The "RAD" Explanation: 20/20 Improves It

 In the Nov.9 and Nov. 11 posts on this blog, I  talked about a show that appeared last month on the ABC 20/20 program, and about the trailer that preceded it. The program itself was an examination of an Arkansas case from last Spring, involving the Arkansas state legislator Justin Harris and his wife, and their adoption of three little girls whom they declared to have Reactive Attachment Disorder; after various treatment efforts, including exorcism, the Harrises “rehomed” the girls by giving them to a household where one was raped.  

In the actual program, 20/20 did an adequate job of showing the details of this case--  although for my money, not nearly as good a job as was done for the Arkansas Times by Benjamin Hardy and Leslie Peacock. However, I, as well as other people, had serious concerns about the trailer posted to advertise the program. In its original form, the trailer, entitled “RAD: Explaining Reactive Attachment Disorder”, began with two clips showing shrieking children being restrained physically. We felt this was a problematic beginning because of the implication that screaming wildly and needing restraint were particularly symptomatic of Reactive Attachment Disorder, which is not correct. The trailer continued with a view of perhaps a dozen women, not described or introduced, but rising one by one to speak about the extreme difficulty of dealing with their teenage adopted children, and their certainty that serious violence occurred because of Reactive Attachment Disorder. This last clip was problematic for several reasons: there is no method of diagnosing Reactive Attachment Disorder in older children and adolescents, there was no evidence given that there had been a professional diagnosis rather than the mothers “just knowing it was RAD”, and in any case violent behavior is not a symptom of Reactive Attachment Disorder, although of course it may be a symptom of other emotional disturbances.

After sending the multi-signer complaint letter quoted in my Nov. 9 post, I received phone calls from Miguel Sancho and Lynn Redmond, producer and assistant producer of 20/20. They told me that the two “shrieking children” clips had been provided by the residential treatment center Villa Santa Maria in Cedar Crest, New Mexico. Villa Santa Maria has for years focused on children said to have Reactive Attachment Disorder and was at one time associated with holding therapy, a physically intrusive treatment using restraint as a method of therapy (see http://poundpuplegacy.org/node/26944 ). Villa Santa Maria now uses Dyadic Developmental Psychotherapy, a non-evidence-based treatment, but shows its connection with highly authoritarian treatment forms like holding therapy by demands that children cannot be outside an adult’s eyesight without permission at any time, and that they must ask for everything they need or want so that they recognize their dependence on adults, and that they must experience non-negotiable “closeness” (www.villasantamaria.org/treatment_philosophy.asp). Assistant producer Lynn Redmond told me that she had spent a day at Villa Santa Maria, as well as receiving the video clips, so it is not surprising that the views offered at the school had considerable influence on the trailer.

Happily, Sancho and Redmond recognized the importance of what the signers of the letter were saying, and quickly agreed to make a new trailer. Dr. Anne Marie Albano of Columbia University, a clinical child psychologist, was interviewed for the trailer and made it clear that although Reactive Attachment Disorder exists, its symptoms are not those suggested by the original trailer. The new video, http://abcnews.go.com/2020/video/experts-parents-discuss-rad-reactive-attachment-disorder-34667787, begins and ends with statements by Dr. Albano and shows a much-reduced segment of comments by adoptive mothers (the statements about knives have been removed, and no shrieking or physical restraint is included).

It is really gratifying to know that a major television organization is willing to turn around when informed of a mistake. Naturally, it would be better if 20/20 had sought better information to begin with, but it’s understandable that they would be convinced by people who declare themselves “RAD experts”. It’s not very common knowledge that families don’t need a RAD expert, or an ODD expert, or an OCD expert, but that they do need a highly-trained practitioner who can treat the child and the family—not the disorder. I recommend against employing any person who claims special training in a narrow area; emotional disturbance in childhood rarely involves a single diagnosis, and families need broadly-trained professionals. The “RAD expert”, all too often, resembles the little boy who has a hammer and finds lots of things that need hammering--  having a diagnosis and a treatment, the “expert” may find reason to use the two things on people who don’t benefit in the least from being “hammered”, and even on those who suffer as a result.    

Does Trauma Stop Development?

When you explore some of the beliefs of unconventional, “alternative” therapists like Nancy Thomas, one idea that often emerges is that development stops when a child experiences psychological trauma.  This idea serves as justification for treatment methods involving ritualistic re-enactment of normal early-childhood experiences, based on the assumption that recapitulation of early experiences will cause development to “start over” and follow a desirable pathway. That assumption would be remotely plausible only if it were true that trauma stopped development--  and even if it were plausible, such treatments would have to be supported by systematic evidence in order to be truly acceptable.

But let’s look at the idea that development stops after trauma. Presumably this view of development—which is actually speaking of cognitive and emotional development, especially the latter—is based on analogies to specific aspects of development and specific types of trauma. It’s clear that serious traumatic brain injury can stop some aspects of development and slow others. For example, a child who receives radiation therapy for brain cancer can end up with such serious brain damage that she is never conscious again, although her life may continue for some time. She grows, but slowly, and unless she receives careful physical treatment her limbs become distorted into a “fetal” position. Much of her development has slowed, and some has stopped, but as long as she is alive she will continue to change in some ways over time—and that is what development is: changes with age.

Now let’s consider less drastic physical trauma. Suppose, for example, a child is nutritionally deprived in early life. The result will be slowed growth, but also some much more subtle problems. The bones will ossify (become hardened by absorbing calcium into their structure), but they will not do so in the order typical of well-nourished children. Development does not stop, but continues in a way that is distorted or “detoured”  rather than following a typical developmental pattern.

The effects of trauma and deprivation also depend on “critical periods” of development. A young baby who loses half of the brain through injury will develop largely normal cognitive and emotional abilities; an older child will be permanently handicapped by such a loss, sustained when  neuroplasticity is less. A malnourished infant or toddler may have slowed brain growth and development; he will “catch up” developmentally if nutrition is corrected by about age 4, but not after that, no matter how excellent the later diet may be. It’s a mistake to assume that an event that may be traumatic at one age--  abrupt separation from familiar people at age three, for instance--  is also traumatic at other ages; separation at birth does not in itself  cause emotional trauma (although learning about that separation years later may be distressing).

The effects of any kind of trauma or deprivation are also determined in part by a range of factors other than the one that seems most important. Babies exposed to lead in the environment develop better when their diets and general health are good, while lead exposure has a more serious impact on those who are poorly nourished. Similarly, infants and young children who are exposed to terrifying or painful events do better when competent parents and good family relationships serve to buffer the effects of the trauma. Events that influence development all work together, so an apparent trauma cannot be considered as having a predictable outcome all by itself.  

Research by famous names like Michael Rutter suggests that children who have suffered from trauma and deprivation in poor care settings will in most cases develop normal cognitive and emotional abilities. Better recovery is likely to occur for those who move to family care or to enriched institutional care when they are still infants or toddlers. This situation seems analogous to what we see in children who are brain-injured or nutritionally deprived—“catch up” growth is possible up to a limited age. Because emotional and cognitive life depend on brain functions, it is plausible that emotional and cognitive development follow the same rules as brain development and allow for recovery from trauma or deprivation by intervention fairly early in life.

Finally, it’s important to realize that there are individual differences in children’s vulnerability, or its mirror image, resilience. For reasons of genetic or other factors in early development, some children “rise above” traumatic experiences relatively easily, while others have lasting and potentially serious effects.

Whatever roles all these factors may play in a child’s response to trauma, the result of traumatic experiences is a matter of distortion of development or changes in developmental trajectory, not of “stopped development”. Brain-injured children, for example, continue to grow and develop along the lines permitted by their injury; they do not simply stop and remain exactly as they were, without learning or emotional maturation proceeding at all. Treatment of trauma works by fostering positive change in areas where the child is not doing well, and exactly how that can be done depends on the child’s age and environment. Part of this process is recognition of the behavior problems that have emerged from trauma (like anxiety and anger about certain situations) as well as of those that occur for different reasons. 

It’s clear that one size of trauma does not fit all, and neither does one size of treatment help guide distorted development back onto a desirable trajectory.

"Faux-RAD" and the ABC 20/20 Video: Some Progress

There has been some interesting progress with respect to the letter to 20/20 I included in a post two days ago. I received a phone call from Miguel Sancho, a 20/20 producer, and another from his assistant Lynn Redmond. They plan to modify the video that caused so much concern, and to do this with the help of Dr. Anne Marie Albano of Columbia University, a clinical psychologist and one of the signers of the letter.

In talking to Sancho and Redmond, I realized how easy it is for people to assume that if an approach to childhood mental illness or problem behavior does not use holding therapy, it must be all right. Naturally I am pleased when the dangerous and physically-intrusive techniques of holding therapy are abandoned, but I continue to be concerned about the use of related methods without evidentiary foundations. There are a number of these methods that were historically associated with holding therapy and have persisted on their own as holding therapy has diminished. These methods include demands for “strong sitting”, assertion of adult authority by requiring children to ask an adult for permission to do anything they need (including toilet use), making sure that a child is within the line of sight of an adult at all times, and the assumption that physical contact between child and adult has a therapeutic value of its own.  These methods are not likely to do direct harm to the child, but they add to what Michael Linden has called the emotional burden of therapy, and because they are ineffective may cause indirect harm by keeping the child out of effective treatment.

I have been trying for years to find a term that will describe not only these methods, but the related diagnostic efforts, and the unconventional theory that supports the whole can of worms. I recently encountered the expression “faux-RAD”, which I think conveys the disparity between these beliefs and practices and those of the conventional, evidence-based practice of psychotherapy. Michael Shermer years ago referred to the suffocation of Candace Newmaker  by her therapists as “death by theory”, and I consider that insight to be essential to the understanding of faux-RAD. It is faux-RAD theory that allows the replacement of one harmful or ineffective treatment with another that is based on the same assumptions.

To deal with the faux-RAD problem, as exemplified by the 20/20 video, we need to understand the tenets of the theory. I am going to state them here in simple form:

1. Emotional attachment normally begins before birth and is present in basic form in newborn babies.
2. Children separated from their biological mothers are filled with rage and grief even if the separation is immediately after birth.
3. Rage and grief prevent development of attachment to new caregivers, as do later experiences of abuse and neglect.
4. Normally, in non-separated children, attachment advances in two stages during the first and second years.
5. In the first year, attachment to caregivers progresses because the child comes to recognize that the caregiver is the source of all satisfactions of needs. The repeated experience of need followed by satisfaction given by a parent (called an “attachment cycle”) establishes the authority of the caregiver.
6.  In the second year, the caregiver sets limits on the child’s behavior, further establishing authority and therefore attachment.
7. Children are obedient, compliant, and grateful when parental authority has been established in these two ways, and they are said to be attached.
8. Children who are disobedient, noncompliant, and ungrateful are not attached but have attachment disorders, and they do not recognize parental authority. This situation may occur because of persisting rage and grief, and/or because of the absence of the attachment cycle.
9. To make children obedient, compliant, and grateful, they must express their rage and grief and achieve catharsis; then, they must experience re-enactments of the attachment cycle which involve complete dependence on adults for food, drink, etc. This treatment causes obedience by establishing attachment.
10. Because infants need touch experiences, children in treatment also must experience re-enactment of frequent adult touch; this must be given at the decision of the adult and not at the request of the child, and indeed may be against the child’s wishes.
11. Children who are not attached (have attachment disorder) by faux-RAD criteria are filled with hatred and the desire for violence; if treated by conventional psychotherapies, they will get worse; if untreated, they will grow up to be serial killers or prostitutes.

The tenets of faux-RAD described here are at odds with everything known about attachment, about parent-child relationships, about sources of violent behavior, and about effective psychotherapy, as well as with established definitions of Reactive Attachment Disorder. The confusion of attachment and authority is especially noxious, as it opens the door for practices that are distressing and potentially harmful to children.

Regrettably, a look at doctoral and master’s theses written in U.S. social work schools in recent years reveals that faux-RAD ideas are sometimes taught and accepted. This  fact, together with the state-sponsored faux-RAD trainings of adoption workers in Georgia and Utah some years ago, means that the undercurrent of these potentially harmful beliefs is still very real and may have been exacerbated by the 20/20 video. However, I look forward to correction by ABC and to increased awareness of the issues on the part of psychologists, social workers, parents, and teachers.

Letter to ABC About Their Inaccurate Portrayal of Reactive Attachment Disorder

Some readers may have watched an ABC 20/20 program in late October that dealt with a very disturbing adoption story from Arkansas. While the program itself was passable, a video trailer posted as a "teaser" for the program was not. A number of psychologists and social workers have written to David Sloan at ABC and to the ABC ombudsman, outlining our concerns and asking that ABC make some positive move to undo the harm done by the trailer's misinformation.

Here is the text of that letter:

David Sloan, Senior Executive Editor, ABC                                              Nov. 5, 2015

Dear Mr. Sloan:

As psychology and social work professionals concerned about public understanding of childhood mental health, we are deeply disturbed by the video clip http://abcnews.go.com/2020/video/rad-explaining-reactive-attachment-disorder-34667787. The material in this clip conveys to the public a view of Reactive Attachment Disorder (RAD)  that belongs to “fringe” therapists and is not shared by professionals with serious training in psychology. In addition, this view has been used to support the use of potentially harmful interventions with children and to argue that abused children have somehow forced their caregivers to harm them.

The opening scenes of the clip appear to show a method called “holding therapy” or “attachment therapy”, which was strongly rejected in 2006 by a joint task force of the American Psychological Association (APA) and the American Professional Society on Abuse of Children (APSAC). This method has been associated with child deaths and injuries.

A later part of the clip features women stating that their children a) had RAD, and b) were dangerous to other people and to animals, as has been suggested by “fringe” therapists. The implication was that the disorder itself is characterized by aggressive and oppositional behavior. This is not the case, as can be seen by consulting the Diagnostic and statistical manual of mental disorders of the American Psychiatric Association, 5^th edition (DSM-5). Sadness and social disengagement are in fact the leading features of RAD. In addition, it has been recommended that RAD be diagnosed in young children and not in the teenagers some of the women mentioned.

Our concerns are not simply that there was some inaccuracy in the clip, or that the discussion of RAD was insufficiently nuanced. The problem is that the content of this video supports a common misunderstanding that, among other things, can cause people to fear and reject children who have histories of abuse or abandonment, or can lead the children’s caregivers to seek “fringe” treatments that may cause real harm. In addition, this content can be used to support the “RAD defense” in abuse cases--  the argument that children who have been mistreated are so dangerous because of RAD that their caregivers were forced to hurt them.

Now that the inaccurate clip is on the Internet, it will be available for a long time. Taking it down from the ABC website will not get rid of it. For that reason, we would like to ask you to create an additional, accurate video about RAD, with our help, and to post it with a message that it is to correct the previous clip in a responsible fashion.

We hope that you will understand the reality of our concerns and respond positively to our request.

[signed by 19 professionals in psychology and social work]

Readers who are concerned about the 20/20 presentation may also want to express concerns to ABC.

A Personal Account of Attachment Therapy/Holding Therapy

The following is an account of one adopted girl's experience of attachment therapy in 1995-1997. The author, "Ann Onymous", would like readers to understand what this was like from the child's point of view. As she suggests, treatments of this type are still happening in the U.S. and other countries today.

If readers recognize what "Ann" is describing and know that they had similar experiences, I would appreciate it if they would comment or get in touch. One of the difficulties of the fight against these fringe treatments has been that victims have grown up isolated from social networks and sometimes with little education, and as a result only a few have come forward.

My thanks go to "Ann" for preparing this account:

  " My first experience with Attachment Therapy happened when I was 12 years old. These two women came to my house and my Mother called me downstairs to meet them. I walked in the living room and one of the women immediately ordered me to do jumping jacks “fast and snappy and right the first time”. I laughed and then did a few jumping jacks. She then told me that I had done the jumping jacks wrong and that I needed to clap when my hands were above my head. Because I did them wrong the first time, I was assigned 150 jumping jacks. After doing the jumping jacks, I was assigned 80 pushups, and I was made to complete them before I was allowed to go back upstairs. On my way upstairs, I overheard one of the women tell my Mother that I definitely had Attachment Disorder as evidenced by my failure to look into her eyes. My parents thought there was something wrong with me because I lied and snuck out of the house and hid food and nothing they did made much change in my behavior. After seeking support from many counselors my mother did not agree with, they sought out Attachment Therapists.

            It was after this first meeting that everything changed in my home. The same night, my parents came in my room and installed an alarm on my door. If I tried to open the door, the alarm would go off. The alarm was about the volume of a house alarm, and I think they are normally used to keep dementia patients from escaping. Also, after this meeting, my mother started keeping me out of school for long intervals and locked in my room. I was only allowed to come out to go to the bathroom or when my mother said I could. Sometimes I was allowed to eat with the family and sometimes I ate in my room. This went on for several months.

            Several months after the change, my Father came into my room one morning with a duffle bag and told me to pack it. He told me that I was going to go and stay with someone else for a while. I was not told anything other than that limited information. We got in the car and drove for two hours. During that trip I was excited. I thought living with someone else would be better and that maybe this person wanted me. I was so wrong. I was made to get out of the car, wait on the curb, and not do anything until the lady came out to get me. When she came out, I was shocked. She was an older mean looking lady and she had two other kids with her. Though her name was Mary Harless,she told me to call her “Mom Mary”. We then drove another hour to her home. During the drive she introduced the other two kids. I will call them S and D. I was very interested in S and D and so I began to talk with them. Mary then told me that she expected complete silence in the car. On the way home, Mary stopped at the grocery store and told us to remain seated and silent when she went in the store. While she was gone, S and D and I talked. When Mary returned, she said that we were all in trouble because we had not remained silent. I later found a recording device in her car while I was cleaning it.

            Life with Mary was one of unending horrible. Each day, we were woken up very early and made to go outside and run laps. She would assign laps each morning based on our “behavior” the day before. I never actually knew whether I would have many laps or only a few. Sometimes it took over an hour to run all the laps. We then had to wait in silence outside the front door for her to let us back in the house. We were not to open the door or enter the house ourselves. Mary would then let us in and assign morning work that had to be completed before we were allowed to eat breakfast. The chores included weeding the garden, washing the van, sanding a piano (more on that later). Sometimes those chores could take two to three hours and if they were not done right (which could be something as minor as leaving one weed in the flower bed) we had to either get the thing dirty and clean it again or just do another chore of equal time consumption.

            Once chores were completed, we were given a bowl of plain oatmeal (no milk, no butter, no sugar). After breakfast, we were assigned morning chores. Morning chores were similar to the before breakfast chores except that they were harder or took longer to complete. These chores had to be complete before our lunch of a piece of bread with peanut butter on it and maybe a carrot.

            My chore that I had for several weeks was to sand a piano. This was an upright piano that had been painted green. Mary found this piano and brought it home just for me to sand as my chore. I had to sand the entire piano with small pieces of sand paper. In order for it to be done, there had to be no green left on the piano. Morning, noon, and night, I would sit and sand this piano. Like I said, it took several weeks.

            There were punishments if we did something wrong. Something wrong would be anything but complete and total compliance and completing tasks fast and snappy and right the first time. For a minor infraction, we would be assigned exercise like 300 jumping jacks, 100 push ups, or 150 squats. For major infractions we had to do wall sitting, which is where we would sit cross legged in front of a wall with our hands at our sides and our nose touching the wall. We would sit there for hours, and sometimes even days. My longest time of wall sitting was two weeks. If I was given food, I was allowed to relax my position only long enough to eat. If I relaxed my position or my nose wasn’t on the wall, Mary would come up behind me and grab the back of my neck and squeeze hard until I straightened back to position. The other form of sitting we did was called cookie sheet sitting. We would sit facing the wall with our legs outstretched and feet flat against the wall. Mary would place the cookie sheet upright against our ankles, and we were to sit holding the cookie sheet up with the tips of our fingers. This would also be for hours or days depending on how much trouble we were in. This one was particularly painful for me because I am not flexible and I dreaded it.

            Another particularly tough punishment was to have cold showers. We were told to get into the bathtub with our clothing on, and then she would turn on the cold water. We were not allowed to get out of the shower. We would stand there in the water for a while, then she would turn the water off so we had to stand in our wet clothes. Then she would come back in and turn on the cold water etc… The longest I saw a kid in the shower was S, and she was in the bathtub for a week. She was made to sleep in the tub. At the end of the week S was very ill, but was not taken to receive medical care.

            The most brutal punishment was food deprivation. If we were in minor trouble, we missed two meals and were only given oatmeal once, and if we were in major trouble, we did not eat. The longest I went with no food was either three or four days. The longest I went with oatmeal only once per day was three months. One week, I stole pickles. I was so very hungry and I saw the pickles and I took the bottle and hid it behind my bed. When was caught, I was made to eat the entire jar and then went without food for two days. Another time I stole food, I stole marshmellows from an open bag on the counter. When Mary found out, I was made to eat an entire large bag in one sitting and then did wall sitting for the next week. I stole the food because I was hungry, but soon learned that stealing food caused me to be even hungrier. 

            After a while of living with Mary, we began “homeschooling”. Homeschooling consisted of writing sentences in a notebook. These were done in the afternoon between chores and usually consisted of something awful about ourselves. I once had to write “I hate myself” 5,000 times.

            After living with Mary for a few months, maybe three or four, we moved to Evergreen Colorado. S and D were sent to residential treatment facilities and I was the only foster kid to actually move with her. When we arrived in Colorado, we were greeted by a woman named Connell Watkins. Connell was a therapist that Mary travelled to Colorado to work with. Once again, I held onto hope that things would get better in Colorado and that Connell would be nicer, but not so.

            I started therapy twice a week with Mary, Connell, and sometimes another lady named Deborah Hage. Therapy was bizarre. I was wrapped from head to toe and blankets, and then all three women (who were not small) would sit on top of me and I had to get out of the blanket. It was horrible and sometimes I couldn’t breathe. They would make fun of me as I struggled. They called me a quitter. They said I must not want to be born or live. They told me I should just give up because that is what I always did. Sometimes during therapy, they would hold me across their laps. I would have one arm behind Connell’s back and be laying across two or three laps. They would ask me questions (usually shaming questions about me) and if I answered wrong they would put their faces really close to mine and yell at me. If I answered right, I had to yell the thing I had just said over and over. It was usually something bad about myself. If I was not compliant, they would make me lie down on the couch and kick my legs for long periods of time, and sometimes they would wrap me completely in a blanket and lay there for long periods of time. I would get really hot and sweaty and I felt like I couldn’t breathe. There was a lot of yelling and anger involved with therapy, and in order to do a good job, I had to be angry. They were always looking for anger. If I did not get angry, they would dig their fingers into my ribs until I screamed. They called this hassling.

            During the time I lived in Colorado, I had two very severe punishments. The first punishment happened because I started giving Mary and Connell sassy looks. They bought me a pair of sunglasses, and for several weeks, unless it was therapy time, I had to wear the glasses because they said that other people shouldn’t have to look at me. Once, I took the glasses off. Mary came up behind me and grabbed the back of my neck and led me to the mirror. She made me stand for hours in front of it until I had shouted out all the horrible things I could think of about what I saw when I looked at myself in the mirror. She then explained that all those things were why no one else should have to look at me. I didn’t remove the glasses again.

            For the other extreme punishment, I was locked in my room for three months. I got to come out of my room to go to therapy and that was it. I was given plain oatmeal once a day unless I tried to escape, and if I did that, I was not fed. The room was stripped of everything but the mattress, a bucket for me to urinate in, and a journal and pen. Mostly, I wrote about how I wanted to get out.

            I lived with Mary Harless for a year and a half from the ages of 12 to 14 years old. I spent a Christmas and two birthdays there. I was Connell Watkins client for a year. The abuse I suffered was extreme and horrible. I actually did have some attachment insecurity growing up due to foster care and a negative adoption experience. When I was a child, I lied and snuck around and got bad grades. My Mother (adoptive) and I did not get along. I was absolutely sure she was disappointed over having adopted me at all, and I behaved accordingly. If I was already a disappointment, I figured I could just do what I wanted. I was also angry because I didn’t get a family I “fit” with. Even with all my behaviors, I did not deserve abuse. My Mother took me to several different counselors when I was a child, but each time, as soon as the counselor suggested any changes to her behavior, she would get angry and we would never go back. My Mother wanted to believe that she had just received a defective child and she didn’t want to shoulder responsibility in fixing me. When these women came and told her what she wanted to hear (I was defective and it must be so hard for her), she latched on. It is, for me, the biggest rejection of my life. Not only did she not want me, she paid someone to openly and blatantly abuse me. If parents are still doing this to adoptive children, it needs to stop."

Please, readers, if you have other information like this and are ready to join the fight against this type of treatment--  which is certainly still in existence--  please get in touch!

Once again, my thanks to "Ann" for coming forward--  JM

Orphanages, Foster Families, and Culture Wars

A struggle over the right way to care for unparented children has been shaping for a number of years now. The difficulties of doing good outcome research on this issue are such that evidence tends to be overborne by values, opening the door to confirmation biases. The current arguments in Russia about orphanages, and the encouragement by some parties of a movement toward foster-family care for all unparented children, are examples of a confusion between systematic evidence and values as reasons for making practical decisions.

Child-care institutions have existed in some form back to at least the Middle Ages, when monasteries accepted children as oblates, cared for them, educated them, and reared them to be part of the monastic group. Often, but not always, orphanages were run by religious or other charitable groups. During the Great Depression in the United States, institutional care was common, not only for genuine orphans, but for children whose parents could not afford to care for them at home. Although some institutions involved cruel experiences for the children, others did excellent jobs and were remembered with pleasure by their graduates. During the 1994 Congressional upheaval in the U.S., Newt Gingrich (I never thought I’d be quoting him!) referred to those successful orphanages and suggested that they might do a better job than foster families do.

But today we have people in a range of countries speaking loudly against institutional care for children and advocating family care systems. How did this shift come about? The initial push came from the revelations about the horrible Ceausescu-era Romanian orphanages. This information became public in 1996, following the death of Ceausescu, when news sources published extremely disturbing photographs of malnourished young children tied to cribs and groups of older children naked.  The term “orphanage” quickly took on a powerful negative coloring when people identified highly inappropriate practices as equivalent to all institutional care for children.

A few years after the Romanian revelations, several researchers became interested in the outcomes for children who were adopted from Romanian orphanages. The English-Romanian Adoptees project, directed in part by Michael Rutter , followed these children into young adulthood and found that on the whole their development was quite satisfactory. An American research group, the Bucharest Early Intervention Project, headed by Charles Zeanah, began in about 2000 to conduct an investigation that would compare young children randomly assigned to remain in the orphanage to others randomly assigned to foster families. Zeanah and the rest of the BEIP group reported later that the fostered children showed better development than those who stayed in the orphanage, and that therefore family care had a better effect on development than institutional care did. This conclusion, repeated in several professional journals, in the magazine Science, and in the publication Zero to Three, as well as in popular news sources, has had a strong influence and has been used to support the argument that foster care or adoption are demonstrably better methods for unparented children than institutional care.

However, as I have pointed out in this blog and in letters published in Science and Zero to Three, the design of the BEIP studies does not permit the conclusion that has been publicized. The Romanian foster families received special training and funding, as well as access to frequent consultation with child development experts. The orphanage staff received none of these, nor were they helped to provide more consistent staff assignments that would allow infants and toddlers to be with a few familiar caregivers. The comparison was thus between the best possible foster care and poor institutional care, so the outcome was not surprising. Indeed, it would be interesting to know what would have happened if the institutional staff had been specially trained, paid more, and had consultants available to them, while the foster families were left to get along as best as they could--  that would have been a meaningful test of the advantages of foster care per se over institutional care.

As I have also pointed out on this blog, there is important research that contradicts the BEIP conclusions. That work, by Kathryn Whetten, was a nonrandomized study of children in low- and middle-income countries that compared development of fostered children with that of children in institutions and did not find an advantage for foster care. Whetten’s work has received much less attention than the BEIP work, presumably because her design was nonrandomized, whereas the BEIP involved random assignment to groups—but the fact is that randomization is used to attempt to isolate a variable, and the remainder of the BEIP design did not successfully isolate the variable of type of care, instead conflating type of care with availability of training and resources. In my opinion, the two studies are about equal in appropriateness of design and outcome validity.

A new study in which Whetten was involved is also relevant to the comparison of institutional and family care. This study (and my thanks to Yulia Massino for calling my attention to it!) is by Christine Gray et al., “Prevalence and incidence of traumatic experiences among orphans in institutional and family-based settings in 5 low- and middle-income countries: A longitudinal study” (http://www.gshpjournal.org/content/3/3/395.abstract). The researchers looked at physical and sexual abuse experiences among children in institutions and in foster care, and found no more such experiences in institution-reared children than in those cared for by foster families.

Gray et al. concluded that “understanding the specific context, and elements contributing to potential harm and benefits in both family-based and institutional care, are essential to promoting the best interest of the child.” This comment should be related to recent ideas in clinical psychology, where professionals are beginning to recognize that there are adverse events in psychology just as there are in medicine, and that these should be investigated, recognized, and reported along with  demonstrated benefits.

Decisions about best practice need to take unwanted events into account as well as considering the level of evidence supporting a practice. Yet, as we see in the Russian disagreements about orphanages and about adoption, as well as in the American movement from reuniting families at all costs some years ago, to the current concern about putting child safety first, many such decisions are driven by value considerations other than the best interest of the child, and adverse events are not mentioned. An egregious example would be the push for multiple adoptions by fundamentalist Christians in the U.S., as described by Kathryn Joyce in The child catchers.

As Gray and her co-authors imply, one size does not fit all unparented children. When anyone suggests that there is a single best care approach, we should ask what value considerations are guiding this claim. Culture wars are not a way to provide the best outcomes for children, who are likely to experience “collateral damage”.

   

Very Early Diagnosis of Autism Is Still Not an Option

It’s so sad to see the number of queries that come to this blog from terrified young mothers who have become addicted to Googling about autism and want to know whether the (usually) typical infant behaviors they see mean that their children will be autistic. Other than cursing these insufficiently-informative “red flag” sites, there’s not much I can do except to tell them that they will just have to wait to get a definitive answer, because their babies are too young for anyone to tell whether there is an autism diagnosis in their future.

I recently came across two articles in the very helpful Brown University  Child and Adolescent Behavior Letter (CABL) that I would like to summarize--  not because they tell how to diagnose autism early, but because they underline the problems of trying to do so.

The first of these articles, by Stephen Sheinkopf, is titled “Autism in infancy: Advances and implications for clinical practice” (CABL, March 2013, pp. 1.4-5). Sheinkopf notes that “the presentation of autism in infancy is subtle, with more obvious signs and symptoms emerging over the first two to three years of life… these early developmental differences are difficult to detect, making it a challenge to screen for the risk of autism in early infancy. The gradual emergence of autism symptoms during development also makes diagnosis challenging in later infancy and toddlerhood.” Even when symptoms like poor communication development become evident, it may be far from clear whether there are hearing difficulties, specific speech and language disorders, or even mental retardation at work. Sheinkopf goes on to say that there are “few reliable findings reported in infants younger than 12 months of age”, even when children studied are known to be at risk for autism because they have autistic siblings--  and as Sheinkopf point out, it may not even be possible to generalize from those at-risk children to the rest of the population.

Even when toddlers are diagnosed with autism, a longitudinal follow-up is needed to be sure that diagnosis was correct. Sheinkopf describes two composite cases (in other words, these are not specific real children, but a narrative based on several similar cases). One case involved a 30-month-old boy who had been born at less than 30 weeks’ gestation, had been in intensive care for some time, and had normal motor development, no cerebral palsy, and no hearing or vision impairment. He was quite delayed in language and had some cognitive delays as well. He also showed behaviors  that can be symptoms of autism—repetitive movements, little eye contact, poor communicative abilities, and he received a tentative diagnosis of autism. However, following early intervention services he improved in language skills, performed fewer repetitive movements, and became more social and playful with adults as well as becoming more interested in other children than he had been. Although he continued to have some delays, by the time he was 40 months old, the autism diagnosis was ruled out.

In Sheinkopf’s second case, a 20-month-old boy had one older brother with autism, another with language delays, and a member of the extended family for whom autism was a possibility. He did not speak at all and did not vocalize much. He could solve problems that required no verbal ability but did not respond to verbal instructions.  He was affectionate and playful with his parents and showed some interest in other children. He flapped his hands when excited, but not in ways different from typical children of his age [I hope readers will notice the fact that hand-flapping  is common in toddlers]. It was not clear at this point whether his diagnosis should be autism or language delay. Ten months later, after early intervention services were received, it was seen that although his language had improved it was repetitive and not necessarily directed to other people. His social pragmatic skills had worsened compared to where he was at 20 months. He had an increase in repetitive and stereotyped actions and had begun to examine objects intensely in a way that interfered with play or social activities. By his third birthday, the diagnosis of autism given at 30 months continued to seem appropriate.

Notice that in both these cases the children were seen to have factors that put them at risk for autism, but that even well past the first birthday it was not clear whether their abilities and behaviors were indicators of autism—it was simply seen that autism was one of the possibilities. The first child became less “autistic-like” over time, but the autism diagnosis was not ruled out until he was well over three years old. The second child improved in language, but showed increasing evidence of autism and was finally diagnosed at age 2 ½. The child diagnosed with autism became more different from typically-developing children with age--  the differences were not clear-cut earlier in his life.

In a second relevant piece in CABL, Alison Knopf (“Brief observation not adequate to detect autism risk in young children”, March 2015, pp. 3-4) described a study by Gabrielsen, Farley, Speer, et al., (in Pediatrics, 2025, Jan. 12). Knopf notes that “autism spectrum disorder doesn’t manifest itself suddenly; symptoms appear over time, with gaps between typical and atypical development widening as the child gets older. Children have both typical and atypical behaviors [a most important point—JM] but little is known about what the ratio of these behaviors is during the 10-minute timespan of an average primary care visit.” In the study by Gabrielsen et al., clinicians were asked to see whether they could identify autism in children 15 to 33 months old, by watching two 10-minute video clips of each child.  Children who were previously identified as autistic were missed in 39% of the cases, suggesting that longer observations and more information than most pediatricians get are needed for more accurate diagnosis.

In the Gabrielsen study, a very important point concerned the fact that both typically-developing and autistic children had some typical behaviors and some atypical behaviors. The autistic children showed typical behaviors 89% of the time and atypical behaviors only 11%, while the typically-developing children showed atypical behaviors only 2% of the time. All the children were prompted to respond to their names at least once, and 50% of the children in the typical group failed to respond once or more, while 59% of children in an additional language-delay group did not respond on one or more occasions. Of the children in the autism group, 58% responded  to their name at least once, while 80% of the typically-developing children responded at least once.

Making eye contact, responding to their name, hand-flapping, repetitive behaviors—all of these are found in both autistic and typically-developing toddlers. There is no single symptom or list of symptoms that is a certain indication of autism even in children this old, and much less can such a symptom be found for infants in the first year.

Although specialized early intervention services can be helpful for toddlers and preschoolers, the best thing parents of infants can do is to encourage good development by sensitive, responsive care, by plentiful and playful social interaction that follows the child’s lead, and by minimizing the screen use that so easily keeps parents from these first two development-supporting activities. We would all like to think that a magic device could let us detect autism early, and some other magic ritual could allow us to prevent atypical development, but so far--  it just isn’t so, and all parents can do is the best parenting they can.          

On Rolling Over and Autism (the Latest Parental Worry)

Over the last several years, I have had dozens of queries from concerned parents who had read some “red flag” websites that describe symptoms of autism. These parents were terribly worried that their babies did not make enough eye contact and that meant they would be autistic. There have been a few cases where the parent’s description was worrisome, but in most of the cases the problem was simply that the baby was very young. What those websites often neglect to tell you is that young babies normally show many of the behaviors that would be symptomatic of autism if they were older. The autistic toddler or preschooler continues to show some behaviors that are normal in earlier life; the typically-developing child stops doing things that belong to earlier development. Autism is primarily characterized by developmental delays, not by doing things that are never seen in the lives of typically-developing children. For example, the hand-flapping and toe-walking often noted as indications of autism are also seen in typically-developing children, but at an earlier period of development.

In the last few weeks, in addition to the usual questions about eye contact, I have noticed some new questions about motor development and especially about the way a baby rolls over. I see references to this issue on various chat groups and on Youtube too. They all refer back to a particular publication, and I want to talk about that.

In the mid-1990s, the researcher Philip Teitelbaum became interested in the idea that atypical movement patterns might precede and predict more obvious symptoms of autism. This was by no means a silly idea—many other neurological problems of childhood involve movement anomalies. It’s been known for a long time that infants who already have “handedness” (they use one hand consistently rather than alternating) or who crawl asymmetrically, with one side of the body doing more work, most often have some damage to one side of the brain. Cerebral palsy, which can interfere so badly with speech, may not be diagnosed at birth, but it may be seen in anomalies of movement in the first year. That autism might also involve problems of motor development was a reasonable hypothesis.

In order to see whether babies who were later diagnosed as autistic had unusual movement patterns later on, Teitelbaum advertised and announced his work in various newspapers (this was before much Internet). He asked for parents to send him home videos of their babies, so he could examine movement patterns in early life and see whether he could identify any unusual movements in those who were later considered autistic.

Teitelbaum and some co-authors published the results of this study in 1998 in the Proceedings of the National Academy of Sciences. They had found videos for 17 babies who were later diagnosed as autistic, and reported that these babies showed unusually movement patterns. Delays and asymmetries in sitting and walking were evident, and rolling over was described as not only delayed and awkward, but as involving a different use of head and legs to turn the body that is characteristic of typically developing infants. However, there has been little replication of this work, and there is ongoing discussion of the method that should be used to observe and describe motor behavior (see http://asb.brain.riken.jp/files/Threelessonsfrom.pdf ).

There are several points to be made here. One is that the rolling pattern described has not clearly been shown to be a precursor of autism, and in fact Teitelbaum was criticized for the lack of control or comparison information he provided. Failing to roll at all, past the usual time when this milestone is achieved, is probably a more significant issue.

Second, and very important, Teitelbaum’s work looked at the motor development of babies of whom the great majority slept in the prone, tummy-down position. Babies in the United States, Australia, and Great Britain today are very likely to be put to sleep supine, lying on their backs. This practice is known to delay motor development compared to what was seen years ago for prone-sleeping babies (see www.ncbi.nlm.nih.gov/pubmed/15934485 ). The sequence and timing of motor development Teitelbaum found in typically-developing babies were not what we would see today in typically-developing babies, so delays that Teitelbaum considered to be characteristic of later-found-to-be-autistic infants cannot be used to assess babies today.

Third, every baby has his or her own schedule of achieving motor milestones. There may be a long pause between two milestones, or one may come very rapidly after another--  as when babies hardly creep at all, but go quickly to walking. There is a normal range of development, not a deadline to get something accomplished. That means that only a rather sophisticated observer will be able to detect something out of sequence or dramatically delayed in motor development; Youtube won’t do the job!

Fourth, let me point out that if a baby does have unusual movement patterns, there can be many reasons for them other than autism, and it is important to seek medical care if such patterns are seen.

Conclusion?  The concern about how babies roll over has recently been whipped up on various websites devoted to encouraging parents to be anxious about the possibility of autism. Let me remind you that the present high reported rates of autism are probably caused primarily by changes in diagnostic approaches that include some minimal disturbances in the same category with debilitating autistic disorders. Also, it is clear that quite a few children who are diagnosed as autistic in the preschool period no longer have that diagnosis several years later. Finally, because parents who are worried about eye contact and rolling over also want to know about “early intervention”--  the best thing you can do for any baby is to have fun together and respond to the baby’s communications as best as you can. If you’re worried about movement problems, by sure you do plenty of tummy time. Minimize screen time, and that means the time you are on your phone in the baby’s presence as well as screens for the baby to look at. Talk to the baby a lot. All babies, typical or atypical, will benefit from these actions.   

   

What Adopted Toddlers Really Wish Their Parents Knew About Tantrums

A lot of people who are interested either in adoption or in child care advice have come across Sherrie Eldridge’s book Twenty things adopted children wish their adoptive parents knew. I’ve seen a number of otherwise intelligent and competent people fall for some of Eldridge’s beliefs—especially the one about the child adopted at birth who sorely misses the birth mother and has to be reminded to process that grief. One adopted mother I know spent hours and hours telling her little boy about his birth mother, making scrapbooks, etc., etc., and completely missing the point that because he went to a foster family at birth and was adopted at 15 months, if he missed anybody, it was the foster family!

Eldridge has recently reiterated this advice at http://sherrieeldridge.com/taming-temper-tantrums-in-adopted-toddlers/. She recommends that mothers dealing with toddler tantrums should use what used to be called a “basket hold”, approaching from behind, pulling the child toward them, holding his hands crossed over his chest, and maintaining this position until the child calms down. This is, in my opinion, not at all a bad thing to do if a child is thrashing around and may get hurt--  but not necessary in the more standard fall-on-the-face-kick-and-scream version. But the interesting thing in her post is that a commenter, Mirah Riben, proposes that the adoptive mother should attribute the tantrum to unresolved grief and ask the child, “are you missing your first Mommy? I bet she misses you too”--  to which Eldridge rather testily replies that she has said this many times, but it wasn’t what she was talking about this time.

A couple of issues come to mind here. One is the question: do toddlers (or older individuals) adopted at birth or in the early months remember and miss their birth mothers? Does this make them angry and cause tantrums? Answer: No, probably not, on all counts. Memory for experiences is quite limited in the first months of life, and even events that a baby learns to recognize do not give rise to long-lasting memories unless the events are repeated many times. A toddler or older child who is abruptly separated from a familiar caregiver will grieve and be depressed and irritable for some months, but this reaction does not occur before about 8 months of age at the youngest, and the child recovers completely if given good care and emotional support by a new caregiver.

What about the anger? Is a toddler who is angry only having tantrums because of a past loss? No, to tantrum is human, to forgive, the capacity of a mature adult. In fact, tantrums are not only human, they are characteristic of all the higher primates. Harriet Rheingold, an animal behavior researcher, described years ago how she saw baby baboons on the Serengeti throw themselves on the ground in full-scale tantrums when their mothers would not pick them up and carry them. (Baboon mothers are not the pushovers that humans are--  they refuse to pick up when the baby gets to 7% of the mother’s body weight.)

Tantrums are a response to current frustration, not to long-past separation. Difficult as they may be to cope with, toddler tantrums are also evidence of good development in that the child knows what he wants and recognizes that it isn’t happening, a real step forward from the  easily distracted baby. But they are also an indication of the underlying immaturity of the child, who isn’t yet able to make himself wait or to think about how best to get what he wants.

It’s all well and good to think about how normal tantrums are, but that doesn’t mean that they are easy for parents to tolerate--  especially in public, where stress is increased by people’s disapproving glares or advice to smack the child a good one. Are there things we can do during the tantrum, even when the tantrum doesn’t put the child in any danger? Probably there is nothing we can do to stop an ongoing tantrum, but we do need to keep ourselves from making the tantrum more intense by yelling at the child, hitting, etc. We also need to avoid making tantrum behavior  more likely by “giving in” after the tantrum is well underway.

Are there preventive efforts that can work? I think they are, and some of what I’m going to say about them is drawn from the work of Lisa Poelle, author of Chronic biting extinguished, a book about ways parents and caregivers can change their own ways and improve aggressive and oppositional behavior in children 6 months to 3 years old.

Poelle’s first suggestion, and mine too, is that adults must plan how to work with toddlers in ways that will reduce the frequency and intensity of tantrums. This is not just about what you do when the tantrum begins; it’s about how you structure the child’s life. Poelle suggests using an action plan worksheet, which involves a number of observations to be done before you begin to plan your approach. For each observation, the adult needs to think in terms of the apparent reasons for the behavior: did it have to do with the child’s stage of development? With previous experiences and recent changes in the environment? With the child’s verbal skills? With the child’s physical condition? Understanding these, and working on them when possible, can help reduce tantrums--  and it can improve adults’ ability to tolerate tantrums rather than to take them as personal attacks.

I want to comment on the physical condition issue first, as I think this one is the easiest to work on. Adults need to be aware when children may be hungry or thirsty, and to recognize that additional frustrations at those times may lead to tantrums. (Incidentally, Poelle points out that children in day care often do not get enough to drink.) Fatigue is another contributor to tantrum frequency. This is a situation where the sensitivity of an adult to the child’s needs may make all the difference. I am not suggesting that toddlers should always be given just what they want for fear of a tantrum--  but adults should have the empathetic ability to recognize that the child’s needs  are not the same as an adult’s. For example, imagine this scenario: Mother picks up two-year-old from day care at noon and decides to stop at a store on the way home to see if she can find a wedding present for a friend. She takes the child into the store in a stroller, and from time to time leaves him there while she steps just a few feet away, but to a place the child can’t see from his vantage point. Can we expect a tantrum? Child is  hungry and tired; mother keeps disappearing; mother doesn’t look at him, or frowns when she does so; mother is also hungry, tired, and anxious about her errand, so what else could this combination add up to? Now throw in a few shoppers giving the crying child and mother dirty looks, or clerks muttering to themselves about brats. We have a perfect tantrum-storm, but one that could have been prevented by planning that took the child’s (and mother’s) physical needs into account

Now let’s have a look at the child’s verbal skills. How do these contribute? One part has to do with the child being unable to express his feelings and wishes, another part with his being unable to understand what adults say. (I remember a massive and unexpected tantrum by one of my children when I said I would cut some daffodils for a friend, and then I would cut some forsythia. But to his extreme distress I did not cut any daffodils for “Sythia”!) It can help a lot to work closely with the child’s verbal abilities--  but as Poelle points out, a child can have excellent verbal skills but poor impulse control, so this is not always the answer.

Previous experiences and recent changes? When a child has been subjected to extremes of discipline, both too much and too little at different times, he may have a disturbing level of anxiety about his own distress, creating even more tension and frustration. And recent changes like entering or changing child care, moving to a new house, having a new baby born, and adult moving in or out of the household, may create frustration. It’s critical to remember that good changes as well as bad ones can have this effect, so that wonderful birthday party with the cake and the exciting pony rides and the hats and masks may be followed by tantrums, just as a miserable experience might be. Life doesn’t always allow us to “titrate” a child’s exposure to change, but when it does, we need to think about preventing toddlers from having too much happen in too little time. Or, if we can’t manage that, we should at least be aware that a resulting tantrum is not unreasonable as an outcome.

There’s a lot more to be said about Eldridge’s suggestions—especially at what may result from telling a child he misses someone he can’t remember--  but that discussion will have to wait for another day.

  

You Can't Go Home Again, or Back to the Cradle Either

I recently commented on a book by one Mary Evelyn Greene (http://childmyths.blogspot.com/2015/09/when-nonsense-hurts-mary-evelyn-greenes.html). Greene described all the difficulties of her adoption of children from a Russian orphanage, emphasizing the little boy’s “feral” nature and violent aggression. Subsequently, I received the following comment on my post (the commenter gave other information as well, so interested readers may want to look back at both the comments):

“ But in this book there is nothing about the treatment of Peter but only lyric debris and accusations against Russia and the orphanage. Although she could refuse, and even had an offer from the administration of the orphanage. It is impossible to separate brothers and sisters. She had two children to adopt or reject both. There was no deception. Only 6 months after the adoption has begun a significant regression of Peter. What's foster family did wrong during these 6 months? The book does not answer this question.

"Russian Roulette: A Review of When Rain Hurts: An Adoptive Mother's Journey with Fetal Alcohol Syndrome"
CHRISTINA GOMBAR
November 2014
- See more at: http://www.literarymama.com/reviews/archives/2014/11/russian-roulette-a-review-of-when-rain-hurts-an-adoptive-mothers-journey-with-fetal-alcohol-syndrome.html#sthash.xAgimZIh.dpuf
excerpts from the article -
"Having spent thousands of dollars and precious months filing paperwork, Greene and her husband finally took their first trip to a remote Russian outpost only to discover the boy they'd set their heart on was clearly too ill to take on. There they were introduced to a two-year-old girl, and instantly fell in love ..............
..................
After six months, this boy "woke up in a primal scream" and became completely uncontrollable-defecating at will (though long toilet trained in Russia), and vomiting at every meal. His speech was primitive, he refused eye contact, and he was physically destructive. Greene says he went from being "like a cuddly toddler" to something "more like an explosive device."
............................................
A doctor advised them to try "attachment coaching." They needed to treat Peter like a baby, so he could experience the developmental stages he missed in the orphanage.
.......................................
"At times I felt we were breaking a horse," writes Greene before she realizes: "His entire repertoire of behaviors was designed to inoculate himself against the dangers of love and intimacy. I was not breaking a horse. I was nurturing a helpless foal .  “

Of course, I have no idea of the accuracy of anyone’s statements here --  Greene’s description,  the comments, or the review. However, all of these involve ideas that I think require close examination.

The first of these is ideas that if a child suddenly shows difficult behaviors after a calm six months, the cause of these behaviors must have occurred in earlier life , and not be associated with any more recent experiences. This thinking involves a kind of primitive “infantile determinism” that assumes that all problems must come from an early stage of development—ignoring the reality that past and present experiences as well as maturational factors work together to determine an individual’s present characteristics. The idea that the child woke with a “primal scream” (not just a scream) indicates the assumption that traumatic experiences in very early life have been repressed and now are breaking through; the whole “primal” or “primal scream” concept (popular in the 1970s following the proposals made by Janov) focused on the experience of birth as terrible, and impossible to handle in a rational way unless re-experienced and re-processed.  Related to this belief in “primal” is the view that a child who defecates without control and vomits frequently must be doing these things as emotional acting-out and not because of physical illness. Greene seems to have further revealed her belief system by saying that Peter defecated “at will”, echoing the claim of the holding therapist Keith Reber and others that children with attachment disorders could defecate or vomit voluntarily.

The second issue that needs addressing is the recommendation for so-called “attachment coaching” and for causing Peter to “experience the developmental stages he had missed in the orphanage”. This belief has a long history  (50-100 years of it) among the wilder psychoanalysts like Ferenczi and Fromm-Reichmann, who were convinced that by acting out nurturing  events for patients, they could somehow “re-do” the patients’ early experiences, which the therapists blamed for all mental illness including schizophrenia.  This view--  which naturally appeals to the wish we all have to be able to “fix” emotional disturbances—was also encouraged by claims that hypnosis or other techniques could cause age regression (these claims were strongly contradicted by systematic investigations).

It is not plausible that existing psychological development can be undone and started over, however unsatisfactory were the conditions in which it occurred. Think of that claim and what it would mean if it were made with respect to physical development. A child may be of unusually small stature or may have an unusual pattern of bone development due to early malnutrition. Could we rationally expect a good diet in later years to “regress” the child to a state of infantile skeletal development, and to cause new growth and bone maturation that will create a more typical body? The answer is NO, of course, and I would point out that all the present emphasis on brain development as the basis of emotional development should be considered analogously; no experience can undo the existing synapses or change the history of migration of neurons to different parts of the brain, any more than diet can alter salient characteristics of bones that have already formed.

Third, let’s consider Greene’s statement that Peter’s behavior was designed “to inoculate himself against the dangers of love and intimacy”. This is one of the mantras of attachment therapy/holding therapy, and has been repeated in woozle-like fashion for many years now. No doubt this is what Greene was told before the adoption occurred, and what she heard on many occasions afterward. However, this belief is based not on evidence from child behavior, but on an analogy to the feelings of adults whose companions have chosen to leave them--  post-divorce, for example. These people are often irritable with others and may be preoccupied with the dangers of intimacy, sometimes rejecting possible new mates on the grounds that “women/men are all alike and you can’t trust them”. But is it possible for a young child to do the same?

In the 1940s, Bowlby and Spitz put great emphasis on the idea that young children separated from familiar caregivers would become depressed, eat and sleep poorly, and be unable to accept care from other adults. Bowlby’s film “Nine days in a residential nursery” showed the physical illness and emotional distress of a two-year-old left in a nursery while his mother had a baby; the child rejected his mother when she came back to pick him up. But that film showed that the child received little attention from caregivers (or from his father, who dropped in briefly every day) and was overwhelmed by other children in the nursery. Bowlby’s colleague James Robertson later showed that young children separated from familiar people but given plenty of sensitive, responsive care did not in fact seem nearly as badly affected as the child in Bowlby’s film.

The belief that adopted children intentionally reject love is one that assumes that the adopted child is adult-like in abilities and reactions—indeed, that he is more capable than an adult of controlling his own behavior. Curiously, that school of thought does not assume that nonadopted infants are rejecting love when they cry nerve-wrackingly, have tantrums, or do that trick that enables them to weigh 40 pounds extra when they do not want to be picked up.  Somehow, the adopted child is considered to do on purpose all sorts of things that in other children would be thought to be outside their control. She is also said to do these things because she does not want to be loved, on account of the losses or disappointments she has already experienced. These ideas are simply assertions, because there is no evidence to suggest that a child does not want affection, and it is more likely that he or she has no experience of the codes adults use to signal the giving or receiving of love.

I am not one to quote Freud frequently, but there was a term he used about implausible treatments of these kinds. He referred to their proponents as having a furor sanandi—a frenzied wish to heal. Unfortunately, unless that furor is turned to methods that are at least plausible, and better yet evidence-based, the wish to heal may well culminate in the fact of harm.