Thank, Brian Allen, for Saying "Down With Attachment Disorders"!

A leading clinical child psychologist, Dr. Brian Allen of the Center for the Protection of Children, Penn State Hershey Children’s Hospital, has stood up to make an important statement. His recent article, still in early online form in the new journal Evidence-based Practice in Child and Adolescent Mental Health, is entitled “A RADical idea: A call to eliminate ‘attachment disorder’ and ‘attachment therapy’ from the clinical lexicon”.

Noting that those two terms are well entrenched in graduate education, parenting information, adoption work, and so on, Allen points out that “neither of these two concepts is empirically sound as commonly practiced”. In other words, the assumptions frequently made about the nature of attachment, even by well-trained and legitimate practitioners, are often unsupported by systematic evidence.  

One source of confusion about “attachment” as a clinical concept is that  attachment behavior and attachment theory are two very different things. Attachment behavior is observable and happens in the great majority of children between about 9 months and about three years of age. It involves responding to threats or discomfort by getting and staying close to familiar caregivers. Although most children do this, the manner and intensity of their behavior depends in part on individual  differences and on the caregiver’s response. Children who have experienced many changes of caregiver, or who have had insensitive or unresponsive  caregivers, will still show some attachment behavior in most cases, but (as Mary Dozier has shown) their behavior may be so subtle and understated that caregivers have trouble noticing it--  for example, they may just glance up at a caregiver who leaves the room, rather than bursting into tears and following him.

Attachment theory, like all theories, attempts to put observable attachment behavior into a framework that makes sense and helps us predict what kind of behavior may occur later. In John Bowlby’s first formulation of attachment theory, he proposed a framework that included the development of an internal working model (IWM) of social relationship. The IWM would begin with what a baby learned in the early relationship with a caregiver, including the valuable comfort of being able to get close to the caregiver in distressing circumstances.

The theory of the IWM, and its changes as a result of maturation and experience, provided an explanatory framework for the ways attachment behavior changes with age. As Allen points out, a basic fact about attachment behavior is that it alters as a result of a variety of experiences and goes on altering for many years. Later attachment behavior is not entirely determined  by early events, and the later events that affect this behavior do not always seem to have anything to do directly with attachment (e.g., mothers’ confidence). It is a great mistake to try to cherry-pick portions of attachment theory , such as the importance of early sensitive and responsive caregiving, but to neglect the message of this theory about the long-term changing and reshaping of attachment behavior as the result of a range of experiences. Unfortunately, terms like “attachment disorder” and “attachment therapy” have become shorthand for “early caregiving effects”, and their use often implies that the user is ignoring the larger picture of attachment theory.

With respect to the term Reactive Attachment Disorder, once thought of as encompassing two separate and somewhat opposed forms, Allen points out that one of those forms is now described as Disinhibited Social Engagement Disorder  and divorced in terminology  and otherwise from the attachment concept. The remaining use of the term Reactive Attachment Disorder is applied to a very small proportion even of  children with histories of severely neglect. What’s more, this disorder appears no longer to be present after children have been in family settings for a while, so presumably these children were not locked into the effects of their earliest caregiving experiences, but like anyone else are able to continue the development of their models of social relationships on the basis of maturation and new experiences. This means that the word “attachment” in the current name of this diagnosis has little meaning--  but it particularly lacks the very narrow meaning  so often ascribed to it.

Allen proposes that we stop using terms that incorrectly attribute behavioral problems to attachment difficulties, and that we stop saying we are treating attachment when in fact we are working with specific problems of parents and children. Not all relationship problems are attachment problems, and many behavior problems are not relationship problems  in any case. When we use terms that confuse the issues both of causes and of treatments, we make ourselves more likely to make serious mistakes.

What do we do then? How do we change the familiar names that make us think, wrongly, that we are actually talking about a specific aspect of attachment? Allen suggests a new emphasis on outlining the  problems a child or family is experiencing--  for example, aggressive behavior or callous/unemotional traits--  and adding to these what we know of a history of maltreatment. Then, treat the problems with well-established treatments, and, I would say, forget the popular belief that treating the problems successfully is wrong because  it ignores the “underlying” cause. 

Reactive Attachment Disorder and Attachment Disorder: Compare and Contrast

My colleague Linda Rosa recently sent me a link to an apparently highly commercialized organization called “The Adoption Exchange”. At https://www.adoptex.org/events/understanding-attachment-2016-april-18/, The Adoption Exchange announced a class that purported to explain the difference between Reactive Attachment Disorder and Attachment Disorder, as well as informing students about parenting methods that “heal attachment issues” in adopted children. The instructor was a licensed professional counselor. Nevada social work education units were said to have been requested for this class. A list of learning objectives was provided, but these were puzzling to me because rather than stating some active performance demonstrating mastery (such as being able to define certain terms or differentiate between two conditions), as such objectives ordinarily do, they simply referred to understanding as an objective. (But this is a problem for the Nevada social work association, not for the rest of us.)

I don’t know what the instructor said about differences between Reactive Attachment Disorder and Attachment Disorder, but I think I can guess, because of the very fact that she proposed to discuss a difference between one well-established diagnosis, and another that is essentially the invention of a group who are confused about the nature of attachment and of any problems that may result from a poor attachment history. The title of the course, “Understanding Attachment”, might be better stated as “Completely Misunderstanding Attachment.”

The term Reactive Attachment Disorder has been in the Diagnostic and Statistical Manual of the American Psychiatric Association since about 1980. It’s a term that has gone through various changes over the years, as has indeed been the case for a lot of other diagnoses as well. RAD was initially a term that shared much with nonorganic failure to thrive (NOFTT) as a description of poor weight gain and physical development in the first year or so of life. Because poor development can and does often result from physical disease processes (referred to as failure to thrive, FTT), RAD/NOFTT was a relatively new concept, suggesting as it did that poor growth and development might also result from disturbances of relationships with caregivers, such that a baby did not ingest enough food or was unable to digests and use what was provided. (I remember a lecture on this topic in the ’70s that gave as an example a mother who was so anxious that her baby would not eat enough that she attempted to entertain him after every bite by putting an umbrella up and taking it down again, which amused the baby but distracted him from eating.)  By the 1980s and ‘90s, the failure-to-thrive aspects of RAD had disappeared from DSM, and the term focused entirely on behavioral indications of infant-caregiver relationships. At that point, a spectrum of attachment relationships was envisioned, with normal attachment behavior in the “Goldilocks” position, and aspects of RAD on either side of that--  one side involving children who were did not seem to prefer one adult to another, and the other side including those who were excessively clingy and afraid of separation. The current, DSM-5, position has divided these possibilities into two separate categories, Reactive Attachment Disorder (involving aloofness, unresponsiveness, difficulty in engaging in relationships,  and difficulty in receiving comfort), and Disinihibited Social Engagement Disorder (lack of preference for familiar people, exploring without normal “checking back”, and willingness to go with strangers). Both of these begin before age 5 years (but after 9 months) and are preceded by poor caregiving experiences.

You can see that those two diagnoses, as currently defined, are based on different kinds of behavior . So, how are they different from attachment disorders? Given that the term “attachment disorder” is written all lower-case, they are not entirely different. “Attachment disorder” (all l-c) is a general term that can be applied to either RAD or DSED, and has been applied to disorganized/disoriented attachment behavior in toddlers.  “Attachment disorder” (all l-c) is not meant to indicate a particular kind of problem, any more than “childhood rashes” necessarily means rubella.

However, when people capitalize those words--  Attachment Disorder—they think they mean something specific. Even in the 1990s, proponents of Holding Therapy/Attachment Therapy, who claimed that childhood aggressive or noncompliant behavior resulted from attachment problems, had been told frequently that the things they were talking about were not Reactive Attachment Disorder. As a result, they proposed a new term, Attachment Disorder (with caps) that they claimed was characterized by failure to make eye contact on a parent’s terms, love of blood and gore, aggression toward small children and pets, etc. Elizabeth Randolph, a psychologist whose license had been revoked in California, self-published a test she called the RADQ (not Reactive Attachment Disorder, but Randolph Attachment Disorder Questionnaire [Randolph, 2000]). Randolph, felt that she could validate this questionnaire against her own diagnosis, because she was able, she said, accurately to determine which children had Attachment Disorder—for example, Randolph stated, they were unable to crawl backward on command. Randolph clearly stated that the RADQ did not diagnose RAD, but instead tested for  Attachment Disorder, a diagnosis that was “not yet” in DSM. Sixteen years later, AD is still not in DSM, and the reason is that no one has done any of the substantiating work to show that such a diagnosis differentiates reliably between a specific problem and other problems a child may have.

No one would deny that there are children who are highly (and dangerously) noncompliant, or who seem fascinated by aggressive acts, or who attack both adults and younger or weaker beings. What would be denied is that there is any evidence that such problems are associated with attachment history, or that they can be cured by treatments that focus on attachment. What would also be denied is that there is a need for an additional diagnosis to replace disorders like Obsessive Compulsive Disorder, Oppositional Defiant Disorder, early onset schizophrenia, and so on.

The Attachment Disorder (with caps) concept has been a money-spinner for a shadowy world of practitioners who have little training in either established theory or research facts about attachment. They have sold their views to adoption organizations, who in turn market them to confused and overwhelmed adoptive parents, for whom the idea of fixing previously-damaged attachment is most attractive.

I doubt very much that the instructor of “Understanding Attachment” made any of these points.

       

Are "Coaches" the Same as Psychologists or Psychotherapists?

Anyone can ask a friend for advice, and many friends will give it. The advice may be right or wrong, the friend may or may not know what she is talking about—but it is pretty certain that a friend will not ask for a fee or for agreement to a contract before she gives her opinion.

Today, quite a few people ask for advice from a “life coach”, a “parenting coach”, or one of several other recently-invented kinds of coaches. These coaches may or may not be more knowledgeable than a friend is, and their advice may also be right or wrong. But it is pretty certain that the coach will want a fee, and the coach may also ask for a signature to a contract that protects the coach’s interests. Psychologists, counselors, mental health professionals, clinical social workers, and other licensed sources of advice and help also get paid and often do use a contract to state agreed-upon protections for both parties.

So what is the difference between coaches and mental health professionals? I don’t want to suggest that every member of one group is vastly different from every member of the other, but I do want to point out that coaches may be people whose qualifications are far below those of even a low-level licensed mental health practitioner. I’ll give two examples--  again, I emphasize, not characteristic of all coaches, but showing the worst possibilities.

I’ll begin with Debra “Kali” Miller, an Oregon psychologist whose license was revoked by her state professional licensing board (see http://childmyths.blogspot.com/2015/03/license-revoked-become.html for further details and sources). Miller’s conduct was brought into the open when a boy she had been treating, and whose family she advised about how to act toward him, attempted suicide and was taken to a hospital. There, he told staff how he had been made to crawl on the floor, to be fed with a baby bottle, and to be isolated for periods of time, as advised by Miller’s mentor, Nancy Thomas, a foster parent and self-appointed instructor with a lucrative system of camps and family advice. The board objected not only to Miller’s unconventional and dangerous practices, but to her failure to diagnose the boy’s depression and her use of a highly unconventional belief system to attribute all difficulties to “attachment disorders”. But were Miller, or Nancy Thomas, impressed by this turn of events? No, indeed; instead, Miller now presents herself as a “parenting coach” and is welcomed as such on the Nancy Thomas website. The fact that she has been disciplined and may not practice her profession in Oregon because of her conduct is nowhere mentioned. Now she is a coach, and all that unpleasantness about the suicide attempt is left behind.

For a second example, let’s have a look at one Dorcy Pruter, inventor of a “treatment for parental alienation” (hard to know where to put the quotation marks here, as all the words are questionable). The statements I am about to make here are based on court documents on display at www.tsimhonirevisited.com. Pruter was sued in U.S District Court in Wyoming in 2015, by her former client Theresa Breen, who had hired Pruter to help with a high-conflict divorce and custody disagreement. Pruter states in the trial transcript that she was a high school graduate without any college education and took courses offered by various coaching companies. She started a business called the Conscious Co-parenting Institute. A contract between Breen and Pruter is available. In it, this high school graduate agrees to “provide consulting services to compile evidence, create timelines, and write scripts to provide to Clients (sic) legal team referencing her legal custody dispute between Client, her former spouse and other professionals in her specific custody case.” This was to be done to some extent “on spec”, with Pruter receiving 20% of any settlements or awards. The agreement also stated that Pruter and her company were held harmless financially against any claims arising out of the contract.

Now comes an interesting part. The agreement also covered an Acquisition of Life Story Agreement, wherein Pruter established claim to the use of Breen’s life information for academic research or any other purposes. Indeed, for Breen to use her own life story, she would have to ask permission of the Conscious Co-parenting Institute. Interestingly, in comments on this case, the psychologist Craig Childress noted that as Pruter was not a licensed psychologist, she did not need to conform to professional ethics as presented by the American Psychological Association.

These two examples show that it is quite possible for individuals to market themselves as coaches either without professional training or with serious disciplinary actions by professional licensing boards in their backgrounds.  As a result of these facts, professional psychologists and other practitioners are concerned about the quality of assistance given by coaches. Judith Gebhardt, writing in the American Psychologist, examined some of these issues in an article entitled “Quagmires for clinical psychology and executive coaching? Ethical considerations and practice challenges” (2016, 71, 216-325).  

Gebhardt noted that “Clinical therapists work under clearly documented governance rules and explicit ramifications for malpractice, including reporting of noncompliance and breaking confidentiality. In comparison, coaches operate in a nongoverned profession where the ICF [International Coach Federation] acts as a credential-granting and self-anointed entity, with no oversight body, for example, a state or federal regulator. … Although the coaching profession has taken steps to address ethical breaches, self-oversight and self-management merits attention. …it is still the words from Sherman and Freas  (2014) that seem most appropriate: ‘It’s the Wild, Wild West!’  for the coaching industry and practitioners…” (p. 226).  (Although Gebhardt does not mention this, the ICF seems to be functioning like other quasi-professional groups, e.g. the American Psychotherapy Association, which provide impressive-sounding diplomates and certifications for very little in the way of training or accomplishment.)

I have no doubt that some coaches are exactly the right source of help for some clients, and no doubt someone can provide two examples of excellent coaches to match my examples of two poor ones. I am writing this simply to say caveat emptor--  it’s a client’s responsibility to make sure of the quality of services sought, most especially if that client is making decisions on behalf of children or other vulnerable persons. Craig Childress’ statement that a coach does not have to conform to ethical guidelines tells us much about the possible outcomes of choosing a coach over a licensed mental health professional.

  

   

Swaddling and Sudden Infant Death Syndrome

A brief article in the Science Times section of the New York Times this morning was enough to strike terror into the hearts of young parents: it associated swaddling of babies with SIDS. The article reported a risk of SIDS increased by about one third for babies who were swaddled, with the greatest risk for those sleeping in the prone position.

For readers who haven’t come across this, swaddling is a traditional infant care technique that involves wrapping a baby, fairly tightly, from feet to neck. The head is free and sometimes the arms are too. Some Native Americans used to do this by binding the baby to a cradleboard. As I understand it, the Russian tradition was to use long strips of fabric and to keep the baby swaddled much of the time until a year of age. (These babies were frequently unwrapped to be fed and cleaned, of course.) According to some observers, swaddled babies were sometimes so thoroughly bound that they could be picked up by the feet without bending their bodies. The purpose of swaddling was described as keeping the babies warm, making them easy to carry, and calming them. In developed countries today, swaddling is infrequent except for very young infants who may be tightly wrapped in blankets as a soothing measure. Older babies are usually put into “sleep sacks” or “sleeper” suits to keep them warm while avoiding the loose bedding associated with suffocation during sleep.

So, what about this article that looks at swaddling as a cause of increased SIDS rates? The article, by Anna Pease and colleagues, is titled “Swaddling and the risk of Sudden Infant Death Syndrome: A meta-analysis.” It appears in Pediatrics, May 2016 (pediatrics.aappublications.org/comtemt/early/2016/05/05/peds.2015-3275).

Pease and her colleagues did a meta-analysis by examining data from four studies of SIDS cases, with each case compared to a control infant who did not die. The studies used had appeared over a period of 20 years and used cases from parts of England, from Tasmania, and from Chicago. About 35% of babies were swaddled in Tasmania in the 1980s when that study took place, while about 9% were swaddled in Chicago in the 1990s, about 10% in an English study ten years ago, and about 6% in a more recent English study. Across all studies, about 17% of the babies were swaddled for the sleep that ended with their deaths, and about 10% of the surviving, control babies were swaddled. However, only in the English studies was the difference between swaddled and unswaddled babies’ deaths a statistically significant one, and only in the more recent one did this statistical significance remain after adjustment for other possible causes of SIDS. Babies found dead in the prone position were more likely to have been swaddled, and older babies who were swaddled were more likely to die than younger swaddled babies, whatever their sleep position.

Pease and her colleagues did a careful job of stating the limitations on conclusions that could be drawn from their study, and especially noted that none of the four studies they worked with gave a careful definition of swaddling. They did not advise against swaddling young babies, but did note that there should be an upper age limit of about 4-6 months on swaddling.

For me, this study raises questions about other factors that could both encourage parents to swaddle older babies and increase the chances of SIDS. Why, for example, did any of the parents in these studies continue to swaddle an older baby? The reasons could have had to do with the baby’s own characteristics; when a baby still sleeps very poorly and is easily distressed at age 4-6 months, parents may try to soothe him or her by swaddling or other techniques that were recommended to them much earlier, but there may be developmental problems related to the poor sleeping that are the actual causes of SIDS. Or, the reasons could emerge from characteristics of the parents; parents who abuse drugs or alcohol or suffer from physical or mental illnesses may choose to continue to swaddle because of difficulty in thinking about their babies’ developmental status and needs, or because they are especially disturbed by infant awakening and crying, all situations that are associated with less adequate physical and medical care for infants. Finally, use of swaddling with older infants may be associated with living conditions; parents might choose to swaddle older babies to keep them from rolling off a bed or sofa where they were put to sleep in the absence of a crib, or because of demands of other household members that they try to keep the baby quiet, all of these suggesting the poverty and overcrowding that can compromise infant health and make SIDS more likely.

Factors that make SIDS more or less likely are complex, and it is difficult to pull out single factors that by themselves cause or prevent SIDS.   In addition, making changes—for example, in sleeping position—may pose some developmental risks as well as possibly being associated with a decreased SIDS rate. Babies who use pacifiers/dummies have been reported to have lower SIDS rates, but it is not clear whether rhythmic sucking has a protective factor or whether the parents who provide a pacifier have other characteristics that make SIDS less likely.

Is there a take-home message here? Am I saying swaddle or don’t swaddle, sleep prone or sleep supine? No, simply that we all need to take a deep breath and think carefully about SIDS information as it emerges. It will take a long time to understand this complicated and terrifying phenomenon, and it is not likely that there will be a single action that will save our babies. All parents can do is their best, and it’s an awful truth that sometimes that’s not good enough.

Worried Sick About Autism? Read This Mother's Letter

I have a one year old son who is an absolute delight. He smiles and laughs, and uses eye contact effectively to communicate and interact. I wanted to post because I visited read your page numerous times when I was feeling anxious and found your rational and informative responses reassuring. Up until about 9- 10 months I was incredibly anxious that my son wasn't interacting much or communicating well- particularly in terms of eye contact. I identified with so many of the concerns that people have posted, including fears about Autism even though I knew that such early diagnosis is not possible. I took him to the Dr a few times and despite their reassurance, my gut feeling was that something was wrong. I think parents with young children are faced with a lot of information and we also spend time around other babies who are developing different skills at different paces. Whilst this can sometimes be reassuring it can also be unnerving, depending on perspective at the time. On reflection I think I had some unhealthy postpartum levels of anxiety and seeking treatment for this helped me to shift my focus and start to enjoy my son again while his social skills continued to develop.
Thanks for all the work you do and the time you take to write replies. It’s a minefield out there and a lot of the other information I came across on the internet served to heighten, not allay my fears. 

This letter from "Anonymous" was so welcome to me. Naturally I like to be told that I'm doing a good job--but I also hope that posting her words will send a meaningful message to the many young mothers whose anxiety becomes overwhelming for them. Many women don't understand that perinatal mood disorders can include more than the classical postpartum depression. If they don't hear voices telling them to kill the baby, they think they are quite all right. They don't realize that their moods and concerns may be out of control, causing them to suffer, and interfering with their relationships with the baby and other people (including their husbands).

Of course I am not saying that every worry about a baby is a symptom of a mood disorder. Worrying is a part of being a parent and a painful but realistic reflection of the responsibility parents have. But when no amount of reassurance makes someone feel better, she and her family need to consider whether counseling or even some medication would help them all get through this period of their lives better. Gynecologists nowadays are supposed to receive some training in screening for perinatal mood disorders and making recommendations about treatment, and they are certainly the first people most mothers should contact when they have excessive worry or  concern.  Unfortunately, a number of state programs for education of the public and professionals about these problems lost funding during the economic recession and have not had support renewed. However, if your health insurance allows for some mental health visits, being very worried about your young baby may be a good reason to seek private care and use some of those visits.

I want to reiterate what "Anonymous" says above: comparing your baby to other babies you know is usually just a way to feed anxiety. They are really all different,  and if you are already anxious you will busily look for the things they do better than your baby, and you will ignore the things your baby does better than the others! It's just a shame that most parent education material tells about average development in various areas, but does not mention the very normal deviations from the average that are characteristic of any group of babies. "Average" and "normal" do not mean the same thing at all--  but when you're already prey to exaggerated fears, it's quite easy to think that anything about your baby that's not "average" is cause for terrible alarm.

Evidence-Based Treatment: What Is It?

I’ve had a number of annoyed reader comments lately, claiming that certain mental health interventions were evidence-based, and I should stop saying that they weren’t. I’ve been in various brouhahas in professional journals, too, when authors claimed that they were writing about evidence-based treatments (EBTs), and I (and other people too) pointed out that they were not.

Why is everyone so eager to say that they are using an EBT? First, there is considerable cachet nowadays to be gained by saying you have an EBT. Many professional organizations recommend EBTs as the first choice among psychological treatments, and in the interest of accountability, many funding sources require that EBTs be used if available for the needed work.  Second, most people don’t know what the technical term “evidence-based” means, so it’s not too hard to convince them that a treatment is an EBT when it is not.

Everybody knows what “evidence” is in the everyday and the legal senses. It’s information that comes from people’s direct observations or from expert interpretations of indirect factors--  like DNA on underwear or contacts on cellphones. If I tell you what I experienced during a mental health intervention, and whether it made me feel better or not, that’s evidence. But it’s not the “evidence” in “evidence-based treatment”.

“Evidence-based treatment” is a technical term, a “term of art”, or “jargon” if you like that better. It first came into use in the 1990s, when the evidence-based medicine movement began to discuss definitions of the kind of evidence needed to give acceptable support of the effectiveness and safety of a treatment. Soon afterward, psychologists and others began to discuss the idea of levels of evidence--  that the significance of supportive information depended on how the information was gathered. An anecdote or testimonial, for instance, provides a very low level of evidence, and  treatments should not be chosen on the basis of that kind of evidence. To be called EBTs, treatments must have been supported by two independently-done randomized controlled trials; the studies must also meet other requirements such as presenting measures of intervention fidelity (showing that the treatment was done the same way each time). In cases where a treatment cannot be randomized, clinical controlled trials with many restrictions can be used. If a study just looks at people’s conditions before and after treatment, that treatment can’t be said to be an EBT. There has to be a comparison (control) that takes into account the fact that people’s conditions may change spontaneously or with maturation, and it has to be possible to tell how much change occurred that way and how much was caused by a treatment. In addition to these requirements, nowadays there is increasing pressure to include in research reports any evidence that a treatment can be associated with harm, and EBTs need to be reported in ways that allow both potential benefits and risks to be calculated.

Unfortunately, as EBTs have been seen as more and more desirable, the term “evidence-based” has been thrown around ever more loosely. Sometimes this has been done by unethical practitioners who want to increase their business success and know that interesting anecdotes or testimonials will get people’s attention and interest. But sometimes it has been done, I think almost inadvertently, by organizations that aim to provide lists of EBTs for the information of both practitioners and the public.

Such organizations present lists of treatments, but the material must in many cases be read quite carefully before it becomes clear whether a listed treatment is or is not actually to be considered an EBT. Let’s look at two of these--  the National Registry of Evidence-based Programs and Practices; NREPP, www.samhsa.gov/data/evidence-based-programs-nrepp) and the California Evidence-based Clearinghouse for Child Welfare (CEBC; www.cebc4cw.org). Each of these uses a name suggesting that programs listed there should be expected to be evidence-based.

However, NREPP includes the New Age “tapping treatment” Thought Field Therapy on its list, in spite of clear evidence that this method is ineffective. NREPP lists 205 treatments that are primarily for children and adolescents, and mentions possible adverse events for only ten of them. Until 2015, NREPP used a rating and report method that made it easy for readers to assess adverse events and design problems, and it could be calculated that when design problems were assessed, the average rating for handling confounded variables was only 2.6 out of a possible 4.0. A new rating method (which is supposed to be applied gradually to all old reports) makes these and other aspects of studies much more difficult to see.

CEBC lists very few programs that are not aimed at children and adolescents. The website rates treatments from 1 (evidence-based by the definition given earlier) to 5 (concerning methods). But it also classifies some listed treatments as “non-responders” (when proponents did not provide requested material) or as Not Rated (when the material available was not sufficient for a numerical rating). Of 286 programs for children and adolescents, 26 were non-responders and 77 of the “evidence-based” treatments listed were in fact Not Rated. Only 21 of the listed programs were rated as 1, and none whatever were rated 5 (concerning), even though the list included Corrective Attachment Therapy and a “camp” managed by Nancy Thomas--  both associated with adverse outcomes for children.

“Evidence-based treatment” mustn’t be confused with the kind of evidence that we use for decisions in everyday life. The term has a very specific and important meaning--  even more important now that funding sources and third-party payers may reject anything that does not meet the definition of EBT. Unfortunately, even websites that were intended to help the public deal with understanding EBTs are not doing their jobs well, because treatments appear on their lists when they should not. Teachers of introductory psychology classes, listen up—you can help by making this issue a point for your students to understand!  

  

Flying Monkeys, "Parental Alienation", and... No Vivid Writing Please

Craig Childress, the proponent of non-evidence-based and intrusive treatments for children who reject contact with one of their divorcing parents, has a rather remarkable newsletter going (https://drcraigchildressblog.com/2016/03/01/the-flying-monkey-newsletter/). He uses the term “flying monkeys” to designate the various people who argue against his approach and who thus stand in the way of parents who want to pre-empt child custody and prevent children from communicating with their preferred parent. This vivid term is no doubt gratifying to Childress’ clients, but the American Professional Society on the Abuse of Analogies, an august body that I just made up, is taking exception and umbrage in response to Childress’ effort to demonize psychologists and lawyers who regard high-conflict custody battles as individualized, complex, and nuanced situations.

Childress’ persuasive and inflammatory language technique  is of course hallowed among PR and advertising groups, but is not acceptable in professional circles, where avoiding fallacious reasoning is everyone’s responsibility. Although psychological events are often best communicated through some use of metaphor, it’s necessary that two entities that are compared in this way  share many characteristics, and especially characteristics that are relevant to the predicted outcome under consideration. By using the term “flying monkeys”  Childress is not appealing to a useful analogy for better understanding of high-conflict divorce, but instead suggesting to his fans that those who oppose them are doing so only from vicious inclination, without foundations in fact or logic—and indeed that they do so at the behest of a Wicked Witch, not even for their own purposes. This is regrettably an excellent way to build a base of admirers and supporters whose emotional needs are met by this kind of thinking, but it is not a way to persuade professional psychologists that Childress’ claims are correct. The only way to do that would be by offering information from research that meets current standards for evidence-based treatment.

Let’s hold our noses and examine some other statements from the newsletter linked above. How about “these allies of the narcissistic/(borderline) parent provide support for maintaining the pathology involving the psychological abuse of the child…”? The “allies”, presumably, are people like me who are aware that Childress has not made his case, and ask for acceptable evidence to be provided. The “narcissistic/(borderline) parent” is the person less excitingly referred to as the child’s preferred parent, who is now classified by fiat as emotionally disturbed or even psychotic. The “pathology” would be more accurately described as the family dynamics. The “psychological abuse of the child” is at the very worst discouragement of a relationship with one parent by the other; not admirable in some cases, but not found in Garbarino’s discussion of emotional abuse--  and in addition, it’s the exact action that Childress proposes to “cure” the child’s rejection! So, in translation to a less inflammatory tongue, what we have is this: “ people who think Childress is wrong are helpful to preferred parents who do not want to change present family  arrangements and dynamics and support the child in his or her wish not to have contact with one parent.” So, it would appear that when the statement is stripped of its connotative language, it’s actually quite true--  but the implicit scariness written into Childress’ statement is not true.

Why do we monkey-allies say what we do? Well, it’s very simple, and anyone who has become familiar with pseudoscientific claims will know what I’m about to say, because there are only two reasons anyone ever argues with psychological pseudoscience. Here are the two reasons in Childress’ terms: “They likely do so because of their own ignorance or because of trauma histories in their own background that resonate with the false trauma reenactment narrative being presented in attachment-based “parental alienation” (a process called “countertransference” in professional psychology)” So, passing lightly over the actual use of countertransference, we see that we dissenters are perhaps More to Be Pitied Than Censured. We either just haven’t studied the right stuff, or we are Sick because of our own histories that blind us to reality. This familiar form of faux counterargument is one I’ve been hearing for years from Attachment Therapy and “Nancy Thomas parenting” advocates, who are sure that if I hadn’t had a severe attachment trauma I would certainly see the force of their arguments. Whereas science has ways of responding constructively to criticism, pseudoscience is confined to the arguments Childress uses.

Just one more thing and then I quit. Smack in the middle of the page linked above, Childress places this as a link:

“New APA Position Statement: Some children are manipulated into rejecting a parent.”

This is NOT, however, a new APA position statement, however it may appear to the casual reader. It is a petition that APA make a new statement, and one agreeable to Childress & Co. APA has refused since 1996 to become involved with “parental alienation” and its various treatments. The organization does not reply to letters from persons on either sides of the PA debate. Whether that is wise or not is arguable—but it is clear that Childress’ implication that there has been a new APA statement is not only wrong but profoundly self-serving.

Baby Looks at Toys More Than At You? Probably Not a Problem

If you’re a parent of a young child and feel scared about autism, you probably are aware of “red flags” that might warn you of an infant’s future autism diagnosis. The most popular of these has to do with gaze at faces and especially mutual gaze or “eye contact”. Young parents watch to see whether their baby looks toward their faces and gives prolonged examination to their eyes. Not only the many “red flag” lists, but advertisements (usually showing mothers and babies) suggest that long periods of shared gaze are normally frequent events in the lives of parents and infants. Some parents get the idea that these periods of gazing are not only frequent but should be present practically from birth. Others become more concerned about the role of mutual gaze in joint attention after about 9 months and expect those shared gazes to last a long time. 

‘Tain’t so, however, as I’ve commented before on this blog. What is “so”, then? To know this, we have to turn to some very careful, detailed work of microanalysis on video records of infant-adult activity.

In a recent article (De Barbaro, Johnson, Forster,and Deak, [2016]. Sensorimotor decoupling contributes to triadic attention: A longitudinal investigation of mother-infant-object interactions. Child Development, 87, 494-512), the researchers looked at babies as they developed from four months of age to 12 months. They made videos of each baby playing with his or her mother when objects were available to handle or look at. Both partners’ hand movements and gazes were recorded as they sat with interesting toys between them. Both mothers and babies could and did pick up toys and look at them, or look at them without picking them up, or pick them up and not look at them. Each could also watch what the other was doing. The very large number of recorded events were assessed by trained observers with respect to what the individual was touching and where he or she was looking. (The frame-by-frame analysis contained 610,000 behavioral events, which should show readers what it actually takes to understand developmental changes.)

As the babies got older, they spent more time touching the toys, and less time looking at them, but about the same (relatively low) amount of time both looking and touching. The mothers changed what they did as the babies got older, too--  as the babies touched more, the mothers touched less. With increasing age, the babies also increasingly “decoupled” their actions--  that is, they became more likely to look at something without touching it, or to touch it without looking at it. In addition, they became less locked into having their two hands do the same thing, and increased their tendency to do one thing with the right hand and another with the left (an important ability that lets them hold an object in one hand and poke it with the other, or, later on, tie their shoelaces).

For parents who are concerned that their four-month-olds do not make enough eye contact, I want to point to the findings of De Barbaro and her colleagues that four-month-olds actually showed more “joint attention” by looking at objects the mothers were attending to than they did when they were older. The four-month-olds spent more than 40% of their session time touching objects, and 75% looking at them, even though they  were face-to-face with their mothers and could easily have spent more time looking at faces. These authors cited an earlier study as showing that “3-to-5-mont-old infants were approximately 5 times more likely to look at objects manipulated by their parents than at their parents’ faces”.  In addition, when the babies began to spend less time looking at the toys, they did not look more at the mothers’ faces; “rather, infants increasingly looked at other features of their environment (e.g., tray, floor, and furniture)”. 

DeBarbaro and her colleagues also noted that “decoupling”—changing the tendency to link looking and touching, or to link left hand and right hand movements—“allows infants to watch their mothers’ object activity while maintaining contact with their own objects. This sets the stage for activities like taking turns using toys or attempting to imitate the mother’s actions.”

I don’t at all mean to ridicule young parents’ concerns about autism or about problems of attachment. I just want to point out that babies in their first year have a lot of developmental tasks to do in addition to social interactions and the foundations of attitudes toward the self and others. Sighted human beings use gaze in communication in very significant ways, but they use gaze for a great many other things they learn and do. As a highly visual species, we take in most of our information with our eyes. Looking at just one thing we do with our eyes as infants is a mistake, because we need to be considering all the many ways a child interacts with the world.

I also want to point out that the article by De Barbaro and her colleagues is an excellent example of what it takes to understand development at a detailed level. Rather than just doing things more and more or better and better over the first year, babies do some things more and some things less over time. As is the case for crawling and walking, they may abandon an action they do very well and take up one that is quite challenging at the time. The whole picture of development can’t be reduced to “red flags.”  

Time-Outs, Time-Ins: Good, Bad, and Badly Misunderstood

A brief article published a couple of years ago in Time magazine is still getting a lot of attention. This piece, written by Daniel Siegel and Tina Payne Bryson, was entitled “ ‘Time-Outs’ Are Hurting Your Child” (www.time.org/3404701/discipline-time-out-is-not-good/ ). Siegel and Bryson began with the statement that painful experiences can “change the structure of the brain”  (though they did not follow up by saying what behavioral or mood changes might result, if any). They noted that emotional pain activates the same brain areas as physical pain, commented that isolation can be emotionally painful, and concluded that children who were temporarily isolated in “time-out” may be damaged by the experience. They advised that “time-out” should give way to “time-in” to give increased experience of warm affection.

Members of the Society of Clinical Child and Adolescent Psychology, Division 53 of the American Psychological Association, have been quite concerned about the inaccuracies in these statements. In a press release headed “Outrageous claims regarding the appropriateness of Time Out have no basis in science”, members of the division pointed out the highly selective cherry-picking of neurological evidence that Siegel and Bryson made use of, and noted that there were decades of research supporting the safety and efficacy of “time out”, and little or none supporting “time in”.

The efforts of Siegel and Bryson to argue that “time outs” or harmful were characterized by a common theme among pitchers of woo--  that when the brain is “changed” by events, that the outcome is of necessity a bad one. This ignores the fact that the brain is constantly changing in structure and function because of maturational factors, and is simultaneously being changed as memories of experiences of all kinds are formed. The outcomes of these changes are generally positive, so it is absurd to present “changes in the brain” as evidence of harm. The first problem is to show that an experience (“time out”, for instance) is regularly followed by undesirable behavioral or attitudinal changes; if this had been accomplished, which it has not, the next step would be to trace the brain events that cause the connection between the experience and the bad outcome.

Like all other organisms, children change their behavior in response to reinforcing events that follow behaviors. If something nice happens after you do something, you become more likely to repeat that action. Unfortunately, sometimes behaviors that other people do not want or like get reinforced by accident. For example, most children will cut back on a behavior that gets them scolded and yelled at, but a child who gets very little attention may find that being focused on by an angry adult has reinforcing power. It’s not the yelling itself, but the attention, that reinforces the behavior. Similarly, a preschool child who acts up may find that although the teacher does not reinforce the behavior, all the other kids are excited and interested and attentive--  that reinforces the behavior and makes it more likely to be repeated.  

If children are “being bad” because an undesirable behavior has been reinforced in the past, the unwanted behavior can be reduced by making sure that it does not get reinforced.  The purpose of “time out” is to prevent reinforcement by removing the child temporarily from a potentially reinforcing situation. If done consistently, this is an effective approach--- but ONLY if the unwanted behavior has reached its present frequency because it was reinforced in some way by the social environment.

If a behavior is self-reinforcing, like eating when hungry, scratching an itch, or masturbating, unless it has also been socially reinforced, “time-out” will not affect its frequency. Neither will “time-out” reduce seizures or periods of inattentiveness due to neurological disorders, or fearful behavior stemming from previous traumatic experiences, or attention-getting behavior resulting from the absence of normal adult attention. The reason to choose a method other than “time-out” is that a specific behavior may not have developed as a result of reinforcement, and it will not diminish as a result of non-reinforcement. Under those circumstances, “time-in” and increased interaction with an adult may be helpful to a child who needs social support in order to do his or her best.

“Time-out” is not always the best choice--  but this is not because it “changes the brain” in some mysterious but threatening way.

P.S. Then there’s my two-year-old granddaughter, who when sent to “time-out” trots off looking very pleased with herself as she does just what her older brother is sent to do! Is this experiencing actually reinforcing for her? Maybe, but after all she wasn’t so very naughty to begin with…

How Kids Enlist in the Culture Wars

Anyone who has been watching American political events this year will be aware of the reasons for the term “culture wars”. We’re not just watching groups of people who happen to agree with each other and not with their opposite numbers; we’re watching groups each bound together by beliefs and practices, and each disapproving strongly of the other’s positions. The beliefs and practices of each group are defined as cultures because they are taught and learned by members whose group shares them. The “war” part is unfortunately pretty obvious these days.

Although the United States is fortunately multicultural, there are two broad groups (each a coalition of smaller groups) that form the cultures now struggling in the political arena. The first of these is a modernist, progressive, liberal group,  consisting of the mainstream religious bodies combined with the secular humanists, whose beliefs and practices are not very different from those of the liberal churches. The second group is traditionalist, fundamentalist, and conservative. As adults, the two groups display strong differences in attitudes and preferred behaviors associated with a variety of issues. For examples of differences in the beliefs of these two groups, we can look at attitudes toward contraception and abortion, toward same-sex marriage, and toward reports of global warming.

Not surprisingly, the modernist and traditionalist groups each do their best to inculcate their beliefs and practices into children growing up in their groups. But how do they do this? When do the children begin to share the adult attitudes? Are modernist 5-year-olds and fundamentalist 5-year-olds already very different in their thinking? Or does it take years of teaching and cognitive development before differences are evident? Gilbert and Sullivan claimed that “Every boy and every gal that’s born into this world alive/ Is either a little liberAL or else a little conservaTIVE”. Were they right?

These are not easy questions to answer, but some help has been provided in a recent article (Jensen, L.E., & McKenzie, J. [2016]. The moral reasoning of U.S. evangelical and mainline Protestant children, adolescents, and adults: A cultural-developmental study. Child Development, 87[2], 446-464; N.B., if you look at this paper—I think the captions to figures 2 and 3 are reversed). Jensen and McKenzie compared moral reasoning in members of two Presbyterian groups, the modernist Presbyterian Church (USA) and the fundamentalist Presbyterian Church in America (PCA). The first is a member of the National Council of Churches, the second a member of the National Association of Evangelicals. (Although I mentioned earlier that secular humanists might share a good deal with the modernist churches, I want to point out that no secular humanists were included here, and the results of this study may not apply to them as well.) Interviews about moral judgments and reasoning were carried out with 60 members of each church, the groups divided evenly into 7-12-year-olds, 13-18-year-olds, and adults ages 36-57. For example, at one point, interviewees were asked whether they could tell about a time when they had an important experience involving a moral issue—this might be a situation where they now think their actions were morally right, or they may now seem morally wrong. 

Of course most people find it difficult to explain all the details of their moral reasoning and judgment, whether they think an action is right or whether they think it’s wrong. Jensen and McKenzie worked out some details of the interviewees’ thinking by analyzing issues and answers on three dimensions. One was the age of the participant, a piece of information that would help establish developmental change in moral reasoning. A second was whether the moral issue being discussed was a private experience (like drug use, behavior toward friends, theft, or volunteering) or had to do with public sphere (like giving money to panhandlers, divorce, or capital punishment). The third dimension had to do with the ethical perspective taken. The authors referred to the three possibilities as follows: The Ethic of Autonomy focuses on harm to the self and the interests of the self and the needs of other individuals (as unique persons, not simply as group members). These moral decisions attempt to protect the self and other individuals, and this type of moral reasoning begins in early childhood and persists into adulthood. The Ethic of Community makes moral decisions on the basis of duties toward group needs, initially the family and later schools and even broader social organizations, whose harmony is seen as important. This type of moral reasoning is minimal in early childhood and may gradually increase through adolescence and into adulthood. Finally, the Ethic of Divinity stresses the role of spiritual or religious entities, with moral decisions involving obedience to a god’s authority, natural law, or spiritual purity. The last ethic has received much less research attention than the others.

Jensen and McKenzie’s interviewees used the Ethic of Autonomy most as children and decreased this perspective somewhat through adolescence and into adulthood. The Community perspective increased for everyone from childhood into adulthood.

The great difference between the groups was in the use of the Ethic of Divinity—rare even among evangelical children, almost nonexistent among modernist children, and increasing with age through adolescence, but by far most common among fundamentalist adults thinking about public moral issues (e.g., same-sex marriage).  Mainline adults, though less likely to use the Ethic of Divinity at all, applied it more often in the private than in the public sphere. A major difference between modernist and fundamentalist adults was in the appeal to scriptural authority, with Bibles being used and on display in fundamentalist households but rarely referenced by modernists.

 Jensen and McKenzie pointed out that the two “armies” in the current culture wars are not committed to the same “moral lingua franca” and therefore find themselves unable to carry out any real discussion of their differences. This is not so much a problem in childhood, when evangelical and mainline children tend to share the Ethic of Autonomy, but looms large after adolescence, when evangelicals emphasize the Ethic of Divinity, a perspective rarely taken by modernists.

That such different moral languages are spoken by the two major  groups may be one of the reasons for the current intense emphasis on angry emotion in politics. Neither understands what the other is saying, and the discussion is regrettably reduced to mime. Can we generalize this view to an explanation of world-wide conflicts? I think that’s possible—but such thinking is only a baby step toward  resolution on any stage.  

Adopted Children, Lying, Aggression, and Antisocial Behavior

This blog has intermittently been the scene of disagreements between me and certain adoptive parents. Our discussion usually goes something like this:

Parents: Our adopted children are terrible! They lie and steal and are even dangerous to other people. They have Reactive Attachment Disorder, that’s the problem.

Me: That’s not Reactive Attachment Disorder. Reactive Attachment Disorder is [defines RAD as in DSM-5, even in ICD-10 if feeling energetic].

Parents: Yes, they do have RAD!  How dare you say it’s not RAD! You’ve never lived with these kids, how would you know?

Me: I just said, those things you described are not the symptoms of Reactive Attachment Disorder. I didn’t say the kids didn’t do the things.

Parents: You ignorant no-good know-it-all, can’t you see that they need their attachment fixed, etc., etc.

Outside of the Attachment Therapy model, I have not seen anyone writing about RAD including antisocial behavior, or even about antisocial behavior as a problem of adopted children. However, while doing a search of the trauma literature for another purpose, I came across an article that focused on antisocial behavior as a particular problem of later-adopted children. The article proposed certain reasons for such behavior and also outlined a possible treatment, which I will describe. I must point out, though, that the article seems to have been published twice in the same journal in slightly different forms, is poorly proofread, and occasionally cites authors who have approved of holding therapy, so I don’t know exactly how seriously to take it. Nevertheless, some interesting points are made.

The article I’m referring to is: Prather, W., & Golden, J.A. (2009). A behavioral perspective of childhood trauma and attachment issues: Toward alternative treatment approaches for children with a history of abuse. International Journal of Behavioral Consultation & Therapy, 5(1), 56-74.

As you can see from the title of the journal, this paper takes a behaviorist position relative to both the causes and the treatments of undesirable behaviors of adopted children. They do not mention Reactive Attachment Disorder. Instead, they list various disturbing and undesirable antisocial behaviors like lying, sneakiness, and manipulation. Rather than proposing that these were caused by a poor attachment history, Prather and Golden discuss how these behaviors could have been rewarded, first by the child’s experiences with abusive or neglectful caregivers, and second by unintentional behaviors of foster or adoptive parents and of other children. Please note that these authors are not blaming the foster or adoptive parents, but pointing out that their natural actions toward the child may reinforce the very behaviors that they want to eliminate.

Prather and Golden point out that adopted children who behave antisocially may appear to lack “conscience”  or “attachment”, but in fact they have learned very well from their early experiences with abusive or neglectful caregivers. They have never been punished for lying or using unacceptable language—such actions may have been met with indifference or even amused approval. They may have been taught antisocial rules about hitting as a generally acceptable response, and may have been regularly teased into aggressive reactions by adults. They are likely to have learned to avoid adults in some or even most circumstances, as avoidance has led to the negative reinforcement of evading adult mistreatment. Whether or not they were attached emotionally to their caregivers may be seen as a minor problem compared to their history of learning to behave in “unattached” ways.

It is not surprising that abused or neglected children bring their learned behavior patterns with them to adoptive or foster homes. Once there, it may be a while before the new caregivers realize what undesirable behaviors are going on (and I wonder whether the time this takes is what is perceived as the “honeymoon” period of adoption). During that period, adults in the household may inadvertently reinforce the unwanted behaviors, for example, by failing to notice a lie or a theft. People outside the household are even more likely to provide accidental reinforcement, and this is related to an important issue.

The study of learned behavior has yielded some important principles about how reinforcement affects learning and behavior. The frequency of behavior is raised when the behavior is followed by reinforcement, but there is more to it than that. When the reinforcement stops, the length of time it takes for the behavior to stop depends on how and when the reinforcement used to occur. Paradoxically, when the behavior has been reinforced every time, stopping the reinforcement altogether causes the behavior to drop quickly to a low frequency—but if the behavior was reinforced only intermittently, it will persist for a long time after the reinforcement stops.

Most socially-reinforced behavior is reinforced only intermittently. The abusive and neglectful parents of the now-adopted or fostered children are very unlikely to have reinforced a behavior every time; in fact, they may have been just as likely to punish or to appear indifferent as to be amused or admiring of any action. This means that whatever behaviors were learned by the children, it will take a long time for them to be “unlearned”, especially if they are very occasionally reinforced by well-meaning adoptive or foster parents, by strangers, or by other children who are fascinated by the “bad kid”. Also, of course, some of the unwanted behaviors are self-reinforcing—the child is rewarded by getting the thing he stole or by avoiding punishment by lying.

So, what do Prather and Golden suggest as treatment for the concerning antisocial behaviors? I must emphasize that I have not found any published empirical work that they have done, but they made some suggestions that may be fruitful. Much of the focus is on “catching them being good”: encouraging the family to put less stress on “unattached” behavior and more on times when the problems are not apparent, and especially on ways that problems have been solved and parents have managed not to reinforce unwanted actions . Identifying antecedents, or triggering situations followed by unwanted behavior, can help anticipate and control how the child acts. (For example, does the child act up when the mother goes out without telling him she is going?) Acknowledging and paying attention to negative feelings is another important item, especially as the children may have become numb to their own feelings and therefore fail to experience or to anticipate a sense of guilt or fear of punishment. As Prather and Golden point out,” Unlike traditional attachment based family therapies, which often interpret verbal information in terms of underlying emotional dynamics, the rational cognitive emotive view of human behavior focuses solely on the causal sequences of a child’s experiences and perceptions, and the impact that the child’s negative thoughts concerning trauma have on the role of emotion in behavioral causation.”

Again, there does not seem to be any new evidence about how well this approach can be made to work. And those who are committed to an all-attachment, all-the-time perspective may say, “that’s just treating the symptoms!” But, to quote Nicole Hollander’s “Sylvia”, I might respond: Words to live by!

  

Flint and Elsewhere: What Aspects of Lead Poisoning Are Irreversible?

Far, far be it from me to imply that lead poisoning in infants and children is a minor problem, but I feel uneasy about the repeated declarations that children exposed to lead in the environment suffer “irreversible” effects. This I find especially worrisome when there is stress on mental retardation as a possible outcome of lead exposure—to say that mental abilities have been irreversibly affected when infants and toddlers are lead-exposed may in some cases be correct, but ignores the many factors that work together to determine an individual’s mental development. How awful it must be for parents of lead-exposed children to encounter these statements and know that people have essentially disposed of their children as beyond help!

 The dramatic statements about lead exposure remind me irresistibly of the “crack baby” concept of the 1990s, when headlines regularly stated that children who had been exposed to crack cocaine prenatally were hopelessly ruined. That did not turn out to be correct, and with proper care given to lead-affected children, the present claims will probably not be true either. Naturally it would have been far better if the children had not been exposed to lead to begin with, but they can be helped to develop at normal levels or close to them. This statement applies not only to the children of Flint, whose water supply was contaminated, but also to the many children in the United States who are exposed to lead in paint, dust, and so on in their own homes.

To support this statement, I am going to refer to a document produced by the Centers for Disease Control, “Managing Elevated Blood Lead Levels Among Young Children” (www.cdc.gov/nceh/lead/casemanagement/managingEBLLs.pdf).

Where children’s blood lead levels are very high, the CDC document recommends chelation therapy, a technique that chemically removes lead from the child’s body. (Please note that while this method is necessary and effective for management of heavy metals poisoning, it is most inappropriate and should never be used for treatment of autism or related problems!) The document points out that chelation should be used with caution and that primary care providers need to seek the help of experts. “A child with a [elevated blood lead level] and signs or symptoms consistent with encephalopathy should be chelated in a center capable of providing appropriate intensive care services!” (! in original; this treatment is nothing to take casually—JM). If the treatment is done with oral chelation agents with the child as an outpatient, the dosage needs to be carefully monitored, and the treatment needs to be done in a lead-free environment.

Children with elevated blood lead levels often have inadequate nutritional intakes of iron, calcium, and vitamins, and nutritional changes have been recommended as ways to prevent absorption of lead or to combat its effects. However, it is not at all clear that nutritional factors affect blood lead levels; it may simply be that children whose families live where lead exposure is likely also have families who do not have access to healthy food or information about child nutrition. Nevertheless, improving children’s early nutrition can be an important step toward good child health and development, both physical and intellectual. Low levels of protein intake and lack of iron are associated with problems of brain and mental growth, especially when they occur in the infant, toddler, and preschool years. Giving children adequate diets is a way to fight mental retardation, even if it does not actually lower blood lead levels. The CDC recommends giving pureed meat to infants as soon as they are developmentally ready, and giving red meat to children once a day. Dairy products and fruits or fruit juices several times a day are also recommended. (Minimizing fatty snack foods is also a good idea, in that it will increase children’s appetites for nutritious foods that may be of less interest when calorie-rich snacks  are available.) In order for many parents to assure good nutrition to their children, they need to have not only enrollment in WIC, but access to grocery stores that offer a variety of foods at reasonable prices.

To ensure that each child reaches the highest intellectual level he or she is capable of, high quality preschool programs are of great importance whether or not children have elevated blood lead levels, and it’s possible that such programs can make the difference between moderate retardation and fairly normal achievement for some children, if they are combined with other ways of treating lead exposure. The CDC document also suggests that developmental monitoring is needed for older children who have had elevated blood lead levels in early life. These need to continue into school age, with times of transition like first grade, fourth grade, and seventh grade getting most attention. Children who are inattentive and distractible will need help in order to have the maximum benefit from school.

To summarize, we have a number of ways to encourage good development in children who have been exposed to lead. The lead exposure may be “irreversible”, but a poor developmental outcome is not inevitable, and the worrisome trajectory present when no interventions take place can be reversed to a greater or lesser extent by help we know how to provide. What is needed, of course, is the political will and the funding to put these interventions in place. In the case of Flint, if the right decisions are made, the interventions could begin almost at once, while replacement of water pipes will take years. Similarly, when lead exposure comes from old paint, interventions can be of help now, while actually removing lead from houses can take many years—the process, indeed, can create even more dust and lead exposure than already exist. 

  

Do I hear any candidates for president talking about this? Not really…