself, she did so by discussion with each child’s familiar female caregiver. The RADQ is not a test of what children think or do, it is a test of what their mothers or guardians say they think or do. Randolph, who had already worked with and knew the children, administered the test by talking over each question with the caregivers until she and the caregiver came to a conclusion about the correct answer to the question. In other words, Randolph, who had already come to a conclusion about the child, guided the caregiver to a set of answers on the RADQ--  perhaps unwittingly, but it is impossible to think that there was no influence brought to bear.

 Not astonishingly, there was a high correlation between Randolph’s diagnosis and what the RADQ responses said, so Randolph reported that the test was a valid one. But, of course, it was not, and would not have been even if AD existed as a disorder in any meaningful sense. To validate a psychological test, the test administration and the validating criterion (in this case, Randolph’s diagnosis, whatever it meant) must be independent of each other to begin with. If they influence each other, one will predict the other without actually being a valid way to assess a problem.

What does all this mean about Forrest Lien and the IACD? If they are selling the RADQ, as they advertise on the website, they are committing what appears to be a fraudulent act. If they have paid the slightest attention to the professional literature over the last ten years, they must be aware of the criticisms that have been leveled against the RADQ, and are selling it anyway. If they have not paid any such attention, they have failed to keep up with professional development and are not meeting the  practice standards required for continuing licensure.

The stipulation under which Lien practiced for some years did not clearly state the reasons for the disciplinary action, but it did require him to do further study about assessment and diagnosis. Could it have been the use of the RADQ that was the original problem, and that was why the test disappeared from the website for a while? If so, what will happen now that the RADQ is back? What ought to happen is pretty clear to me.  

Monday, July 7, 2014

You Wouldn't Treat a Dog the Way This Woman Tells Social Workers They Should Treat Foster Children

I was surprised to find out some years ago that some people were disciplining their children with methods like limiting or forcing food and drink consumption.

I was even more surprised when I discovered that Nancy Thomas, a former dog trainer and present foster care educator, has a large Internet following for her advice about confining children to their rooms and demanding that they sit immobile for lengthy periods of time.  Thomas recommends what she calls “basic German Shepherd training”, in which children learn to come, stay, or stop what they are doing instantly on voice command, or receive “consequences” for noncompliance. The kind and amount of food they get may be part of the consequences.

I was astonished when I discovered that a presentation by this same Nancy Thomas had been approved for the award of continuing professional education units by the American Psychological Association, the National Association of Social Workers, and other groups. I received an ad for the presentation by accident, and as a member of APA I immediately contacted the office that deals with sponsorship of continuing education credits, which most clinical psychologists must earn in order to keep their professional licenses. Knowing that APA works with a system of “approved providers” rather than approving each continuing education workshop individually, I did not really think that anyone at the top of the organization had made this decision—but someone close to the top had to refuse to give the credits that licensed psychologists need to maintain their professional standing.

I was delighted and relieved when I learned that APA was cancelling the credits that had been planned for Thomas’s presentation—but less than pleased when I saw on the workshop website that social workers and other mental health professionals who attended would still receive credit toward continuing licensure from their national organizations.

What is the story here? Who is Nancy Thomas and what is the “Nancy Thomas parenting” that she teaches?  Yes, Thomas was a dog trainer, and as such she learned about the functions of reward and punishment and the goal of obedience to authority. When she became a foster parent, she put the same ideas to work and did “treat children like dogs”.  Under many circumstances, Thomas would have received little approval and probably would have moved on to a different nonprofessional job—perhaps back to dog training.

By chance, however, Thomas was in touch with a Colorado psychiatrist (later admonished by his medical licensing board following harm to a child) who shared her views about authority and parenting. This man, Foster Cline, had learned how to do “holding therapy” from a mentor who had surrendered his psychology license after hurting an adult patient. Cline believed, and still believes, that “all bonding is trauma bonding”. He likened the emotional attachment of a toddler develops for a parent, to the Stockholm syndrome phenomenon in which a captive “falls in love” with her captor.  Attachment, he claimed, was shown by obedience and gratitude; if a child was disobedient, he was “unattached” and needed to have parental authority demonstrated until he changed. Otherwise, according to both Cline and Thomas, first we see a bad kid, and later we see--  Ted Bundy!

Cline’s impressive though incorrect argument, and his use of the painful and frightening “holding therapy”, jibed perfectly with Thomas’s methods. In the 1990s, she developed a technique of “therapeutic foster care” in which children received a diet limited in quantity and variety, were required to ask adults for everything they needed including use of the toilet, and spent their days in tedious, pointless labor like moving all the rocks from one side of the yard to the other, and then moving them back again, or like cutting the lawn with nail scissors. Children received “holding therapy” several times a week, and spent the rest of their time being “therapeutically parented” according to Thomas’s rules, one of which was (is) that they receive no answer to their questions about going home or seeing their parents.  Schooling was considered a privilege, not a right.

This idyllic arrangement (from the viewpoints of Cline, Thomas, and their colleagues) halted abruptly in 2000, when a ten-year-old girl, Candace Newmaker, died in the course of a therapy session. Those who had supported “holding therapy” and its theory backed off, and some later returned advocating a “gentle, nurturing” treatment that involved physical holding said to involve no pain or fear. Cline began to put all his energies into a commercialized program for parents and schoolteachers (Thomas, too, has made a minor specialty of instructing teachers). But Nancy Thomas continued to recommend the same practices for children as she had learned for use with German Shepherds—practices that are disturbing to many people concerned with child welfare, and that are in no way supported by research evidence.  In fact, she built something of an empire, with “attachment camps” to which mothers and children may go, and invitations to speak in Russia on issues of adoption and fostering.

How can a person like Thomas become a success as she touts cruel and pointless child-rearing practices? The first reason is probably her extraordinary charm. Youtube pieces and training videos show her as cute, warm, responsive, and infinitely supportive of the parents who consult her. She mothers the parents in a style diametrically opposed to her recommendations for treating children. She praises the parents, and blames the children and the culture for any problems that occur, including the children’s failure to be affectionate enough when the parents want them to be. Her audiences love this stuff.

In addition, Thomas tells some quite exciting stories. In one of her books, she recounts how a badly disturbed preschooler would take a younger child around and around a grassy field on their tricycles while the adults sat out in their lawn chairs. Each time the children would pass behind a clump of grass, the older child would take the opportunity to sodomize the other, then they would emerge again into adult view. This was how Thomas told it, and it’s difficult to know how to interpret it. Was the preschooler the fastest sodomist in the West? Or does Thomas not know what sodomy is?

Stories like this one underline Thomas’s position that foster or adopted children are evil. Their wickedness is not exactly their fault, because it results from their early traumatic experiences, but nevertheless it is demonic in the literal sense. She has counseled against allowing foster or adopted children to say grace before meals, because “you don’t know who they might be praying to.” This level of evil presumably cannot be dealt with by standard child or family psychotherapies, but Thomas states that her methods have been successful with the children she works with, of whom “80% have killed” (the question “killed what?” is not answered). For over ten years, the dramatic made-for-TV movie “Child of Rage”, purporting to show how Thomas’s own adopted daughter was transformed from a potential murderer into a respectable citizen, has served as unpaid advertising for Thomas’s methods, and has convinced many a naïve viewer.

One factor in Thomas’s success is her current care to avoid direct responsibility for what may happen when families take her advice. She simply states her opinion, as the First Amendment allows her to do. If a child is hurt or undernourished or even killed, Thomas wasn’t there; it’s the parents who are the responsible parties and may lose custody of all their children or even go to prison. Thomas cannot be prosecuted for this, and because she is not a licensed mental health professional, she cannot be disciplined by a state professional board. Even when there are tragic outcomes for families, they cannot easily be traced back to Thomas’s influence. In an Oregon case presently under investigation, a 12-year-old attempted suicide after a period of “Nancy Thomas parenting” advised by a local mental health professional; the outcome of this case may be important to the whole issue of responsibility of “coaches” and “educators”.

Finally, the systems that allowed Thomas’s presentation to be approved for continuing professional education units also helped her build her empire. “Approved providers” for the American Psychological Association and the National Association of Social Workers have benefited financially from making decisions that draw large and enthusiastic paying audiences like Thomas’s, and they do not suffer in any way if wrong information has been presented. The professional organizations, too, make money from the fees charged for certification of continuing professional education. Some clinical psychologists and social workers may have been pleased to find an easy and exciting continuing education workshop whose content would appeal to their clientele. So what’s not to like? Only the impact on children and their families, and the adverse events that are someone else’s fault, not the workshop instructor’s.

It’s time for professional organizations to take a stand against “treating children like dogs”. To begin, NASW can follow APA’s lead in cancelling continuing professional education credits for Thomas and her ilk.

Tuesday, July 1, 2014

Infant Eye Contact and Visual Development-- How They're Related

Of all the posts I’ve posted on this site over the years, the one that gets read over and over again is about eye contact between infants and caregivers ( People seem to be looking for information on this subject because they’ve read that there is an “epidemic” of autism, that autism can be detected through certain “red flags” like the absence of eye contact, and because they quite reasonably believe that early detection allows early intervention and early intervention supports typical development. In fact, there is actually no epidemic, but statistics about autism have been inflated by changing the criteria for diagnosis; whether “red flags” are diagnostic of autism depends on the baby’s age, because younger children typically show some behaviors that are also found in older autistic children; and whether early intervention is effective for autism is still open to question.

Still, worrying is a feature of the natural history of parenthood, and we’re all likely to worry about whatever problem we see or hear most about. Seventy years ago, parents worried about polio, and before that, about tuberculosis. When autism is understood and cured one day, there will be different worries!

I don’t propose to be able to make people stop worrying about autism. However, I think it’s possible that if some aspects of development were better understood, there might be less concern about eye contact with very young babies. I have been thinking about this because I’ve had several similar comments recently on the post linked above. These were queries from mothers who were concerned that their babies seemed to look at people across the room from them, to make eye contact and smile and generally be sociable, but not to do this in response to someone who was holding them. It seemed all too easy to interpret the behavior as not “liking” or “being attached to” the holding person, and by extension to say that there was something wrong with social relationships, and therefore there might be autism developing.

Neither I nor anyone else can guarantee that a certain baby will NOT later be diagnosed as autistic, on the basis of that baby’s behavior at a few months of age. However, I think that if we look at some details about development, we’ll see that there are reasons why a baby might look at and be interested in a more distant person and not a nearer one. (Warning: This is complicated, and you might not want to plough through the whole thing--  but it’s one of those things where you either have the details, or you have only a vague and useless statement.)

The important issue here is about how vision changes with development. If a baby is going to make eye contact or smile in response to someone else’s smile, he or she has to be able to see the eyes or the smile, and this ability develops gradually during infancy. (It does not become really adult-like until about age 6 years.) All babies, autistic or typically developing, go through these changes in vision, which are more complex than you might think.

A lot of parents today know that newborns have very little clear vision other than at a fixed focal distance of about 8-12 inches from the eye. Where most people get confused, though, is in thinking that at a distance of 8-12 inches a young baby can see the same image an adult would see. This is not correct. A newborn sees in daylight the same amount of detail an adult would see in moonlight. In addition, babies have poor acuity (the ability to see small details). At age one month, the acuity is about 20/250, meaning that the baby can see at 20 feet away the same size details that an adult with good vision can see at 250 feet. At age 3 months, acuity is still no better than 20/150. And, keep in mind that a baby cannot do any of the things adults can do to improve their view of an object--  they can’t get closer, turn on a brighter light, or hold the object at a better angle.

But what I’ve just said suggests that young babies ought to be able to see near things better than far things, when they can see them at all. So what explains the queries about babies looking at a distant person and not a near one? Here’s where a couple of complicated things come into the  picture. The first is a matter called a contrast sensitivity function. This basically means that if you make a graph showing how bright a light needs to be in order for a baby to see something, that graph will show that not everything is equally easy to see. In order for babies to be able to see narrow lines, they need the lines to have high contrast--  to be black and white rather than grey and white or pink and powder blue. (Interestingly, one of the people who has done a lot of work about newborns imitating facial expressions, Andrew Meltzoff, had really black eyebrows and a contrasting pale face; I’ve often wondered whether a blond could have had the same success!)  

If the lines are medium-sized, babies can see them even when they are of lower contrast and the light is dimmer. Human eyes seem to be specialized for a certain size of detail and level of contrast; this is true for adults too. But here’s the really counterintuitive piece: when the lines are broad, they are harder to see, and the baby needs more contrast and more illumination to see them. This is exactly the opposite of what we would assume--  we expect big things to be easy to see, small things to be harder, but it’s not so. How does this apply to babies looking at faces? Well, when a face is farther away, its image on the eye is smaller, making it more like the easy-to-see  medium “stripes”. When it’s close, its image is larger, making it more like the hard-to-see broad stripes. This means that the baby needs brighter light to see that a face is a face, but if we are bending over the baby, chances are that our faces are in shadow.

[I know this seems like a strange phenomenon, but I should point out that it occurs at the other end of life too. Elderly people lose sensitivity to broad stripes. When we get right in their faces, they may not be able to recognize us, or even to be sure that what they see is a face. Backing off a bit may enable them to see who is there.]

There’s more to be discussed here, if anyone is still with me. How about the baby’s ability to recognize a shape? This too changes in the first months. Newborns tend to move their eyes to look at the edges of any shape, including a face. After about 6 weeks they still do this, but at the same time will spend some time looking at details within the outline. (And guess what, this is about the time that many babies begin to smile back at a smiling face occasionally.) Details about the eyes are often very attention-getting for young babies--  they are shiny, they move, and there is often high contrast between the iris and the “white” and between eyelashes and pale skin or between dark skin and the “white”. (Does this mean young mothers should be encouraged to wear a lot of eye make-up? It couldn’t hurt, certainly!)

One more thing to consider here: part of a baby’s vision depends on the ability to use the eyes together, and to move them so they are looking at the same object at the same time. This ability, convergence, is much more important for near objects than for distant objects. (You can show this to yourself by looking at a near object and then covering first one eye and then the other. You’ll see that you actually have different “pictures” of the object seen by each eye, with extra information coming from the differences between the pictures. Try it again with a distant object--  the two eyes get pretty much the same picture.) Convergence on a near object is quite inconsistent until the baby is about 2 months old, and still takes a lot of time until about 3 months. This means that an adult can quickly look from a near to a far object or vice-versa, but a young baby cannot. When convergence is good, babies can use a lot of information from it to help figure out how far away something is and therefore what it might be. Is it something that is actually an interesting human being, or is it a doll or a picture? What’s obvious to adults may be a puzzle to a young baby.

I hope this shows the parallels in development of visual ability and in expression of interest in other people. When a baby does not make eye contact, the reason may well be that his or her visual development is not sufficient to identify a face under certain conditions of light or distance. Let’s not wave any “red flags” until that possibility is ruled out!

N.B. To save space, I have not given sources for this information, but I have them available if anyone wants them.