Bringing Good Out of Tragedy: Rita Swan and CHILD

Almost forty years ago, Rita Swan and her husband, then devout Christian Scientists, prayed and watched as their toddler son died without the medical treatment that could have saved his life. Many people would emerge from this experience embittered or self-loathing and turn to drugs or alcohol to sustain them in a lifetime effort to avoid their memories.

Instead of succumbing to bitterness, Rita and her husband created an organization that has worked ever since to help educate parents and to push for legislation and law enforcement countering religious practices that bring suffering and possible death to young children. The organization is CHILD--  Children’s Healthcare Is a Legal Duty. Rita has maintained two websites, www.childrenshealthcare.org  and www.idahochildren.org. Childrenshealthcare.org contains material about all the work of the organization over the years and describes a multitude of cases in which mistaken beliefs caused harm to children. The most recent newsletter from CHILD recounts events of faith-based medical neglect in Idaho, and the position of one group of parents that children have no rights, that there are many medical errors made, and that medicine is in any case “of Satan”. This group apparently reports neither births nor deaths of children, so it is impossible to know how many children have died unnecessarily, but there are many child graves on the group’s property.

Rita Swan is now retiring as president of CHILD and the work of the organization is being taken over by the legal scholar Marci Hamilton  of the University of Pennsylvania. The new organization’s website is www.childusa.org. Much remains to be done, and in a final letter Rita Swan states that she will continue to work on issues in Washington State, where Christian Scientists are exempt from charges of criminal mistreatment, second-degree murder, and failure to report abuse.

No one says that it is always easy to know when it is right to give children medical treatment and when it is right to withhold it. The recent case of the infant Charlie Gard has shown some of the many conflicts over decisions that no more can be done for a child and that further attempts simply prolong suffering. However, arguments based on the ideas that children have no rights, or that a supreme being will be insulted by parents’ lack of faith if they seek medical help, really cannot be allowed to influence either difficult or easy decisions about children’s health care. Nor, in spite of all respect and concern for parents’ relationships with their children, can a community allow parents to make decisions alone while under the enormous stress of caring for a very sick child. We all have a stake in these decisions and the precedents they set for the future.

Rita Swan has done so much to clarify personal and legal thinking on these issues. Thank you, Rita, from everyone concerned with children’s welfare!

CALO and the Transferable Attachment: Love Your Dog, Love Me

From time to time I see advertisements for a residential treatment center known as CALO (www.caloteens.com), or for programs apparently related to this model. The programs provide residential treatment for children and teenagers who, the proprietors claim, are difficult to parent because they suffer from Reactive Attachment Disorder. RAD is said to make them lonely and miserable, unable to “bond” with others, uncooperative, poor school achievers, etc., etc. As occurs all too often, these proprietors note their belief that adoption even at birth is likely to result in these undesirable outcomes.

Let’s have a look at one CALO website, where “our proprietary treatment” is described at www.caloteens.com/message2.html. I want to note first that “proprietary treatment” is a term generally reserved for methods whose details are considered to be trade secrets, statements about which are protected as commercial speech in the United States. Unlike information about research-validated, evidence-based treatments, for which details are easily available if you know where to look, proprietary treatments are difficult and usually quite expensive to learn about--  as a rule, you have to sign up for workshops or seminars or buy material from a suggested reading list sold only through the proprietors.

Material at caloteens.com suggests that a major CALO concern has to do with a rivalry with behavioral modification programs. As is typical of non-evidence-based, commercially driven proprietary treatment programs, the CALO discussion argues that behavior modification, which is seen as a rival, replicates harmful situations that have already affected the children, and that recovery from childhood problems must begin “with the heart” and be followed later by behavior change. It is not stated with any clarity how any “heart” changes can be detected before they are followed by behavior change, and therefore it is far from clear how CALO’s claimed (but unlisted) research basis could have been established.

      

The CALO website also stresses the need for specialized treatment of childhood mental health problems, and notes that their staff are specialists in treatment of attachment and trauma disorders, as described and trained by groups like ATTACh and the Attachment & Trauma Network. These comments are red flags for the possibility of two difficulties often associated with proprietary treatments.

One is the assumption that some single factor, such as attachment, is the single most important cause of a wide range of developmental and emotional problems; like the bed of Procrustes, this assumption compresses or stretches problems caused by combinations of biological and environmental problems so that they “fit” the chosen bed—in this case, the attachment bed. As has been pointed out by the British psychologists Woolgar and Scott, this sort of single-factor explanation opens the door to choices that ignore not only complex causes, but even simple factors that differ from the chosen cause.

A second red flag has to do with the assumption that the details of a CALO program are of necessity essential for treatment. However, serious work in clinical psychology has for years focused on general or shared factors that contribute to good outcomes achieved through treatments that are different in details. In some cases, such as EMDR, specific details (like eye movement) may have nothing to do with positive outcomes, which probably result from general helpful factors like empathic responses. The CALO claim to uniqueness of its program is thus not likely to be a strong argument for people with training in understanding therapeutic approaches—but it is quite likely to appeal to worried parents.

However, let’s go on to my favorite bit of the CALO website. This is the part about golden retriever therapy and the transfer of “attachment lessons” learned from dogs, to human relationships. Kids in CALO programs take care of dogs; they are said to “learn trust” from the dogs, therefore to understand attachment, and therefore (with some additional, undescribed help) to transfer the attachment they have learned from the dog to a human being. This is quite an interesting idea, but one that makes a common but mistaken assumption about emotional development, and also one that betrays considerable confusion about how attachment works and what an attachment relationship is.

The first issue here is one that I have often termed “ritual reenactment”. The basic idea is that if certain events lead to a positive outcome for infants and young children, those events, reenacted in some way in later life, will recapitulate normal development and correct any problems that occurred when they were wrongly experienced earlier on. This belief has appeared in many forms from Sandor Ferenczi’s “babying” of patients to the methods of Frieda Fromm-Reichmann as fictionalized in I Never Promised You a Rose Garden  to Nancy Thomas’s insistence on bottle-feeding older children. None of these methods has ever been shown to be effective, but somehow the thought of a “do-over” continues to have a strong appeal to the public.

But--  suppose that just for the sake of argument we accepted the idea of the “do-over”, would caring for a golden retriever be a way to do this? A comparison of the ordinary and the “treatment” situations says it would not. In typical early development, a child is cared for by a consistent and responsive small group of adults. The adults  care for the infant physically, but they also spend much time showing their positive feelings about him or her, working toward communication of child to adult and adult to child, and enjoying play and social interactions that bring pleasure to both adult and baby. The outcome of these experiences is that the toddler stays close to the familiar adult if anything is scary or distressing, can be comforted by the adult hen distressed, and explores new things best if allowed to have contact with a familiar person at will. (This set of behaviors has been summarized as “trust” or as “attachment”, although those terms really apply to a hypothesized inner state that guides the behavior. ) Well before school age, children put their social experiences to work to build a set of ideas about how people interact socially, sometimes called an internal working model of social relations (IWM). The IWM continues to develop, sometimes along new lines, as the child grows and has new social experiences.

How does that set of events compare to caring for a dog? First of all, the roles are reversed. The human being acts as the “parent” and the dog as the “child”. If the boy or girl does a good job of nurturing and playing with the dog, the dog will develop trust in the boy or girl—but certainly not an exclusive trust, especially if the dog is a very sociable golden retriever. The CALO website says that the child learns empathy for the dog and therefore becomes more empathic toward his or her parents, but it is far from clear how either of these things could happen. If a child is a callous, unemotional individual, in what way will doing the work of caring for a dog teach or motivate empathic skills? And, if the child did become able to empathize with a dog, read the dog’s signals, become aware of the dog’s usual needs, even realize that any golden will convey that he needs yet another roast beef sandwich because there really wasn’t any meat in the one you just gave him—how do any of these skills relate to the more complex needs and messages of human beings, the facial expressions, the body language, and all the other factors that influence empathic responses?  How do any of these enter into the IWM’s further development? Indeed, if trust and attachment were transferable, there would presumably be no attachment disorders in adopted children, as all (according to the CALO website) must have been attached to adults in the past, even at birth, so they ought to be able to hand that attachment package over to a new caregiver, just as they are claimed to “transfer” attachment from a dog to a human.  

Since the relatively new developmental trauma disorder fad came on the scene, I’ve been expecting to see fewer extravagant claims about attachment, but it seems that CALO and similar groups are getting all the juice they can out of the mythology of attachment. And, of course, therapy dogs, emotional support animals, etc. are now in fashion, so why not bring in the golden retrievers too?

Perhaps we’re lucky that they haven’t decided to create attachment through pot-bellied pigs.

  

Exporting Pseudoscience: Attachment Therapy Comes to Russia

Communications and interactions between the United States and Russia are marked by suspicions and sanctions these days. Some commodities that used to be readily available in Russia are no longer imported from the West.

Regrettably, sanctions have not prohibited the export to Russia from the United States of various pseudoscientific ideas about psychology and child development. In particular, we are seeing the spread in Russia of the theories and practices of “attachment therapists” and their helpers who subscribe to the use of “Nancy Thomas parenting” with vulnerable children.

Some readers will already know exactly what I am talking about, but for those who do not, I’ll supply some brief definitions. “Attachment therapy”, sometimes known as “holding therapy”, is an implausible, non-evidence-based treatment claimed by its proponents to be effective for certain childhood mental health problems. Advocates of “attachment therapy” (AT) also claim that their principles are derived from the work of John Bowlby, the originator of attachment theory, a framework for understanding the feelings and behavior of young children with respect to familiar and unfamiliar adults. As I have pointed out in other posts on this blog and in various print publications, the beliefs about attachment employed by AT proponents share almost nothing with Bowlby’s theory, but are instead essentially retrofitted to provide a rationale for AT practices such as restraining children physically, shouting at and intimidating them.

Two other points to define here: AT proponents describe adopted and foster children as suffering from Reactive Attachment Disorder, a real though rare psychiatric syndrome described in DSM-5 and ICD. However, the alarming symptoms they list, including eventual serial killing, have nothing to do with the symptoms of RAD. They form instead a pattern that I have referred to as faux-RAD , resulting in a counterfeit disorder to be treated with a counterfeit therapy. Finally—and to my mind perhaps most importantly—AT advocates claim that their restraint treatments need to be accompanied by adjuvant methods sometimes referred to as “Nancy Thomas parenting”, created and taught by one Nancy Thomas, a self-identified instructor of foster parents, who recommends limiting the amount and variety of a child’s diet, withholding information as well as food from the child, requiring the child to ask permission for “privileges” like a drink of water or use if the toilet, and so on. These methods, joined with rocking the child like a baby and hand-feeding him caramels (yes, really, but I don’t want to take time to explain her reasoning right now) are said by Thomas and her followers to correct attachment problems that adopted and foster children may have experienced, and as a result to render the children docile, grateful, and affectionate. (The actual results of this kind of  treatment in one case may be seen at http://www.wbay.com/cotent/news/Wrightstown-couple-accused-of-starving-adopted-son-mentally-abusing-him-433665943.html --- and this case is not an outlier.)

AT and “Nancy Thomas parenting” (NTP) had their beginnings in the United States, and they have always seemed to me to have a peculiarly American, pioneer spirit, rough frontier justice, snake-oil salesman flavor to them—like something out of Mark Twain. Other countries have their own ways of abusing children (as witness the old German “black pedagogy”), but AT and NTP seem to be genuinely “made in America”. Our British cousins have picked AT up a bit, but on the whole their [former] EU membership made them somewhat wary about legal concerns related to maltreatment.

Now, however, we see Russia picking up AT and NTP with apparent great enthusiasm. For some years. American advocates of authoritarian child treatments have flirted with Russia, occasionally being invited to speak, and occasionally being prevented from speaking. In the last few years, an influx of AT proponents and AT ideas has penetrated Russia—in spite of the very clear fact that Russian adoptees who were harmed in the United States, leading to the ban on foreign adoptions, were in many cases harmed by AT and NTP practices! This connection appears to be invisible to groups of Russians who have hurried to encourage adoption of large groups of children from orphanages and have sustained the belief that they can “fix” these children by following AT and NTP precepts.

What exactly has happened in Russia? I have been receiving a series of descriptive comments from Mihail Able (see comments at childmyths.blogspot,com/2017/07/the-russian-adoption-ban-magnitsky-act.html; scroll down to the comments section, and please understand that Mihail is doing this with Google Translate). Mihail discusses specific families’ problems resulting from their acceptance of AT and NTP principles and practices.

In addition, my friend and esteemed colleague Yulia Massino has been following with distaste news of tours in which Nancy Thomas herself has come to instruct the Russians how they should deal with adopted and foster children. She has made her usual claims of “curing” 87% of children who have come to her as crazed future killers. (For some reason, the numbers 80%, 85%, 87%  have great power in AT circles, although of course there have never been systematic studies either of the children’s initial conditions or of the outcomes of NTP or similar treatments --  much less any randomized trials, and much less any detailed publications.) Interestingly, Thomas describes this trip as a “missionary” trip without mentioning the country visited (http://www.facebook.com/ntparenting/posts/1322659427848500).

Following Thomas, there has recently been an exporting trip by staff of the Attachment Institute of New England, an organization that has for many years pushed AT principles and practices. Yulia Massino wrote about this trip on her own blog, http://yuliamass.livejournal.com/232733.html   and http://yuliamass.livejournal.com/235689.html    (in Russian; use Google translate to read). She pointed out the activities of the two AT visitors, Ken Frohock and Megan “Peg” Kirby, who raised money from sympathizers for their trip and now describe it on the AINE Facebook page and announce lectures at their website http://www.attachmentnewengland.com.

A 2007 press release from AINE (www.attachmentnewengland.com/press.html ) referred to their therapy as utilizing parental eye contact and parental holding of children. The same press release mentioned a presentation by Nancy Thomas and referred to her training with Foster Cline, probably the best-known proponent of intrusive, authoritarian treatments targeting adopted and foster children. AINE has never recanted publicly from these positions; they have in the last few years picked up the most recent terms having to do with trauma, but have not stated any changes in their treatment methods. Although I do not know exactly what they said or did on their trip to Russia, if they were horses I would bet that their track record of AT and NTP involvement would be the best predictor of their performance there.

It seems that a fruitful new market has opened in Russia for the export of pseudoscience manufactured in the U.S. Interestingly, Yulia Massino has told me that the concept of emotional attachment, which “everybody knows” (not always correctly) in the U.S. and U.K., has not been discussed much in Russia. This may leave many Russians open to the impression that attachment, and therefore AT, is a brand new discovery of ingenious Western scientists. Fortunately a new article in circulation by Michael Ivanov may help counter this impression—but I am very much afraid that Russians are not learning from observation of the ill effects these beliefs have had for children in the U.S. You would think they might remember the harm done to Russian adoptees in the U.S. some years ago…

You can see Michael Ivanov's new article at https://www.researchgate.net/publications/318420576_Harmful_Treatments_in_Child_Psychotherapy.

The Russian Adoption Ban: Magnitsky Act, or Attachment Therapy Problems?

On July 9 and 10, 2017, the New York Times published articles by Jo Becker, Matt Apuzzo, and Adam Goldman on the subject of meetings between Trump campaign representatives and a Russian lawyer during the 2016 election campaign. These articles reiterate a common belief about the Russian prohibition of adoption of Russian children to the United States—they claim that Putin put this restriction in place when infuriated by the Magnitsky Act of 2012 and the sanctions it put on Russia.

It may well be that Putin was annoyed by the restrictions, but concerns about the fates of Russian children in the United States had started rather earlier in both countries. Russian-adopted children had appeared repeatedly in news reports of ill-treatment and even child deaths. In 201l, I commented on this at https://childmyths.blogspot.com/2011/11/nathaniel-craver-case-many.html. In the same year, www.childrenintherapy.org/news.html discussed the USA-Russia Adoption Treaty, with reference to child maltreatment; at that time, Pavel Astakhov, the then-ombudsman for children in Russia, had been asking for continued contact with children adopted from Russia to the U.S. and for continuing their status as Russian citizens. Also in 2011, this issue was discussed at https://phtherapies.wordpress.com/2011/08/24/reactive-attachment-disorder-rad-dispelling-the-myths/. The Beagley case in Alaska, involving mistreatment and “hot-saucing” of a Russian-adopted boy, caused much horrified discussion in both the U.S. and Russia.

All of these very genuine concerns about inappropriate treatment of Russian children in U.S. adoptive families were under discussion before the Magnitsky Act. There is no question in my mind that Russian adoptees, as well as children adopted from other places, were in many cases badly mistreated by adoptive parents who had bought into mistaken beliefs about attachment and about Reactive Attachment Disorder.  These parents had been told by “attachment experts” that emotional attachment of children to parents occurred because of power assertion by the parents, and that such attachment was essential to prevent later vicious criminal behavior. The parents believed this, and they did assert power by physical means including withholding food and exposing children to cold and other discomfort. In some cases, they countered disobedience by forcing children to eat or drink large amounts, sometimes causing death.

Pavel Astakhov investigated these problems carefully and recommended prohibiting adoption of Russian children to foreign countries. One part of his reasoning about the U.S. is that this country has never ratified the U.N. Convention on the Rights of Children, a distinction that we share only with Somalia.

The point I am making here has nothing to do with the Trump campaign or any election events, of course. I simply want to remind people that the ban on Russian adoption is not a simple tit-for-tat reprisal created by Putin in response to the Magnitsky Act. It was based on very real events in this country, and I could only wish that Americans could ban adoption of American children to persons who are likely to use attachment-therapy related power assertion methods that have harmed children in the past—and are still harming them today.    

   

The Attachment Spandrel: A Speculation

When people talk about evolution of structures and functions or of behaviors through natural selection, they sometimes use an intriguing metaphor. They suggest that human evolution can have a an aspect that can be compared to a spandrel—an architectural feature like an arch that was originally developed as a way to support a building, but that later was liked for its attractive appearance and put to work as a way to decorate a structure. It seems possible that human evolutionary change involves spandrels too, with traits that began with one function later becoming useful in other ways. For instance, eyebrows might originally have been useful for keeping sweat out of our eyes, but now are used in facial expressions and gestures that convey our moods and intentions to people we encounter.

Can young children’s emotional attachment to their parents be considered as a trait that can be “spandrelized”? (Maybe there’s a proper word for this but I don’t know it.)   This would certainly not be the way that many people, including quite a few unconventional psychologists and counselors, think about it.  It’s commonly, but incorrectly, assumed that once an attachment relationship develops in early life, that attachment stays the same unless something happens to stop it. For example, the death of a parent and subsequent mourning would deactivate that attachment; some “parental alienation” advocates hold that one parent can destroy or at least suppress a child’s attachment to the other parent by emotional manipulation. People who believe in these ideas apparently miss the fact that both attachment behavior and cognitive abilities that are part of thinking about attachment change in the normal course of development, and this contributes to changes in the nature of relationships that originated in toddler’s emotional connections to familiar adults.

So where does the spandrel part come into this? What I am going to say is speculation, just like most of the Just-So stories that are put forth as ideas about the evolution of behavior. But it is possible to make the case that attachment began as a result of natural selection for certain advantageous behaviors, and then later was put to work for other purposes.

Many birds and mammals show some form of “attachment” to parents. Ducklings and goslings, for example, follow moving objects that they see soon after hatching, and those objects are most likely to be their mothers. Whatever kind of object they initially follow, they will during early life follow that same object, and in adulthood will court and attempt to mate with a similar object. This initially serves a protective function and encourages survival, because although a mother duck might not be able to fight off a fox, her behavior against a predator does increase the young duck’s chances of escape. The same consideration applies for young humans, whose curiosity and exploratory behavior could lead them straight to an enemy if they were not “attached” so that they stayed close to familiar adults and avoided strange creatures. Whereas ducks and some other animals form their “attachments” shortly after birth or hatching, humans, who are very immature at birth and cannot move independently for many months, do not show attachment behavior until roughly the time when they might be able to wander away.

Looking at it this way, we can see the enormous survival value for the young of preferring to stay near familiar adults and being wary of strangers and unfamiliar creatures. But within a few years after birth, human children become much more able to judge danger and to keep themselves safer (perhaps not in today’s high-speed traffic, but in the environment of early adaptation). They don’t need attachment for survival in the same way, yet they retain strong relationships with familiar adults under many circumstances, and do this right up until their own adulthood, often modulating into a “reversed” relationship when an aging parent needs the adult child’s care.

Feelings and thoughts about attachment thus lose much of their survival value after the child gets to “school age”, but those feelings and thoughts can be seen as serving new, useful purposes for both the individual and the group--  in other words, attachment has become a spandrel. For the individual, behaviors learned from experiences in the attachment relationship can provide a foundation for understanding other social relationships—that is, they form the internal working model (IWM) of relationships that John Bowlby proposed. The IWM allows the older child and adult to participate in any social relationship with some confidence in assumptions about how social interactions work. The individual does not have to develop new rules from scratch about interacting with any new person he or she meets, and this saves time and energy.

The community also benefits from the attachment spandrel for several reasons. One is that the social rules learned in the early attachment relationship help young adults care for their own children effectively and enlist other community members to help in this task when needed.  In addition, the community survives and thrives better when social interactions among members are orderly and constructive, when conflicts and aggressive impulses are modulated by attachment-influenced social rules. For just one more, community values and beliefs are more easily shared and passed on in the context of existing close relationships where they are modeled and implied, than if they had to be taught through direct instruction.

Thinking about attachment after the toddler period as a spandrel can be a helpful way to understand how some aspects of attachment work. But the really basic point is that attachment changes through the course of development, and that toddler attachment, fascinating though it is, cannot be considered to define the nature of attachment later in life.

Too Little or Too Much: Bringing Complaints About Patterns of Child Maltreatment

Now and then I encounter questions about some abusive practices that are done as part of unconventional “attachment therapies”. Adopted and foster children are often the targets of practices advised by non-mainstream therapists, counselors, and coaches of various stripes. The suggested methods can include all or some of the following:

·         Limiting the quantity and variety of children’s diets

·         Requiring children to “strong sit” tailor-fashion for periods of time without speaking or moving

·         Insisting that children ask permission for everyday actions that are normally handed independently after age 2 or 3, such as using the toilet or getting a drink of water

·         Punishing children who eat or drink without permission by forcing eating or drinking of large quantities

·         Confining children to a bedroom or a basement for many hours, sometimes providing only a bucket for sanitary purposes

·         Placing alarms on bedroom and cupboard doors

·         Removing all but minimal furniture from the bedrooms where children spend much of their time

These methods are claimed to be directed at creating parent-child attachment and preventing children from becoming murderers in later life—claimed goals that would certainly get the attention of most parents and make them likely to work zealously to do as they are told.

The first problem, of course, is that these methods have nothing to do with creating attachment, attachment has nothing to do with murder, and thus the methods do not treat either mental illness or criminal tendencies a child may have.

The second problem? Well, this is what I want to get at. I hear from worried people who tell me they have seen a sister or neighbor or someone else who seems to be using methods like those above. Sometimes they have reported to child protective services, sometimes they haven’t but wonder if they should—don’t want to get anyone in trouble unnecessarily but don’t like the looks of the situation, etc. What would happen if they reported?

Generally speaking, nothing would happen.

Unless a child is injured or killed as a result of an adult action, using methods like the list above is not illegal. Research definitions of child abuse contain categories that most of those items would fit into, but laws about child maltreatment do not. Like most laws, those laws have the goal of covering as much territory as is needed without getting into too many details.  We don’t have laws that say not to lock the child in a bedroom, because such a law could easily be evaded by locking the child in the basement, woodshed, broom closet, or garage instead. A law can’t include all the possible places a child could be locked up. And, we don’t want a law that will punish parents for child abuse if they accidentally shut a door and leave a child locked in until they hear him yelling five minutes later. Many of the things on that list are actions that a parent might carry out unintentionally or in a very mild form. (“You took that extra pancake that your sister wanted, now I want you to eat it!”)

Because we do not have such very detailed laws about child abuse, and because most parents might occasionally do something that was a bit like the items on the list, it would generally be assumed that any parental act that would be considered abusive must pass a pretty high bar--  one that could not be met by insisting someone eat the pancake he swiped or ask permission before eating something specially prepared for a party. As a result, a complaint about one incident of a listed action  would not—and probably should not—be given much attention by a child protection agency. Even a set of complaints about many items on the list would probably not contain any one item that would reach that high bar. The items on the list would not even be picked up by a checklist of adverse childhood experiences (ACEs) that are known to be associated with problematic developmental outcomes.

Each item is too little to trigger official action, but many repetitions of many items  are likely to form a pattern of experience that includes too much adversity to foster good development. Just as an accumulation of small injuries can lead to untoward physical consequences, it seems possible that repeated psychological injuries can have an outcome that is greater than the sum of its parts. Unfortunately, there is usually no way for a concerned observer to report a pattern of problems; an outsider sees only the occasional event and has no way to know what happens between times. Even if the pattern were carefully recorded, child protective staff may have no mechanism for interfering when each incident, standing alone, looks unpleasant but minor. The parent’s actions may not be “best practice”, but which of us can claim that we always make the best choices? There is plenty of evidence that we just need to be “good enough parents”, and we do not really have clear standards about what is “good enough”.

I would like to propose that agencies and organizations move toward recognizing the patterns of multiple, apparently low-impact, possibly cumulative, but risky, parenting behaviors. At the least, such an approach could prevent some of the child deaths from slow starvation and exposure that crop up in the news with relentless regularity. At the most, such an approach, coupled with parent education and supervision, could improve the chances of excellent developmental outcomes for large numbers of children now at risk.