Supersized Families and Words of Knowledge: A Connection? Or, Right You Are If You Think You Are

When I was commenting on Kathryn Joyce’s Slate article about the terrible life and death of Hana Williams last week, I was struggling to think of a reason why adoptive parents would try to care for more children, and more challenging children, than common sense would say anyone could manage effectively. It’s clear, as Kathryn and other writers have frequently pointed out, that fundamentalist Christian beliefs have often driven the growth of “megafamilies”--  although in cases like that of the Schultzes in Tennessee a few years ago, it was not God but Mammon that was probably the motivating factor. Still, there are many fundamentalist Christian families who have adopted some children, but stopped while they were still in control of the situation--  so why do some go on and on? In my earlier post, I speculated that there might be some form of emotional disturbance that would create a powerful, anxiety-based drive for more and more children--  but even in talking about this, I realized that I was trying to separate some aspects of megafamily adoption from religious beliefs, in the hope of identifying some characteristic of potential adoptive parents that could be used to keep their family size within manageable limits.

While reading about the Williams family, I noticed particular statements about the adoptive parents’ emotional reactions to pictures or information about come children--  that their hearts went out to Hana, for example. This stayed in my mind as I went on to read a second article about a megafamily, or, as the author Maggie Jones called it, a “supersize” family (www.nytimes.com/2013/11/17/magazine/god-called-them-to-adopt-and-adopt-and-adopts.html?_r=0). So far, I’m delighted to say, this family has not had a tragic history, although the adopted children come from difficult histories of their own.

According to Jones, the adoptive mother of this family “latched onto the idea of adopting from foster care after hearing an ad on K-LOVE, a  [Denver area] Christian radio station, about a new organization… that was helping Christians adopt foster kids… ‘Has God been calling you to adopt?’ the voice-over asked.” Jones also noted that of “the dozens of evangelical and conservative Christian parents I spoke to, many said that church sermons, Christian radio shows or other Christian campaigns, including Focus on the Family’s national foster-to-adopt program, pushed them to adopt.”

Why were these ads and sermons so effective? Presumably, Christian adopters are not more susceptible to persuasion in a general way than other people are—they don’t, I suppose, buy more from catalogs or e-mail ads than most of us. Can it be that there is something in their belief system that makes them more easily persuaded to adopt, and adopt more and more? I think there are a couple of points of belief that do have this impact.

One of the points is institutionalized to some extent because of its appearance in the New Testament. James 1:27 tells Christians to care for distressed orphans and widows. (As others have pointed out, the widows seem to be getting pretty short shrift, but that’s a whole different issue). The form that care should take is not described, and in the past contributions to missionaries and orphanages were generally considered to put a person in compliance with this admonition. Today, as Kathryn Joyce pointed out in The child catchers, care for orphans is conflated with the Great Commission of spreading the Gospel, and for many the child’s conversion to Christianity is as important a goal as relieving physical distress. (One can see why this is the case, given the belief system.)

A second point of belief has become part of one type of Christian belief system over the last hundred years, in spite of the rejection of this idea by mainstream churches. This is the belief that miraculous events, of the types described in the Bible, can still occur today for people who are committed to a system that is variously described as charismatic or Pentecostal. Charismatic believers consider that they can experience or carry out supernatural events like those described as occurring for Jesus’ followers after his death. These include the ability to detect evil spirits and to exorcise them--  an ability to be expected after one is shown to be part of the system by “speaking in tongues”.

Of the phenomena to be expected by a convinced charismatic, a superlatively important one is to be spoken to by God, who will indicate his wishes for a person. The K-LOVE ad literally referred to this: “Has God been calling you to adopt?”

The idea of a direct message from God is a difficult one for nonbelievers to understand, and this is partly because even when joking about this we tend to think of a spoken message of the kind we would receive from another person. Gary Trudeau made much of this idea several years ago in showing his reporter Rick Redfern at a press conference where God spoke to the person being interviewed--  but “only on background. This was not for attribution.”

But charismatics do not necessarily expect a message from God to come in the form of a voice they can hear. It is more likely to be in the form of a “word of knowledge”. According to www.christcenteredmall.com/teachings/gifts/word-of-knowledge.htm, a word of knowledge is “a definite conviction, impression, or knowing that comes to you in a similitude (a mental picture), a dream, through a vision, or by a Scripture that is quickened to you. It is supernatural insight or understanding of circumstances, situations, problems, or a body of facts by revelation; that is, without assistance by any human resource but solely by divine aid.”  If I understand this definition, it means that a divine message could come in the form of preoccupation with an idea or text, as well as by intense emotional responses that are experienced as conviction. I don’t understand to what extent self-editing or examination of conviction and impressions is acceptable, and to what extent it would be considered as disobedience to the divine message. It would seem, though, that all that is needed to identify a word of knowledge is a sense of certainty--  or, in the title of Pirandello’s play, Right You Are If You Think You Are.

Mr. and Mrs. Williams reported the sense that their “hearts went out” when they saw Hana’s pre-adoption photograph. Did they identify this experience as a word of knowledge or a divine command, I wonder? Similarly, the family Maggie Jones wrote about, when they were reluctant to adopt more children. received an e-mailed picture from an adoption caseworker, which they said “pulled them in”.  Did they too identify  as a divine message the compassionate impulse that most of us feel toward children in trouble ? If so, perhaps we have an explanation of why some adoptive parents do go on accumulating children, sometimes with obviously tragic outcome, sometimes, perhaps, with unknown impacts on the children and the adoptive parents themselves.

What should we do, then? Can we possibly ask potential adoptive parents if they have charismatic beliefs that might affect how they manage their families? No, of course not, and I don’t think even the most militant atheist would care to countenance such a question and its influence on adoption decisions. (Presumably most of us would not want free-thinking or any other view of life to prevent us from adopting.)

However, we can limit the size of adoptive and foster families as we limit the size of other care groups. For example, in many states, family day care homes (services that care for young children in the caregiver’s residence) are limited in the number of children to be cared for and the age range of those children. In New Jersey, family day care providers may not care for more than three children under a year of age, or more than four children under two years of age, of whom no more than two may be under one year. If one or more children under 6 are present as well as those younger children, a second caregiver must be present as well as the primary caregiver. Interestingly, with respect to the family described by Maggie Jones, the New Jersey guidelines for family day care prohibit leaving children alone with an assistant under the age of 18 except in an emergency, and forbids children under 16 from working so many hours that schoolwork is affected--  whereas Jones’ article describes a daughter now 18 who has been driving siblings to school and changing one child’s tracheostomy dressing, apparently for some time.

Whatever the religious or personal motives for the creation of megafamilies, it would seem that we already have a template for limiting them. Like so many other issues, however, applying the template requires political will, and acceptance of conflict with some adoptive parents--  and, no doubt,some adoption caseworkers.

   

A New German Book on Festhaltetherapie (Holding Therapy as Practiced by Welch and Prekopova)

A new book, Festhaltetherapie: Ein Pladoyer Gegen Umstritten Therapie…. (Holding Therapy: An Argument Against Controversial Therapies) was published in 2013, and I thank Mrs. Alena Bilkova for calling it to my attention. I hope to get in touch with the editor, Dr. Ute Benz, but I haven’t managed this yet (maybe LinkedIn will do it?).

Festhaltetherapie is a treatment that resembles American “rage-reduction therapy” and other methods that use physical restraint of children in the belief that these procedures have therapeutic effects on psychological problems. Unlike the  “classic” American holding therapy, Festhaltetherapie (or, to give its Czech abbreviation, TPO) does not hold the child in the therapist’s lap, use provocative physical prods,  or demand that the child shout slogans about wanting to kill people. Festhaltetherapie involves a parent holding a child tightly while the parent expresses feelings about the child and the child cries and struggles, until both are exhausted. Young children are held on the lap facing the parent (usually the mother), but larger children lie on the back with the mother face-to-face on top of them, restraining their hands with her own. Festhaltetherapie is used with autistic children and those who are oppositional by Jirina Prekopova, the Czech proponent of this treatment, but her American counterpart, Martha Welch, now uses her technique “Prolonged Parent-Child Embrace” for treatment of Reactive Attachment Disorder (although she originally saw it as a treatment for autism).

In the 1980s,  Prekopova and some German colleagues presented some weak research purporting to give scientific support to the effectiveness of Festhaltetherapie. Before her return to the Czech Republic, however, Prekopova became acquainted with the spiritualist family therapist Burt Hellinger, and her TPO approach now eschews scientific evidence and bases the treatment entirely on the “flow of love” through non-material channels. Prekopova has adopted Hellinger’s view of a hierarchical, patriarchal family power structure that can be healthy only if the child submits to parents completely--  and, by the way, if wives are submissive to husbands. Prekopova now presents Festhaltetherapie as a “lifestyle”, not a treatment, but others continue to promote it as a treatment for autism.

Dr. Ute Bemz and her colleagues wrote their book on Festhaltetherapie in protest against the use of a treatment that is not only ineffective but painful and distressing to children and to families. I have ordered the book from Amazon, but don’t have it yet--  however, from material at http://www.psychosozial-verlag.de/catalog/product_info.php/products-id/2290 I can see a series of intriguing chapters on this little-discussed topic. Here are some chapter titles, in my own clumsy translation (I am translating Festhaltetherapie as holding therapy):

“Power and authority as a therapeutic principle? Methods and psychodynamics of holding”

“Possibilities and limits of parent-infant-toddler psychotherapy”

“Holding therapy in the market of the education industry”

“The attraction of holding therapy for people in the helping professions with the example of occupational therapy”

“Long-term consequences of holding therapy”

“Unmasked pictures. Prekopova in action”

“Consequences and lengthy healing processes in psychotherapy”

“Critical observations on a faulty theory from an analytic perspective”

“ ‘We meant well. Is there trauma in holding therapy?’ Experiences of holding therapy in professional and family contexts.”

“If parents only want the best. Conversation with a mother who believed in holding therapy.”

Of course I can’t tell the contents of these chapters from their titles, but it would appear that they include something I have never seen published before, information from one or more parents who have experienced holding therapy from the parental side. Although people concerned about these restraint therapies ordinarily concentrate on the painful experiences of the child undergoing treatment, as well as with the later anxiety and post-traumatic phenomena reported by adults who were treated when they were children, it seems probable that some parents carrying out holding therapy may also be traumatized as they are instructed to ignore their child’s patent distress.

I also look forward to reading the comments connecting holding therapy with occupational therapy, a discipline that has offered some extraordinarily helpful techniques for children but has also been prone to theories with little empirical support.

A sample of Dr. Benz’s book can be seen at http://www.psychosozial-verlag.de//pdfs/leseprobe/2290.pdf.  I’ll translate (again clumsily) a few important remarks:

Bernd Ahrbeck states: “Holding therapy is no safe undertaking. Forcing of attachment on children who have at their disposal no reliable attachment is full of risks. The probability is high that old traumas will be reactivated and new ones established. There should be no illusions about the authoritarian character of holding therapy, even if its proponents are constantly declaring their good intentions and celebrating this treatment as an especially humane method. Anyone who has seen the published videos of holding therapy will not be able to avoid shuddering.

Michael Krentz writes: “The practice of holding therapy, carried on with trivializing ideological-esoteric foundations or camouflaged under veiled terms as ‘supportive and attachment-based pedagogy’ or as ‘attachment holding’ or as ‘reconciliation therapy’, harms the psychological development of the child over the long term.”

If anyone can correct my translations I would appreciate it. I am not sure whether Gewalt in this context should be translated as “abuse” rather than “power”.

   

Kathryn Joyce's Discussion of the Death of Hana Williams (and a Suggestion for a New Diagnosis)

Kathryn Joyce, the author of The child catchers and other publications about child abuse associated with fundamentalist religious convictions, has published a heartbreaking narrative about the death of Hana Williams, a 13-year-old adoptee from Ethiopia  (http://www.slate.com/articles/double_x/doublex/2013/11/hana_williams_the_tragic_death_of_an_ethiopian_adoptee_and_how_it_could.html). The story is truly a dreadful one and involves years of mistreatment culminating in Hana’s death from exposure and hypothermia, for which the adoptive parents have been convicted and given prison sentences of many years.

Hana’s life in a family of nine children had been ruled by the infamous book To train up a child, by Michael and Debi Pearl, which advocates punishments such as thrashing with plastic plumbing supply line from the age of four months (yes, months). The punishments she experienced, which also included being confined in small or isolated spaces and made to shower with the garden hose outdoors, were inflicted for getting homework wrong, standing in the wrong place, cutting the grass too short, and “sneaking” food (this last being a frequent theme in abuse of foster and adopted children).  Her death from hypothermia occurred after hours without shelter in drizzly 40-degree F. weather; her adoptive mother, Carri Williams, no doubt was unaware that a person does not have to literally freeze to death, but can die as a result of lowered body temperature at temperatures far above the freezing point. Death caused or facilitated by hypothermia has occurred in other similar cases, like the death of the Russian adoptee Viktor Matthey (or, commonly, the deaths of boaters who fall overboard in cold waters).

Kathryn Joyce’s article connects the Williams’s adoptions, and the abuse of Hana and other children, with the parents’ religious beliefs. As Joyce has pointed out in The child catchers, a movement for adoption has in recent years been part of American evangelical Christian thinking. In addition, some fundamentalist religious groups have emphasized publications recommending parenting that demanded children’s obedience and enforced it with physical punishment. This tendency began with the Baby Wise books in the 1990s (publications later strongly criticized because the rigid regulation of early feeding had harmed some infants), and proceeded to approval of  the obedience-producing manual To train up a child (see http://childmyths.blogspot.com/2010/07/child-death-by-thousand-cuts-in.html for another death associated with this book). The enforcement of child obedience as the principle task of parenting dates back to Puritan times in the United States, and belief in this value has always considered intense punishment as regrettable but essential to save the child from danger of hellfire. In most cases, however, the children do not die or even have severe enough injuries that the parents would seek medical attention for them, so we are not likely to hear of them--  and as many of the children in  question are homeschooled, there are no teachers, and perhaps no near neighbors, to notice chronic mistreatment.

Joyce also describes the connection between fundamentalist Christian beliefs and multiple adoptions resulting in “mega-families” with 20 or more children. The belief that the “Great Commission” of spreading the Gospel requires adoption of children who would otherwise not be Christians is clearly related to this phenomenon--  if a person believes it is a religious duty to take as many children as possible, clearly only practical barriers will limit family size. As Joyce points out in The child catchers, any care deficits that may occur as a result of having too many children are considered to be outweighed by the spiritual victories accomplished. But any parent or child care provider can testify that having too many children to care for makes it impossible to do a good job, or even to notice the needs of every child. For this reason, state laws and guidelines set limits on the staff:child ratio of  day care centers in order to facilitate good individual development. For whatever reason--  perhaps shared faith or personal relationships—not all adoption organizations take these issues into consideration, but instead cooperate with the creation of adoptive families too large to care for effectively. (Yes, the children may help care for each other, but they do not do the job that a committed adult can do with a small number of children.)

I wonder, though, whether in addition to religious beliefs, we may be seeing these “mega-families” formed as the result of a form of emotional disturbance in the adoptive parents. It’s certainly clear that excessive motivation toward some normal activities should be regarded as pathological. Excessive eating and drinking, and “sex addiction”, interfere with normal life and are reasons for psychological treatment. Hypersexuality may even be a symptom of brain damage. Could there, then, be a pathological level of the wish to have children that most (but certainly not all) people experience? Is there some yet undescribed problem we might call “hyperparentalism”, which leads to an inescapable, anxious yearning for more and more children, but does not cause good care for the children when they arrive? If so, can we detect this before adoption--  and can we get adoption caseworkers to regard such urges as pathological rather than admirable?

I throw this idea out as a possible explanation of part of the megafamily phenomenon. I know, of course, that there are plenty of other reasons for this kind of behavior. These may include financial benefits for foster care or adoption. There may be advantages of social respect and honor for women whose religious and cultural milieu does not permit her to be employed or to study toward professional qualifications. There may also be advantages for husbands who would prefer for their wives to stay at home and be as dependent as possible.

 When these benefits are mingled with religious beliefs, they seem to offer some explanation of multiple adoptions, and even of cruel treatment. Nevertheless, I have to wonder whether the explanation is complete without some consideration of the more personal motives of adoptive parents who seek more children than they can care for, and maltreat the ones they have.      

An Open Letter to Temple Grandin About Holding Therapy for Autism

 Dear Dr. Grandin:

I am writing to ask you to retract or correct a statement you made more than twenty years ago, a statement that I believe has had the unfortunate effect of helping to continue the use of holding therapy as a treatment for autistic children.

In 1992, you published in the Journal of Child and Adolescent Psychopharmacology (2[1]), an article entitled “Calming effects of deep touch pressure in patients with autistic disorder, college students, and animals” (on line at www.grandin.com/inc/squeeze.html). In this article, you described your own gratification with the use of your “squeeze machine”. You also spoke approvingly of the holding therapy for autistic children recommended by Martha Welch in her book Holding Time, and because you were and are a respected figure in the community of people concerned with autism, this approval no doubt carried a good deal of weight. You did not mention a point that many have made since then: that there is a world of difference between choosing to be “squeezed” in a machine that you can control, and being physically restrained and shouted at without being able to control the beginning or end of the experience. Holding therapy, as performed by Martha Welch, Jirina Prekopova, and others, presents the latter situation.

Many changes and revelations have occurred since 1992. The use of holding therapy has never been shown to be an effective treatment for autism, despite some of the efforts of Prekopova and her German colleagues in the 1980s. Practitioners of holding therapy, including Welch, have gradually come to say that they are treating Reactive Attachment Disorder or oppositional disorders rather than autism. Deaths and injuries from holding therapy have been publicized.

A small number of adults have come forward to tell of their distress during their treatment for autism using holding therapy. One of these, a British man whom I will call Walter, has e-mailed me describing his disturbing memories of the treatment for autism he received in the 1980s, memories on account of which he is being evaluated for Post-Traumatic Stress Disorder. In talking about his treatment by a therapist in the north of England, he said: “The first holding session was in her room when we went to [town] to see her. It was lying side by side, me in the middle facing my mum. Then at home my mam was on top of me holding my arms, in the hands-up position while I lay on my back, but she never had her weight on top of me. I know its not as bad as what I saw in the videos of Jirina with a mother lying on top of her boy and even shaking his head, but it was bad enough for me with being uncomfortable with forced touch, and having no freedom to scratch an itch or wipe my eyes during crying.  As a child with unknown autism and aspergers syndrome,   I had insufficient vocabulary to explain my way out of this and felt trapped as to why I reacted the way I did, so it felt horrible for a therapist to watch telling me I’m angry all the time, it felt like she was playing with my emotions as well. “ In another e-mail, Walter said, “Communication is harder for autistic children and also with aspergers, and when in a [holding therapy] position, it must be a bit like someone has had a stroke and knowing what they want to say but just can’t get it out, that was how I felt. It was that feeling of how do I tell my mum not to, or that she can’t hug or touch me because it hurts without taking it the wrong way or thinking I’m being silly…” Walter’s father put a stop to his holding therapy treatment after four sessions, and Walter comments, “I recently sat and explained to my parents that this therapy was like me being abused while this lady sat and watched me in a emotional state, and they are now so sorry that this had happened and now see how traumatic it really was, and unlike what it said in the book about the parents not being tempted to feel sorry or guilty of it,  well my parents did because they loved me so much regardless of the way I was. I broke down and cried when I told them this, and my mam came over to me sitting in the chair and, pleaded with her not to touch me, and she didn’t as she now understands I am touch sensitive, which is quite common among autistics.”

Walter’s treatment occurred many years ago, and it would be easy to assume that no such practice exists today. Perhaps you, Dr. Grandin, have assumed that the use of this method of treating autistic people had gradually vanished. However, it is very clear that in the Czech Republic Jirina Prekopova and her followers continue to do holding therapy and have much popular support (as well as considerable professional antagonism). In 2006, Henry Massie, writing in the newsletter of the Northern California Regional Organization of Child and Adolescent Psychiatry, described holding therapy as “a new, effective psychosocial treatment for autism”. He referred to the use of the method at the Mifne Center in Israel. In 2006, Stella Acquarone recommended the method in her book Signs of autism in infants (published by Karnac). Acquarine appears to be describing holding for regulatory purposes at www.youtube.com/watch?v=Q1MwRuHhdIE.

And, of course, your 1992 statement remains on the Internet and provides support for this non-evidence-based, implausible, potentially harmful treatment. I hope that Walter’s description of his experience and its aftermath will persuade you finally to speak out against holding therapy, and to put your great influence to work against this and other wrongly-conceived treatments for autism.

Sincerely yours,

Jean Mercer, Ph.D.

Infants, Autism,and "Eye Contact"

I notice on my blog information this morning an unusually large number of reads of an old post, http://childmyths.blogspot.com/2011/07/eye-contact-with-babies-what-when-why.html. I would guess that this interest is because of various announcements of a research article in Nature by Warren Jones and Ami Klin, “Attention to eyes is present but in decline in 2-6-month-old infants later diagnosed with autism” (on line, 6 November 2013). A piece on the front page of the New York Times discussed the Nature paper (http://well.blog.nytimes.com/2013/11/06/a-babys-gaze-may-signal-autism-study-finds/).

I hope everyone will understand that this research does not make it possible for parents to assess their young baby’s typical or atypical development by seeing whether they “make eye contact”, that is, engage in mutual gazing for short periods with another person, or visually track another person’s eyes. This study, valuable as it is, does not give guidelines for evaluating a baby’s gaze in an everyday social setting.  All babies, like all older persons, look at eyes sometimes, at mouths sometimes, at other parts of the face sometimes—and away from a person at other times. Whether they do “mutual gazing” with another person depends to some extent on what the other person looks like or does, whether the distance and illumination are favorable, whether the baby is tired, etc. An important point made by Jones and Warren is that differences in eye-tracking are not present at birth, when babies do not reliably look at eyes, but are seen after two months, when typical development involves an increase in attention to eyes so that by 6 months typically-developing babies look at eyes as much as adults do.  

In any case, the babies in the Jones and Klin study  did not “make eye contact”; there was none to be made, because the babies were watching a video of another person, not engaging face-to-face with a real person who could look back at them. The question was whether recordings of their eye movements showed that the babies looked at the videorecorded eyes or at other parts of the face or the screen, and how long their gaze lingered on a particular area. Typically-developing babies begin to look at the eyes more and more as they mature from about 2 months to about 6 months, but it appears that for babies who will later be diagnosed as autistic, this developmental process is “derailed” during that period.

The Times report quoted Warren Jones as saying that eye-tracking (following another’s eyes with one’s gaze) is only one channel that may be related to autism. He proposed that social communication through  touch or listening is probably similarly related to autism, but these processes are more difficult to measure than eye movements. (This suggests, by the way, that a treatment that increased eye contact might not necessarily affect autistic development, because the atypical gaze may be only one symptom of a central problem.)   

Naturally, the concern with early diagnosis of autism is associated with the hope that early intervention would get the “derailed” social development back on track. The New York Times report included the suggestion that intensified or pleasurable social experiences might be helpful if they were provided during the possible sensitive period or window of opportunity that may be indicated by the Jones and Klin study. Does this suggestion imply that parents of autistic children have done something wrong, or failed to do something right? Does the strong genetic factor at work in autism determine that these infants need unusual care given by their parents, different care than is needed by more typically-developing babies? How do the interactions between genes and environment guide development?

There are several ways in which genes and environment can interact. One of these, a passive interaction, means that the environment directly affects development in different ways depending on a person’s genetic make-up. For example, if a genetic problem made a baby not very sensitive to social signals like gaze, and if those signals needed to be experienced for good development, more intense or noticeable signals might help development. This is an idea that has been around for some time. Nikolaas Tinbergen, the Nobel Laureate in Medicine, suggested that people working  with autistic children should wear masks with big eyes to get the children’s attention. Some alternative treatments for autism have parents wear large eyeglasses and hold objects beside their eyes when they offer the objects to autistic children. There is no evidence that this is effective, though, so if there is a gene-environment interaction in autism it may not be this kind, and treatments that use these methods will probably not be helpful no matter how early they are provided.

Gene-environment interactions may also be evocative. This means that the genetic material causes the individual to act in ways that make some experiences more likely to happen. This might mean that when typically-developing babies pay attention to eyes, they attract adults to socialize with them, and that socialization facilitates good development. If babies who will later be diagnosed as autistic do not pay attention in that way, or do other things that attract adult play and interaction, they might not receive social interactions that are needed to facilitate development. In that case, treatment might involve helping parents become more responsive to any cues the babies give, or more able to find ways of interacting even though the baby doesn’t “give the signal”. This might or might not need to happen during a particular early period, although the Jones and Klin study seems to suggest that there are important changes early on.

Gene-environment interactions can also be active. This means that the genetic material causes the baby to do things that naturally provide certain experiences--  like moving in ways that strengthen muscles and increase flexibility, or preferring some foods over others. Children who find dancing or singing or talking easy and fun will do those things over and over and get even better at them as they actively seek these experiences. Toddlers with Williams syndrome are said to seem to have a “hunger” for eye contact, and although they are initially slow to talk they later become extremely sociable and communicative. If this were the case in autism, it may be that typically-developing children are genetically determined to do things like looking and imitating that encourage good development, and autistic children lack that determinant. In that case, it would be a matter of a great deal of work to determine what it was that babies typically did that gave them the “right experiences”, and to figure out how such experiences could be given to autistic children. Even then, it would have to be shown empirically that the treatment was effective.

Finally, it’s possible that there is little or no gene-environment interaction. The Jones and Klin finding may simply show a developmental trajectory that is different for typical and autistic children because of their genetic differences. The increasing differences between 2 and 6 months might, unfortunately, not indicate a sensitive period, but just result from innate developmental patterns. In that case, early diagnosis might or might not help interventions work.

There is a lot of  other interesting work that Jones, Klin, and others have published, and I hope to be able to comment on it soon.

More Day Camp Pre-and Post-Treatment Claims Outrun the Evidence

A day or two ago, I posted some comments on a study published in Journal of Child and Adolescent Psychiatric Nursing by Karyn Purvis and colleagues. That study claimed, on the basis of before-and-after tests of child characteristics, that a day camp experience had a significant ameliorative effect on symptoms shown by adopted children; I explained why the design of the study and the nature of the treatment could not be used to draw this conclusion.

Now I find that Purvis and her colleague David Cross had earlier published in Adoption Quarterly another report about the effects of the day camp (“Improvements in salivary cortisol, depression, and representations of family relationships in at-risk adopted children utilizing a short-term therapeutic intervention”, 2006, Vol. 10, pp. 25-43). In this study, the authors looked at 12 children whose age range was not clearly stated (a younger group with a mean age of a little over 4 years, and an older group with a mean age a little over 10). These adopted children had been in their adoptive homes for between 1.5 and 11 years, and had been gathered through referrals from parent support groups and child and family therapists. This is a tiny and variable group, and in fact it would be most surprising if any clear results came out of a properly-done study.

Purvis and Cross used a measure of salivary cortisol as an indicator of the children’s distress and arousal. They predicted that there would be a reduction in cortisol levels associated with the camp experience (although in fact in their brief literature review they noted a paper showing lower cortisol levels for maltreated children, as well as a number connecting high levels with stress). They measured salivary cortisol during the week prior to camp and the week after camp, as well as on Mondays and Wednesdays during the 5 day camp weeks.

Reporting the results of the cortisol measures, Purvis and Cross state that although “salivary cortisol was measured three times a day, only the morning data are show because there were no statistically significant differences for the other measurement times (noon, afternoon)” (p. 34)[!]. They then present a table showing the results of t-tests comparing morning measurements for weeks 1, 3, and 5 to pre-test salivary cortisol measures. Two of these, for weeks 1 and 5, were significant at the .05 level. In addition, the table shows highly significant differences between the three weekly measures and the post-test measure--  the post-camp cortisol reading being significantly higher than the measures during camp, and indeed rather higher than the pre-camp measure!

Words temporarily fail me as I look at this report, which resembles an intentionally easy problem I might set as a present to weak students on a research methods exam. But let’s soldier on. First: is it okay to leave out of a table comparisons where there was no significant difference found? No, Virginia, that is not okay, and in the trade we refer to it as “cherry-picking”. The table as it stands makes it appear that there was a high proportion of significant differences found whereas in fact there should have been ten comparisons shown rather than six, and five significant differences out of those ten rather than five out of six.

But hey, that still sounds like a lot, doesn’t it—five out of ten? Sure, that’s how it sounds, but this is exactly the reason why a study like this should use analysis of variance to examine all the comparisons at the same time, rather than multiple t-tests. Here’s the deal: using the .05 probability level, by definition 5 tests out of 100 will appear “significant” but do so by chance alone. With each additional t-test on a set of data, you increase the probability of events appearing to indicate a significant difference but actually occurring by chance. Analysis of variance avoids this problem, and that’s what should have been done here.

Let’s also look at what the results seem to indicate. Taking cortisol level as an indication of troubled mood, we see that the children improved quickly as seen in weeks 1 and 3--  that their cortisol was significantly lower at those measures than it had been before they started camp. By week 5, however, although the cortisol reading is lower than at the pre-test, it is no longer significantly lower. Did the treatment “work” quickly to begin with, then “stop working”? And how is it that if this treatment is effective, the post-camp cortisol readings are significantly higher than the readings taken during camp, and somewhat higher than they were before the treatment began? Isn’t a treatment supposed to have a longer-term effect than this?

Considering both the pre-and post-test design used by Purvis and Cross, and the very peculiar set of differences presented to us, I can only assume that we are seeing the effect of the confounding variables natural to this type of design--   the confounding variables that are the reason this design cannot be used to claim that an intervention is an evidence-based treatment (EBT). Confounding variables here could be as simple as the different circumstances under which the cortisol sample was taken at home and at the camp, although there are many other possibilities of the kind I discussed with respect to the more recent day camp publication. The “scientific” study of cortisol levels gives no advantages when the design is this weak, although, as Dr. Spock used to say about alcohol rubs, it smells important.  

Once again, it seems that a peer-reviewed journal’s reviewers did not do their job, to the possible detriment of adoptive families and children. The evidence here seems to be that use of this day camp intervention may simply waste family resources and delay access to effective treatment.

More Discussion About Conversion Therapy, An Alternative Psychotherapy

The Philadelphia Inquirer this morning headlines a story “Parents challenge state ban on gay conversion therapy” (Nov. 5, 2013; B1, B8). As many readers will know, in recent months New Jersey and California both passed  legislation prohibiting the use with minors of conversion therapy, an intervention that purports to alter same-sex attraction so that the treated person experiences heterosexual attraction and behaves accordingly. Conversion therapy has been practiced both by a small number of mental health professionals and by members of the clergy; the New Jersey legislation applies only to licensed therapists.

The California law has been upheld in a federal appeals court. There are presently two challenges to the New Jersey law, both in federal courts. According to the Inquirer article, one case has two licensed therapists among the plaintiffs. The second involves parents who claim a violation of their constitutional rights by the law that prevents them from seeking conversion therapy for their 15-year-old son (by the way, it does not prevent them from “seeking treatment”, as the Inquirer says; they are free to seek treatment that will help the son resist inappropriate impulses or will help him come to terms with his developing sexuality). The parents argue that the law violates their rights to free speech, freedom of religion, and equal protection of the laws.

One of the lawyers representing these plaintiffs, Demetrios Stratis, also argued that the law was based on faulty and incomplete research, and pointed out that even the American Psychological Association report, which opposed conversion therapy, agreed that the scientific basis was weak. Stratis also stated his belief that reports of harm from the treatment are inaccurate.

Is this correct? Was this law enacted without sufficient scientific evidence to support it? As one who testified in favor of the New Jersey law, I must say that the answer is probably “yes”--  but that the question is not nearly as simple as it appears to be.

Much of the evidence I heard given was personal in nature. Members of the LGBT community spoke of their terrible difficulties in growing up as part of a rejected minority. A few spoke of undergoing conversion therapy and of the distress they experienced. Members of fundamentalist Christian groups spoke deploring the troubles and dangers of a life of same-sex attraction, and argued that although the clergy might be able to do the treatment, they needed real mental health professionals to handle tough cases. A very small number of us addressed the nature and foundational beliefs of conversion therapy. It would be quite inaccurate to say that the information witnesses provided to the Assembly committee emphasized scientific evidence, either about the nature of sexual orientation or of the effectiveness and safety of conversion therapy. Although the committee presumably sought more information elsewhere, the effect of  testimony was probably to pit the strength of one political group’s power against that of another.

Although I strongly support the New Jersey law, I cannot claim that it is based on scientific evidence rather than political positions. There is little scientific work examining the safety and effectiveness of conversion therapy, and that fact raises one of the questions packed into the question about the evidence for the law. Why is this the case? Why are we lacking an evidence basis that would support arguments for or against conversion therapy?

A possible answer to this question--  and the answer that I think the plaintiffs in these appeals want to imply--  is that conversion therapy is an emerging psychotherapy. This would mean that it is a treatment so new and so underutilized that it has not yet been possible to collect the data that would allow us to evaluate it. There are such therapies, and it would be quite inappropriate to claim that laws should prohibit their use simply because of lack of evidence.

A second possible answer is that there is little evidence about conversion therapy for two reasons. One is that practitioners of the treatment do not believe such evidence is necessary and therefore have not systematically collected outcome data. The other is that practitioners of conventional treatments have regarded conversion therapy as not worth their while to study. They have thought of it with a range of rejecting terms like unconventional, complementary-and-alternative, fringe, New Age, or snake oil--  although they might not have spent much time considering how or why conversion therapy should be classified in one of these ways.

In my opinion, conversion therapy is best classified as an alternative psychotherapy. I offer this term to describe a treatment that has three characteristics: first, it lacks a clear evidence basis; second, it has been demonstrated to do harm, in which I would include unnecessary emotional pain or burdens for the client; and third, it is implausible, or incongruent with established information about personality, development, or mechanisms of emotional change. Unlike emerging therapies, there may be very good reasons for prohibition of alternative psychotherapies, especially prohibition of their use with minors.

Let’s look at conversion therapy and see how it fits into the category of alternative psychotherapy. We have already established the lack of a clear evidence basis supporting the effectiveness of the treatment--  this in fact forms part of the foundation of the legal appeals. In addition, testimony has established harm to clients in the form of distress and emotional burdens which appear to me to be beyond the level to be expected from a psychotherapy.

Our remaining question is about plausibility—the extent to which a treatment agrees with or contradicts established information. We can look at conversion therapy’s plausibility both in terms of its assumptions about the causes of homosexual attraction and about the methods for changing such attraction.

All the present evidence states that same-sex orientation as part of personality (rather than as a situational factor, such as a long prison term, or as culturally determined) is dependent on the individual’s genetic make-up.  This means that the primary factor causing same-sex attraction is in every cell of the body throughout life. This does not mean that the individual must act on the attraction—obviously neither heterosexuals nor homosexuals act on every attraction they feel! But it does mean that the orientation is an intrinsic part of that person’s constitution.

Conversion therapy, incongruently, attributes same-sex orientation of males to a failure of a loving attachment relationship with a father. Such an assumption is implausible in the light of what is known about causes of sexual orientation. Heterosexuals do not prefer the opposite sex because they had good relationships with a same-sex parent, but because of much more basic factors. Some readers may remember the blundering work of John Money in the 1970s; he recommended that a baby boy whose penis had been badly damaged in a circumcision accident should be castrated and raised as a girl. In spite of hormone treatment and constant reinforcement by affectionate and concerned parents, the boy later abandoned the hormone treatment, returned to living as a male, fell in love with a woman, and married. The same considerations apply to same-sex attractions.

Conversion therapy is also incongruent with established knowledge about development in its use of the attachment concept. Rather than following conventional theory and research about the natural history of emotional attachment, conversion therapy has simply picked up the views of another alternative psychotherapy, so-called Attachment Therapy. Attachment Therapy, which is also potentially harmful and without supportive research evidence, which assumes that emotional attachment is caused by experiences of dependency and by prolonged eye contact, and which posits that where attachment has failed it can be produced in older persons by experiences of physical restraint and forced submission. Conversion therapy also uses methods that attempt to re-enact through physical restraint the experiences that are erroneously believed to be the causes of attachment--  at the same time that its practitioners erroneously assume that attachment is related to same-sex or opposite-sex attraction.  (Bizarrely, this produces a situation in which a young man lies in the arms of an older male therapist in order to be persuaded not to be attracted to males.)

Conversion therapy is thus clearly implausible, as well as being without an evidence basis and potentially harmful. It is an alternative psychotherapy, and that is why conventional mental health professionals do not study or practice it.

But should all alternative psychotherapies be prohibited by law? This is tempting, but would seem to be a Draconian measure that would violate the First and Fourteenth Amendments, if treatment of adults were included. Minors, however, need and deserve the full protection of the law against ineffective, unsafe treatments, whether medical or psychological. I hope the appeals court in New Jersey will act to provide that protection against conversion therapy.

  

    

When Conclusions Outrun Evidence: Karyn Purvis's Camp Study

Having had many arguments with people who promote unsupported theories, I have to state approval for those who go through the tedious work of collecting empirical evidence that can support or disconfirm a hypothesis. However, those who have collected evidence should not think they are finished with the job. They must still analyze the evidence and draw logical conclusions--  and, if in the course of this work it appears that they did not design the study well to begin with, they need to start over. Otherwise, conclusions and support for theory will go beyond what the evidence shows, and readers may be deceived into accepting conclusions when they should not do so.

A case in point is a recent publication by Karyn Purvis, L.Brooks McKenzie, David Cross, and Erin Becker Razuri, in the [theoretically] peer-reviewed Journal of Child and Adolescent Psychiatric Nursing (“A spontaneous emergence of attachment behavior in at-risk children and a correlation with sensory deficits”, 2013, 26(3), pp. 165-172). The flaws in this article raise many questions about the efficacy of peer review--  although I suppose that if a reviewer is really at a peer level with a confused author, we can hardly expect the reviewer to notice problems.

The Purvis et al paper discusses a therapeutic day camp experience for a group of children recruited from local support groups and therapists (in other words, a group whose parents believed this camp was a good idea and likely to have positive effects on the children). Data were collected from 18 children whose ages ranged from 3 to 14 years (in other words, a small group with such a wide age range that it is difficult to know either how they could all have been given the same treatment, or how different treatments would have been chosen). All had been adopted and “many” (but how many, or which, remains unclear) were institutionalized as infants or toddlers. These children and adolescents were tested on a range of tests--  including the much-rejected Randolph Attachment Disorder Questionnaire and the questionable Beech Brook Attachment Disorder Checklist--  that looked at social and emotional capacities and at sensory abilities as noted by parents and by occupational therapists.

Testing was done before and after the camp experience. In other words, the design of this study was at the low level of evidence characteristic of the pre- and post-treatment design. This design admits multiple confounding variables into the situation, so that upon completion it is impossible to tell whether a treatment or some other factor(s) caused an outcome.  In this case, Purvis and her colleagues concluded that the treatment itself caused various improvements in the children’s behavior and abilities. They did not discuss the possibility that parents who believe that their children are receiving a helpful treatment may themselves change both their responses to and their evaluations of the children. They ignored the fact that parents as well as children in this study might have been directly affected, as each camp day began with direct questions to the parents in the children’s presence: “May I be the boss of your child while you are gone?” and “If your child asks for a hug today, may I give them a hug?” These questions communicated to both parent and child beliefs about the importance of the parent in the child’s life and positive attitudes about the relationship between the child and the staff member. Purvis et al also neglected to consider that 6 weeks of camp experience, including interactions with a college student assigned to be the child’s buddy, could make a difference to children’s experience in the camp situation and therefore to the impact of that experience on behavior at home. These confounding variables could well be responsible for the reported emergence of attachment behaviors; it’s notable, by the way, that there was no measure of reduced attachment behaviors, which might well be expected and appropriate for the older children.

There is much more to be said about the design and implementation of the study, particularly about the statistical analysis. However, I would like to move on to comment on certain assumptions made by Purvis and her colleagues and often shared by occupational therapists and some educators. These have to do with the function of the vestibular system and the effects of stimulating the system. As it happens, I did my Ph.D. thesis on the effects of vestibular stimulation on other sensory processes, and would be the first to concede that when there is very little sensory information to use, strong and directed vestibular stimulation influences perceptual judgments. However, outside the laboratory, there are few situations where there is a minimum of information (e.g., being in the dark) and directed vestibular stimulation like accelerated rotation in one direction. Most experience of vestibular stimulation is highly variable and undirected, and it happens literally all the time. The vestibular system is always affected by the pull of gravity unless a person is in outer space, and it is simultaneously affected by every movement of head and body or head alone, self-produced or caused by the environment. Infants and young  children like and are interested and soothed by forms of vestibular stimulation, just as they are by rhythmic sound, touch, or changing visual stimulation.

It is certainly true, as Purvis says, that “each time a child is picked up, the fluid in the … semicircular canal shifts, creating what has become known as vestibular input” (p. 170). But this also happens every time the child turns the head or the whole body, turns over in sleep, walks, jumps up and down, crawls, changes sitting position, etc., etc.  There are three semicircular canals on each side of the head, each specialized to respond to a particular direction of rotation, and there are also gravitational receptors that send messages along the auditory-vestibular nerve even if there is no rotational head movement. It is inconceivable that a living person existing in a gravitational field could be without vestibular activity. There is no evidence that extra vestibular activity causes better development, or indeed that therapeutic additions give more than a slight increment to children’s self-produced vestibular activity. These are beliefs that have been promoted without evidence by people like Ayers and Wilbarger, whom Purvis cites. (Incidentally, isn’t it a bit inconsistent that we want these children to be less active, when their activity gives them vestibular stimulation? Or is it that only the kind therapists give is any good?)

As the Reuters study a few weeks ago, showed us, adoptive families sometimes need extra help. But it seems to me a shame that a journal has published an article that states unsupported conclusions about the kinds of help that may actually be effective. Readers, please do take care about accepting some of these ideas! There are evidence-based treatments that can be of real help. 

Holding Therapy from Westminster to the Castle: Discussions in London and Prague

A kind invitation from APLA, the Czech organization for parents and professionals working with autistic children, gave me a chance to travel to Prague this month, to see the city’s beautiful buildings and meet fine people, and to take part in extensive discussions of alternative psychotherapies for autism. Partly for fun and partly to ward off jet lag before lecturing in Prague, I first spent some days in England, where as luck would have it I had two hours of discussion of Holding Therapy with a British psychologist and a Member of Parliament who is concerned about the practice. (Not knowing the politics of this situation, I think I will not name either of them here—but I do want to thank the MP for his time and attention and for a tour of the House of Commons.)

Both the Czechs and the British are concerned about the use of Holding Therapy, but the types of HT in use in the two countries are not identical. In the UK, HT methods resemble the American “rage-reduction” version, with the child restrained while held in the therapist’s lap and provoked to angry resistance. In the Czech Republic, the method is that proposed by the U.S. child psychiatrist Martha Welch (who now uses the term Prolonged Parent-Child Embrace or PPCE) and the Czech psychologist Jirina Prekopova (whose method is abbreviated in Czech as TPO, or “hard hug therapy”). The Welch-Prekopova method has small children sit on the mother’s lap, facing her and restrained by her arms, and has older children lie supine with the mother prone on top of them, while both are coached by the therapist to“express feeling” until exhausted. In both cases, the child’s resistance or distress is interpreted as showing the need for further treatment of the same kind.  

Although most people in Britain assumed that HT use had stopped long ago, it turns out that it has not, and according to the MP there are at least three children still being given this treatment, although the plan is to stop soon. Revelations about ongoing use of HT have followed the coming forward of two young men who were given the treatment by a well-known child welfare organization in the 1990s. It is impossible to tell how many more young adults were subjected to HT as children, and if the British experience is like the American, most of them will be unwilling to make public statements. The National Health Service, and through it the Child and Adolescent Mental Health Service, have initiated a movement toward the use of evidence-based treatments, and therefore should be inclined to refuse payment for non-evidence-based HT, no matter what reports from former patients are made public. However, a legislative ban would be necessary to prevent HT from being done and paid for privately, and such a ban would be difficult to enforce.

Children in the UK who have been subjected to “rage-reduction” style HT have generally been adopted or fostered and stated to suffer from “attachment disorders”. However, I recently had a contact from another British man who reported a history of HT done in the manner of Welch and Prekopova. (He wrote a description of his experiences which I will be posting on this blog in the near future.) In his case, although he was adopted, the treatment focus seems to have been on symptoms related to autism or to sensory problems, which he has been diagnosed with as an adult; these included an aversion to touch that made the holding treatment agonizing for him. The HT therapist mistakenly considered these symptoms to indicate a lack of love between the child and his adoptive parents. It is well-known that Martha Welch traveled through England on a book tour for her 1989 publication Holding time, and that she supervised groups of mothers restraining autistic toddlers at that time. It would be surprising if there are no other people who had these experiences, but most of them will probably not want to come forward. The man who contacted me does not want to be identified, although I hope he may change his mind about that.

The situation in the Czech Republic is a different one and is in some ways in flux. The primary Czech practitioner of HT, Jirina Prekopova, began in the 1970s to regard autism as a problem of lack of attachment which she believed could be repaired by intensive re-enactments of some experiences that might naturally occur between mothers and infants. (In taking this viewpoint, she followed an earlier perspective on autism which is contradicted by the present understanding that 90% or more of the cause of autism emerges from genetic problems.) Working in Germany, Prekopova stressed the existence of a scientific basis for her methods and published several weak studies claimed to support HT. Criticism of her methods developed, and there was an attempt to prosecute her in Stuttgart in 1996, but this could not be accomplished without charges being made by families (https://vikas.de/DOKUMENTE/Goldner%20-%20Festhaltetherapie.html). She returned to the Czech Republic not long after this and dropped the scientific claims she had once made, instead taking a spiritual/religious view based on the system of the spiritualist family therapist Bert Hellinger. Prekopova has continued to present HT as a treatment for autism (hence the concern of APLA) but has added oppositional behavior as a reason for HT.

Possibly because of concerns expressed about HT, Prekopova has stopped referring to her method as a psychotherapy and presents it as a “lifestyle” that fosters family love and that counters factors in modern life like screen use, factors which she believes cause autism and other mental disorders. In spite of this claim, Prekopova seems to have started “clinics” in a number of other countries. It would appear that she now recommends the use of HT in schools and institutions; this recommendation may put HT in the reach of legal attacks that are impossible when the practice is confined to private family situations.

Banning HT in the U.S. has proved difficult because of the reluctance of professional groups to be involved, the differences in powers of federal and state governments, and the large number of states that need to be dealt with individually. But after my European trip I am feeling cautiously optimistic that some countries will take the lead in this matter and the U.S. may even follow.

P.S. My best thanks to APLA and its members, especially Alena Bilkova, Andrea Kralova, Katerina Slaba, and Katerina Thorova for their kind invitation and the good care they took of me in Prague and Samechov!

  

An Orphanage Study: High Tech, Perhaps Not So Much Science

There’s been a good deal of discussion recently about the possible effects of neglectful orphanage experiences on children’s development, with some claims made about damage to brain development in the proposed “Children in Families First” legislation. A recent publication is bound to be made grist for this legislative mill, and I would like to go over some aspects of the study before this happens. The paper is by Jamie L. Hanson et al (“Early neglect is associated with alterations in white matter integrity and cognitive functioning”) and was published in Child Development, Vol. 84(5), pp. 1566-1578.

Before I address the Hanson et al paper, let me point out that I am far from claiming that neglectful care, whether in an institution, a foster home, or the birth family, can possibly do infants and toddlers any good! Nor am I about to say that Hanson et al are wrong in their conclusions, and I will note that the paper’s discussion carefully lays out cautions about the results. However, I am concerned that this paper’s technical pizzazz and use of neuroimaging have the potential for convincing readers that a clear statement about the relationship between experiences of neglect and brain development has been made, whereas it seems to me for various reasons that it has not.

Hanson et al looked at a measure of white matter organization in the brain and compared 25 adolescents who had been adopted from orphanages to 38 individuals in the same age range who apparently had not been adopted (at least I don’t see a statement about this) and were growing up in homes of about the same SES as the post-institutional adolescents. There were 15 males and 13 females in the post-institutional group and 23 males and 12 females in the comparison group. Nineteen of the post-institutional children had been adopted from Romania and Russia, 3 from China, and 2 from Bulgaria, while one family did not report the country of origin. The groups were not different on measures of pubertal status. Neurological measures mapped brain connectivity, not brain volume, and found associations between experience of neglect, decreased white matter in the prefrontal and temporal cortex, and increased problems on a spatial planning task and on a visual learning and memory task. There were also developmental problems in other brain areas that did not appear to be related to the behaviors measured.

This paper reported an enormous amount of difficult work aimed at answering a question of real practical import. So, why do I think it’s a problem if anyone rushes to make use of this study for political purposes? It’s because I have a number of questions about the whole thing.

Most of my questions turn on the fact that adoptive parents were the source of information about experiences of neglect. As far as I can see, the paper fails to state how these parents were brought into the study. Were newspaper advertisements used, or were there contacts with organizations of adoptive parents? Or, is it possible that Hanson et al had a list of nearby foreign-adopted children in the right age range and were able to contact parents and find a reasonable number who were interested? In any of these cases, it is likely that the parents’ own interests and beliefs determined their participation in the study, and those interests and beliefs could also have determined their recollection and reporting of details about the children’s early experiences.

Hanson et al noted that “there was variability in the duration and exact timing of the neglect suffered” as it was reported by the parents, and that the parents’ reports were not correlated with brain or behavioral findings. In other words, the expected dose-response relationship--  more neglect, more problems of brain and behavior--  was not demonstrated. The range of ages at which children had been adopted was from 3 months to 92 months, but the range of time spent in institutional care was 3 to 64 months, suggesting that one or more children had not been placed in the orphanage in the first months of life.

In the adoptive parents’ reports, they “consistently reported [that in the orphanages children had] few one-to-one interactions with caregivers, lack of toys or stimulation, and very little linguistic stimulation before 2 years of age”. Objective reports about orphanages in the past suggest that these are probably correct statements, but one wonders how the parents were able to make such reports. How long did they spend at the orphanage, and how much were they actually able to see of institutional life when no visitors were present? Could it be that their descriptions of their children’s early experiences were determined by what they had heard and expected about these institutions, rather than their own experiences? The highly technical side of the study gives us great detail about neurological and cognitive events, but without clear evidence about experiences of neglect, it’s not possible to conclude that neglect caused the problems.

What else could have caused the adopted children’s developmental problems? Hanson et al point out that there was no information available about prenatal history or about possible malnutrition. (Relevant to this, I searched the paper for references to head size or weight and stature, all measures potentially reduced by malnutrition, and did not find any—although pubertal status ia also a useful measure.)

 Hanson et al noted that malnutrition and social neglect could play separate or interactive roles in shaping development, but I would suggest that elements of social neglect often cause malnutrition even though enough food is available. Most family babies probably have occasional experiences of poor feeding because of maternal distraction (I am thinking of a mother at a party who couldn’t get her 6-week-old to take a bottle as they stood in the middle of a crowded, noisy room), and babies in medical care may be fed insensitively (I am thinking of a NICU nurse who cleaned and diapered a preterm baby with terrible diaper rash, then perched the screaming baby on the end of her knee and pushed a bottle into the child’s mouth). But these events are probably intermittent and temporary for most babies outside of institutions, whereas in an institution it may be a consistent experience to have food spooned in too rapidly or a bottle that is too hard to suck, when overworked and undertrained staff just try to get through the task. A study of the feeding patterns that had been in place at the children’s orphanages might give some very useful information, combining an index of neglect with a view of nutrition.

One of my concerns about this paper is the ease with which proponents of some system changes may jump to the conclusion that effects of neglect on brain connectivity have actually been shown, rather than that a method for looking at this issue has been created.  A second concern is that readers will equate “orphanage” with “neglect”. Given sufficient funding and well-trained staff, there is no reason why group care has to be neglectful. And, if caregivers have few resources and poor information, there is no reason to think that foster care or adoption  never involves neglect--  or even abuse.

In the Wake of the Reuters Report, A Scientifically Questionable Legislative Proposal

You would think that the Reuters investigation of “re-homing” of unsatisfactory adopted children would be followed by legislation that would protect all adoptees, foreign or domestic, in the United States. Instead, we see introduced in the Senate a bill called the Children in Families First Act of 2013 (CHIFF). Senators introducing this bill were Landrieu, Blunt, Burr, Inhofe, Kirk, Klobuchar, Shaheen, Warren, and Wicker. If any of these are your senators, I hope you will try to make them understand what they are doing. If not, please join me in contacting your own senators and representatives and cautioning them about giving support to CHIFF.

A summary of talking points about this bill can be seen at www.childreninfamiliesfirst.org/wp-content/uploads/2013/08/CHIFF-Messaging-Points.pdf.  According to this summary, “CHIFF fixes the functional problems without (sic) our government bureaucracy with a smarter, not bigger, approach that will allow international adoptions to become a strong and important part of how we protect children”. The bill itself, at www.childreninfamiliesfirst.org/wp-content/uploads/2013/09/CHIFFBill.pdf, is worth the attention of everyone with an interest in children’s welfare.

The bill begins with a statement about “the core American belief that families are the best protection for children and the bedrock of any society” and proposes “ensuring that every child can grow up in a permanent, safe, nurturing, and loving family”. What is not revealed at this point is that the bill has less to do with children living in the United States than with other countries that rely on institutional settings to care for children without responsible parents or other kin. As most societies assign child-rearing tasks to near kin whenever possible, it seems hard to consider this an exclusively “core American” position. It is also difficult to envisage how family love can be legislated. (As for the geological metaphor, I am puzzled, but suspect that bedrock and apple pie are in some way related.)

The issue I would like to address with respect to this bill is its effort to call in some science to support its proposals. This is seen in the talking points mentioned earlier, which state: “Today’s science shows that children cannot are terribly damaged, often irreparably, by living in institutions or without any parental care (again, sic)”. The bill itself says, “Science now proves conclusively that children suffer immediate, lasting, and in many cases irreversible damage from time spent living in institutions or outside families, including reduced brain activity, reduced IQ, smaller brain size, and inability to form emotional bonds with others.”

Let’s look at these points under a strong light.

1. Who are the children? Parts of the bill refer to children as persons under 18 years of age. Do all children from birth to the 18^th birthday experience the same effects from group care? No, certainly not, and to claim that they do is to fly in the face of the well-established principle of developmentally appropriate practice, a guideline based on both common sense and observation of different care needs at different stages of development. The children to whom the bill’s statements might apply are infants and toddlers, who are far more vulnerable to the effects of caregiving quality than are older children--  and certainly than adolescents.
2. Does the science now show that children suffer the stated damage from living in all institutions, by virtue of their being institutions? No; the evidence is that neglect by caregivers distorts developmental trajectories in early life. Institutions may be highly neglectful, and no one has forgotten the ghastly Romanian warehouses (incidentally, these throve where abortion and contraception were prohibited). “Natural experiments”, like the Hampstead nurseries administered by Anna Freud during World War II, the Bulldogs Bank children who came as a small group of toddlers from a concentration camp, and the “children’s house” residents of the traditional kibbutz, have all shown that excellent care and development can be achieved in a non-family setting.

      When institutional staff are neglectful, and developmental problems result, a major  reason may have to do with the poor nutrition that results when caregivers feed  insensitively and unresponsively, failing to work with a child’s eating rhythm or state of    arousal.  Family caregivers may also present these problems and cause unwanted outcomes; children adopted into “mega-families” may experience neglect in this way.All caregivers can be trained to do a better job of feeding and to reduce the           possible effects of neglect.

3. Does the science show immediate effects of institutional life? No, certainly not. Length of time spent in even the worst institution will have a significant effect on the developmental trajectory for most children, and none are instantaneously affected. (The reasoning behind this exaggeration is not at all clear to me.)
4. Does the science show lasting and possibly irreparable damage from institutional life for all children? No, it does not. The English-Romanian Adoption study followed over 300 adopted children into adolescence (Rutter et al, Deprivation-Specific Psychological Patterns: Effects of Institutional Deprivation [Monographs of the Society for Research in Child Development, Serial No. 295, Vol. 75, No. 1, 2010). Rutter’s study concluded that “A striking finding at all ages was the heterogeneity in outcome. Thus, even with the children who had the most prolonged experience of institutional care, there were some who at age 11 showed no sign of abnormal functioning on any of the domains we assessed. Conversely, there was a substantial proportion of children who showed impairments in multiple domains of functioning” (p. 14). This heterogeneity suggests that institutional care may be only one of many factors that interact with genetic background and post-adoptive care to determine a child’s development.
5. Does the science show an inability to form emotional bonds with others? This is difficult to answer, because the bill does not define “emotional bonds” in any way. However, if we consider this in term of age-appropriate attachment behavior: No, it does not. Of the children Rutter’s group studied, there were cases where children were unusually friendly to people outside the adoptive family, but by the time they reached adolescence most of these children were viewed positively as outgoing and socially engaging. Megan Gunnar, writing in the Deprivation-Specific volume, proposed that these behaviors, sometimes defined as “attachment disorders”, were not in fact caused by differences in attachment.

      However, it may well be true that the children’s ways of communicating their need for parental care may be difficult for adoptive parents to “read”, and this may be the basis of  some of the Reuters reports’ quotations from parents who said they could not “bond  with” an adopted child.

It seems, then, that the scientific basis presented by the authors of CHIFF does not provide any reason to accept the proposed bill. But does the bill in itself contain any desirable plans? Much of the bill, with its concerns about whether UNICEF has a more powerful effect on international policy about children than the U.S. does, is clearly driven by ideological motors. This is made plain when the bill and the talking points are walked back to the organization Children in Families First, and we see the involvement of the Christian Alliance for Orphans (see Kathryn Joyce’s The child catchers) and Saddleback Church. These contributors may be the source of concerns mentioned in the bill about Muslim fostering practices and attitudes toward adoption in the Western sense.

However, the bill does contain a highly desirable repetition of a previously agreed-upon change: that administrators shall “establish and operate a database containing data respecting children involved in intercountry adoption cases who have immigrated to the United States.” This would be a helpful and appropriate move toward protection of adopted children--  especially if it were written to include domestically-adopted children as well, and either to remove from the States to the Federal government the role of overseer, or to require States to do this job properly. Enforcement of data collection through adoption tax credits and adoption assistance programs could help to establish the proposed database.  

ADDENDUM: An article by McCall et al in the most recent issue of Child Development ("Maintaining a social-emotional intervention and its benefits for institutionalized children", Vol. 84 (5), 1734-1749) reports a comparison of a Russian Baby Home that maintained its usual practices with another that gave staff additional training and a third that used staff training plus structural changes (reduced group size, assigned caregivers, fewer caregivers, and elimination of graduations to other wards). Developmental scores improved significantly for the third group of infants, and were maintained over the next 6 years. This finding contradicts the assumption of the CHIFF initiators that institutions of all kinds have equally ill effects.

FURTHER ADDENDUM: https://www.facebook.com/StopCHIFF lets you state your opinion of this bill.