Shades of "The Snake Pit": The Wet Pack is Back

I thank my colleague Linda Rosa for bringing this to my attention: http://autismum.com/2012/01/18/le-packing-pack-it-in. The piece describes the use of “packing”, or wrapping naked children in cold wet sheets, as a “treatment” for autism. It quotes the opposition of Michael Rutter and Simon Baron-Cohen--  leading British researchers on causes and treatment of childhood mental illness--- and their signatures on a 2009 statement rejecting this practice. The “Autismum” author also points out that “packing” has been used in Europe for over thirty years.

I want to point out that in fact this practice goes back much farther than that, is based on ideas such as the hydropathic (“water-cure”) beliefs of the 19^th century, and has never been supported by any empirical evidence. It has, however, been fostered during the last thirty years by related suggestions and treatments, some of them put forward by occupational therapists.

The use of “wet packs”  for the mentally ill probably originated in their use (appropriate for the time) in treating fevers. With minimal pharmaceutical knowledge or resources, physicians of the 18^th century and before used “packing” as a treatment for the high and dangerous fevers associated with typhoid and other serious infections. The agitation and  restless activity that may be associated with fever were easily confused with the agitation and activity that may characterize manic episodes, autism, or other mental disturbances. Just as John Hughlings Jackson later took the regression of function resulting from brain damage and supplied it as a metaphor for cognitive or emotional dysfunctions, physicians treating the mentally ill thought of physical illness as a model for their treatment. Dr. Willis, George III’s physician and “mad doctor”, used hydrotherapy in the form of both warm and cold packs, a cold pack on the chest being expected to calm the action of the heart. According to Joseph Whorton’s book Nature Cures, a “wet-sheet” technique was thought  by 19^th-century hydropaths to draw off impurities that disturbed both physical and mental functioning.

The use of “packing” in mental hospitals continued well into the 20^th century. Mary Jane Ward’s semi-autobiographical novel The Snake Pit, in the 1940s, depicted its heroine’s experiences of wrapping in wet sheets, the “wet pack” treatment. (Incidentally, when this novel was issued in paperback in the 1960s, it was supplementary reading in many a psychology class; I have to wonder how many students of that time came to accept “packing” as a legitimate treatment. Just goes to show, you have to watch what reading you assign--- someone might actually do it!) Tubs full of hot water were also used by some practitioners, leading to the scalding death caused under the supervision of the egregious Jacqui Schiff of Transactional Analysis fame.

An issue related to the use of “packing” was the employment of restraints for calming purposes. George III was restrained in a special chair when agitated. The idea of restraint as a treatment in addition to a safety measure has remained with us, and it’s only recently that the use of restraint and seclusion has been considered to need careful regulation. Restraint in the form of physical pressure was advocated by chiropractors and similar practitioners from the 19^th century on (by the way, there were chiropractic mental hospitals up until about 1960).

In the 1960s, the occupational therapist A. Jean Ayres posited individual variations in sensitivity to sensory stimulation, including both light and deep pressure, and argued that developmental problems of children could be treated by a program of carefully balanced sensory stimulation—a “sensory diet” that might include regulation of light and sound, deep and light massage, and vestibular stimulation. (These ideas were also associated with programs designed for handicapped children by French educators like Itard and Seguin.) A connection between physical pressure and autism was suggested by the high-functioning autistic Temple Grandin, who described how as a child she longed for the pressure of the “squeezer” that held her grandmother’s calves for medical treatment; in her most recent book, Animals Make Us Human, Grandin refers to placing an animal in a box and filling the box with grain to provide all-over pressure and calm the creature. All of these claims lent support to the idea that physical pressure is calming and beneficial.

There are common practices that use pressure to have a soothing effect. For example, swaddling young babies is a world-wide method, and in Russia and some other places used to be continued until the child was a year old. The babies were so carefully wrapped that it was said you could pick one up by the legs and wave it around like a package without its body bending at all (I doubt that this was advised, however!). But although swaddling of young babies is still recommended as a calming method, not all uses of restraint and pressure are so harmless. For example, at www.sptimes.com/2006/12/15/Tampabay/letter_explains_schoo.shtml, there is a description of the use of stretchy bags called  “Body Sox” as a substitute for “timeout” for preschoolers. The practice of the complimentary and alternative psychotherapy called Holding Therapy or Attachment Therapy also involves physical restraint of a child in the form of an extended embrace by a parent or therapist, sometimes in spite of the child’s struggles to get away. Neither Body Sox nor Holding Therapy is based on evidence of efficacy, and the latter has well-demonstrated dangers in the form of injuries and deaths resulting from restraint and from related practices.

Physical restraint of the kind exemplified by “packing” is a practice left over from previous centuries--  what we might call the “trailing edge” of an idea. Historically, a variety of related beliefs have melded with the original treatments for fever and agitation to extend the lifespan of restraint intended as therapy. However, it is more than time for these practices to come to an end. They are without therapeutic merit, and they are potentially dangerous both mentally and physically. It’s time for us to follow the recommendations of Michael Rutter and Simon Baron-Cohen, about “packing”, and to question carefully all other practices based on similar ideas.

  

 I thank my colleague Linda Rosa for bringing this to my attention: http://autismum.com/2012/01/18/le-packing-pack-it-in. The piece describes the use of “packing”, or wrapping naked children in cold wet sheets, as a “treatment” for autism. It quotes the opposition of Michael Rutter and Simon Baron-Cohen--  leading British researchers on causes and treatment of childhood mental illness--- and their signatures on a 2009 statement rejecting this practice. The “Autismum” author also points out that “packing” has been used in Europe for over thirty years.

I want to point out that in fact this practice goes back much farther than that, is based on ideas such as the hydropathic (“water-cure”) beliefs of the 19^th century, and has never been supported by any empirical evidence. It has, however, been fostered during the last thirty years by related suggestions and treatments, some of them put forward by occupational therapists.

The use of “wet packs”  for the mentally ill probably originated in their use (appropriate for the time) in treating fevers. With minimal pharmaceutical knowledge or resources, physicians of the 18^th century and before used “packing” as a treatment for the high and dangerous fevers associated with typhoid and other serious infections. The agitation and  restless activity that may be associated with fever were easily confused with the agitation and activity that may characterize manic episodes, autism, or other mental disturbances. Just as John Hughlings Jackson later took the regression of function resulting from brain damage and supplied it as a metaphor for cognitive or emotional dysfunctions, physicians treating the mentally ill thought of physical illness as a model for their treatment. Dr. Willis, George III’s physician and “mad doctor”, used hydrotherapy in the form of both warm and cold packs, a cold pack on the chest being expected to calm the action of the heart. According to Joseph Whorton’s book Nature Cures, a “wet-sheet” technique was thought  by 19^th-century hydropaths to draw off impurities that disturbed both physical and mental functioning.

The use of “packing” in mental hospitals continued well into the 20^th century. Mary Jane Ward’s semi-autobiographical novel The Snake Pit, in the 1940s, depicted its heroine’s experiences of wrapping in wet sheets, the “wet pack” treatment. (Incidentally, when this novel was issued in paperback in the 1960s, it was supplementary reading in many a psychology class; I have to wonder how many students of that time came to accept “packing” as a legitimate treatment. Just goes to show, you have to watch what reading you assign--- someone might actually do it!) Tubs full of hot water were also used by some practitioners, leading to the scalding death caused under the supervision of the egregious Jacqui Schiff of Transactional Analysis fame.

An issue related to the use of “packing” was the employment of restraints for calming purposes. George III was restrained in a special chair when agitated. The idea of restraint as a treatment in addition to a safety measure has remained with us, and it’s only recently that the use of restraint and seclusion has been considered to need careful regulation. Restraint in the form of physical pressure was advocated by chiropractors and similar practitioners from the 19^th century on (by the way, there were chiropractic mental hospitals up until about 1960).

In the 1960s, the occupational therapist A. Jean Ayres posited individual variations in sensitivity to sensory stimulation, including both light and deep pressure, and argued that developmental problems of children could be treated by a program of carefully balanced sensory stimulation—a “sensory diet” that might include regulation of light and sound, deep and light massage, and vestibular stimulation. (These ideas were also associated with programs designed for handicapped children by French educators like Itard and Seguin.) A connection between physical pressure and autism was suggested by the high-functioning autistic Temple Grandin, who described how as a child she longed for the pressure of the “squeezer” that held her grandmother’s calves for medical treatment; in her most recent book, Animals Make Us Human, Grandin refers to placing an animal in a box and filling the box with grain to provide all-over pressure and calm the creature. All of these claims lent support to the idea that physical pressure is calming and beneficial.

There are common practices that use pressure to have a soothing effect. For example, swaddling young babies is a world-wide method, and in Russia and some other places used to be continued until the child was a year old. The babies were so carefully wrapped that it was said you could pick one up by the legs and wave it around like a package without its body bending at all (I doubt that this was advised, however!). But although swaddling of young babies is still recommended as a calming method, not all uses of restraint and pressure are so harmless. For example, at www.sptimes.com/2006/12/15/Tampabay/letter_explains_schoo.shtml, there is a description of the use of stretchy bags called  “Body Sox” as a substitute for “timeout” for preschoolers. The practice of the complimentary and alternative psychotherapy called Holding Therapy or Attachment Therapy also involves physical restraint of a child in the form of an extended embrace by a parent or therapist, sometimes in spite of the child’s struggles to get away. Neither Body Sox nor Holding Therapy is based on evidence of efficacy, and the latter has well-demonstrated dangers in the form of injuries and deaths resulting from restraint and from related practices.

Physical restraint of the kind exemplified by “packing” is a practice left over from previous centuries--  what we might call the “trailing edge” of an idea. Historically, a variety of related beliefs have melded with the original treatments for fever and agitation to extend the lifespan of restraint intended as therapy. However, it is more than time for these practices to come to an end. They are without therapeutic merit, and they are potentially dangerous both mentally and physically. It’s time for us to follow the recommendations of Michael Rutter and Simon Baron-Cohen, about “packing”, and to question carefully all other practices based on similar ideas.

  

 I thank my colleague Linda Rosa for bringing this to my attention: http://autismum.com/2012/01/18/le-packing-pack-it-in. The piece describes the use of “packing”, or wrapping naked children in cold wet sheets, as a “treatment” for autism. It quotes the opposition of Michael Rutter and Simon Baron-Cohen--  leading British researchers on causes and treatment of childhood mental illness--- and their signatures on a 2009 statement rejecting this practice. The “Autismum” author also points out that “packing” has been used in Europe for over thirty years.

I want to point out that in fact this practice goes back much farther than that, is based on ideas such as the hydropathic (“water-cure”) beliefs of the 19^th century, and has never been supported by any empirical evidence. It has, however, been fostered during the last thirty years by related suggestions and treatments, some of them put forward by occupational therapists.

The use of “wet packs”  for the mentally ill probably originated in their use (appropriate for the time) in treating fevers. With minimal pharmaceutical knowledge or resources, physicians of the 18^th century and before used “packing” as a treatment for the high and dangerous fevers associated with typhoid and other serious infections. The agitation and  restless activity that may be associated with fever were easily confused with the agitation and activity that may characterize manic episodes, autism, or other mental disturbances. Just as John Hughlings Jackson later took the regression of function resulting from brain damage and supplied it as a metaphor for cognitive or emotional dysfunctions, physicians treating the mentally ill thought of physical illness as a model for their treatment. Dr. Willis, George III’s physician and “mad doctor”, used hydrotherapy in the form of both warm and cold packs, a cold pack on the chest being expected to calm the action of the heart. According to Joseph Whorton’s book Nature Cures, a “wet-sheet” technique was thought  by 19^th-century hydropaths to draw off impurities that disturbed both physical and mental functioning.

The use of “packing” in mental hospitals continued well into the 20^th century. Mary Jane Ward’s semi-autobiographical novel The Snake Pit, in the 1940s, depicted its heroine’s experiences of wrapping in wet sheets, the “wet pack” treatment. (Incidentally, when this novel was issued in paperback in the 1960s, it was supplementary reading in many a psychology class; I have to wonder how many students of that time came to accept “packing” as a legitimate treatment. Just goes to show, you have to watch what reading you assign--- someone might actually do it!) Tubs full of hot water were also used by some practitioners, leading to the scalding death caused under the supervision of the egregious Jacqui Schiff of Transactional Analysis fame.

An issue related to the use of “packing” was the employment of restraints for calming purposes. George III was restrained in a special chair when agitated. The idea of restraint as a treatment in addition to a safety measure has remained with us, and it’s only recently that the use of restraint and seclusion has been considered to need careful regulation. Restraint in the form of physical pressure was advocated by chiropractors and similar practitioners from the 19^th century on (by the way, there were chiropractic mental hospitals up until about 1960).

In the 1960s, the occupational therapist A. Jean Ayres posited individual variations in sensitivity to sensory stimulation, including both light and deep pressure, and argued that developmental problems of children could be treated by a program of carefully balanced sensory stimulation—a “sensory diet” that might include regulation of light and sound, deep and light massage, and vestibular stimulation. (These ideas were also associated with programs designed for handicapped children by French educators like Itard and Seguin.) A connection between physical pressure and autism was suggested by the high-functioning autistic Temple Grandin, who described how as a child she longed for the pressure of the “squeezer” that held her grandmother’s calves for medical treatment; in her most recent book, Animals Make Us Human, Grandin refers to placing an animal in a box and filling the box with grain to provide all-over pressure and calm the creature. All of these claims lent support to the idea that physical pressure is calming and beneficial.

There are common practices that use pressure to have a soothing effect. For example, swaddling young babies is a world-wide method, and in Russia and some other places used to be continued until the child was a year old. The babies were so carefully wrapped that it was said you could pick one up by the legs and wave it around like a package without its body bending at all (I doubt that this was advised, however!). But although swaddling of young babies is still recommended as a calming method, not all uses of restraint and pressure are so harmless. For example, at www.sptimes.com/2006/12/15/Tampabay/letter_explains_schoo.shtml, there is a description of the use of stretchy bags called  “Body Sox” as a substitute for “timeout” for preschoolers. The practice of the complimentary and alternative psychotherapy called Holding Therapy or Attachment Therapy also involves physical restraint of a child in the form of an extended embrace by a parent or therapist, sometimes in spite of the child’s struggles to get away. Neither Body Sox nor Holding Therapy is based on evidence of efficacy, and the latter has well-demonstrated dangers in the form of injuries and deaths resulting from restraint and from related practices.

Physical restraint of the kind exemplified by “packing” is a practice left over from previous centuries--  what we might call the “trailing edge” of an idea. Historically, a variety of related beliefs have melded with the original treatments for fever and agitation to extend the lifespan of restraint intended as therapy. However, it is more than time for these practices to come to an end. They are without therapeutic merit, and they are potentially dangerous both mentally and physically. It’s time for us to follow the recommendations of Michael Rutter and Simon Baron-Cohen, about “packing”, and to question carefully all other practices based on similar ideas.

  

 I thank my colleague Linda Rosa for bringing this to my attention: http://autismum.com/2012/01/18/le-packing-pack-it-in. The piece describes the use of “packing”, or wrapping naked children in cold wet sheets, as a “treatment” for autism. It quotes the opposition of Michael Rutter and Simon Baron-Cohen--  leading British researchers on causes and treatment of childhood mental illness--- and their signatures on a 2009 statement rejecting this practice. The “Autismum” author also points out that “packing” has been used in Europe for over thirty years.

I want to point out that in fact this practice goes back much farther than that, is based on ideas such as the hydropathic (“water-cure”) beliefs of the 19^th century, and has never been supported by any empirical evidence. It has, however, been fostered during the last thirty years by related suggestions and treatments, some of them put forward by occupational therapists.

The use of “wet packs”  for the mentally ill probably originated in their use (appropriate for the time) in treating fevers. With minimal pharmaceutical knowledge or resources, physicians of the 18^th century and before used “packing” as a treatment for the high and dangerous fevers associated with typhoid and other serious infections. The agitation and  restless activity that may be associated with fever were easily confused with the agitation and activity that may characterize manic episodes, autism, or other mental disturbances. Just as John Hughlings Jackson later took the regression of function resulting from brain damage and supplied it as a metaphor for cognitive or emotional dysfunctions, physicians treating the mentally ill thought of physical illness as a model for their treatment. Dr. Willis, George III’s physician and “mad doctor”, used hydrotherapy in the form of both warm and cold packs, a cold pack on the chest being expected to calm the action of the heart. According to Joseph Whorton’s book Nature Cures, a “wet-sheet” technique was thought  by 19^th-century hydropaths to draw off impurities that disturbed both physical and mental functioning.

The use of “packing” in mental hospitals continued well into the 20^th century. Mary Jane Ward’s semi-autobiographical novel The Snake Pit, in the 1940s, depicted its heroine’s experiences of wrapping in wet sheets, the “wet pack” treatment. (Incidentally, when this novel was issued in paperback in the 1960s, it was supplementary reading in many a psychology class; I have to wonder how many students of that time came to accept “packing” as a legitimate treatment. Just goes to show, you have to watch what reading you assign--- someone might actually do it!) Tubs full of hot water were also used by some practitioners, leading to the scalding death caused under the supervision of the egregious Jacqui Schiff of Transactional Analysis fame.

An issue related to the use of “packing” was the employment of restraints for calming purposes. George III was restrained in a special chair when agitated. The idea of restraint as a treatment in addition to a safety measure has remained with us, and it’s only recently that the use of restraint and seclusion has been considered to need careful regulation. Restraint in the form of physical pressure was advocated by chiropractors and similar practitioners from the 19^th century on (by the way, there were chiropractic mental hospitals up until about 1960).

In the 1960s, the occupational therapist A. Jean Ayres posited individual variations in sensitivity to sensory stimulation, including both light and deep pressure, and argued that developmental problems of children could be treated by a program of carefully balanced sensory stimulation—a “sensory diet” that might include regulation of light and sound, deep and light massage, and vestibular stimulation. (These ideas were also associated with programs designed for handicapped children by French educators like Itard and Seguin.) A connection between physical pressure and autism was suggested by the high-functioning autistic Temple Grandin, who described how as a child she longed for the pressure of the “squeezer” that held her grandmother’s calves for medical treatment; in her most recent book, Animals Make Us Human, Grandin refers to placing an animal in a box and filling the box with grain to provide all-over pressure and calm the creature. All of these claims lent support to the idea that physical pressure is calming and beneficial.

There are common practices that use pressure to have a soothing effect. For example, swaddling young babies is a world-wide method, and in Russia and some other places used to be continued until the child was a year old. The babies were so carefully wrapped that it was said you could pick one up by the legs and wave it around like a package without its body bending at all (I doubt that this was advised, however!). But although swaddling of young babies is still recommended as a calming method, not all uses of restraint and pressure are so harmless. For example, at www.sptimes.com/2006/12/15/Tampabay/letter_explains_schoo.shtml, there is a description of the use of stretchy bags called  “Body Sox” as a substitute for “timeout” for preschoolers. The practice of the complimentary and alternative psychotherapy called Holding Therapy or Attachment Therapy also involves physical restraint of a child in the form of an extended embrace by a parent or therapist, sometimes in spite of the child’s struggles to get away. Neither Body Sox nor Holding Therapy is based on evidence of efficacy, and the latter has well-demonstrated dangers in the form of injuries and deaths resulting from restraint and from related practices.

Physical restraint of the kind exemplified by “packing” is a practice left over from previous centuries--  what we might call the “trailing edge” of an idea. Historically, a variety of related beliefs have melded with the original treatments for fever and agitation to extend the lifespan of restraint intended as therapy. However, it is more than time for these practices to come to an end. They are without therapeutic merit, and they are potentially dangerous both mentally and physically. It’s time for us to follow the recommendations of Michael Rutter and Simon Baron-Cohen, about “packing”, and to question carefully all other practices based on similar ideas.

  

 I thank my colleague Linda Rosa for bringing this to my attention: http://autismum.com/2012/01/18/le-packing-pack-it-in. The piece describes the use of “packing”, or wrapping naked children in cold wet sheets, as a “treatment” for autism. It quotes the opposition of Michael Rutter and Simon Baron-Cohen--  leading British researchers on causes and treatment of childhood mental illness--- and their signatures on a 2009 statement rejecting this practice. The “Autismum” author also points out that “packing” has been used in Europe for over thirty years.

I want to point out that in fact this practice goes back much farther than that, is based on ideas such as the hydropathic (“water-cure”) beliefs of the 19^th century, and has never been supported by any empirical evidence. It has, however, been fostered during the last thirty years by related suggestions and treatments, some of them put forward by occupational therapists.

The use of “wet packs”  for the mentally ill probably originated in their use (appropriate for the time) in treating fevers. With minimal pharmaceutical knowledge or resources, physicians of the 18^th century and before used “packing” as a treatment for the high and dangerous fevers associated with typhoid and other serious infections. The agitation and  restless activity that may be associated with fever were easily confused with the agitation and activity that may characterize manic episodes, autism, or other mental disturbances. Just as John Hughlings Jackson later took the regression of function resulting from brain damage and supplied it as a metaphor for cognitive or emotional dysfunctions, physicians treating the mentally ill thought of physical illness as a model for their treatment. Dr. Willis, George III’s physician and “mad doctor”, used hydrotherapy in the form of both warm and cold packs, a cold pack on the chest being expected to calm the action of the heart. According to Joseph Whorton’s book Nature Cures, a “wet-sheet” technique was thought  by 19^th-century hydropaths to draw off impurities that disturbed both physical and mental functioning.

The use of “packing” in mental hospitals continued well into the 20^th century. Mary Jane Ward’s semi-autobiographical novel The Snake Pit, in the 1940s, depicted its heroine’s experiences of wrapping in wet sheets, the “wet pack” treatment. (Incidentally, when this novel was issued in paperback in the 1960s, it was supplementary reading in many a psychology class; I have to wonder how many students of that time came to accept “packing” as a legitimate treatment. Just goes to show, you have to watch what reading you assign--- someone might actually do it!) Tubs full of hot water were also used by some practitioners, leading to the scalding death caused under the supervision of the egregious Jacqui Schiff of Transactional Analysis fame.

An issue related to the use of “packing” was the employment of restraints for calming purposes. George III was restrained in a special chair when agitated. The idea of restraint as a treatment in addition to a safety measure has remained with us, and it’s only recently that the use of restraint and seclusion has been considered to need careful regulation. Restraint in the form of physical pressure was advocated by chiropractors and similar practitioners from the 19^th century on (by the way, there were chiropractic mental hospitals up until about 1960).

In the 1960s, the occupational therapist A. Jean Ayres posited individual variations in sensitivity to sensory stimulation, including both light and deep pressure, and argued that developmental problems of children could be treated by a program of carefully balanced sensory stimulation—a “sensory diet” that might include regulation of light and sound, deep and light massage, and vestibular stimulation. (These ideas were also associated with programs designed for handicapped children by French educators like Itard and Seguin.) A connection between physical pressure and autism was suggested by the high-functioning autistic Temple Grandin, who described how as a child she longed for the pressure of the “squeezer” that held her grandmother’s calves for medical treatment; in her most recent book, Animals Make Us Human, Grandin refers to placing an animal in a box and filling the box with grain to provide all-over pressure and calm the creature. All of these claims lent support to the idea that physical pressure is calming and beneficial.

There are common practices that use pressure to have a soothing effect. For example, swaddling young babies is a world-wide method, and in Russia and some other places used to be continued until the child was a year old. The babies were so carefully wrapped that it was said you could pick one up by the legs and wave it around like a package without its body bending at all (I doubt that this was advised, however!). But although swaddling of young babies is still recommended as a calming method, not all uses of restraint and pressure are so harmless. For example, at www.sptimes.com/2006/12/15/Tampabay/letter_explains_schoo.shtml, there is a description of the use of stretchy bags called  “Body Sox” as a substitute for “timeout” for preschoolers. The practice of the complimentary and alternative psychotherapy called Holding Therapy or Attachment Therapy also involves physical restraint of a child in the form of an extended embrace by a parent or therapist, sometimes in spite of the child’s struggles to get away. Neither Body Sox nor Holding Therapy is based on evidence of efficacy, and the latter has well-demonstrated dangers in the form of injuries and deaths resulting from restraint and from related practices.

Physical restraint of the kind exemplified by “packing” is a practice left over from previous centuries--  what we might call the “trailing edge” of an idea. Historically, a variety of related beliefs have melded with the original treatments for fever and agitation to extend the lifespan of restraint intended as therapy. However, it is more than time for these practices to come to an end. They are without therapeutic merit, and they are potentially dangerous both mentally and physically. It’s time for us to follow the recommendations of Michael Rutter and Simon Baron-Cohen, about “packing”, and to question carefully all other practices based on similar ideas.

  

 I thank my colleague Linda Rosa for bringing this to my attention: http://autismum.com/2012/01/18/le-packing-pack-it-in. The piece describes the use of “packing”, or wrapping naked children in cold wet sheets, as a “treatment” for autism. It quotes the opposition of Michael Rutter and Simon Baron-Cohen--  leading British researchers on causes and treatment of childhood mental illness--- and their signatures on a 2009 statement rejecting this practice. The “Autismum” author also points out that “packing” has been used in Europe for over thirty years.

I want to point out that in fact this practice goes back much farther than that, is based on ideas such as the hydropathic (“water-cure”) beliefs of the 19^th century, and has never been supported by any empirical evidence. It has, however, been fostered during the last thirty years by related suggestions and treatments, some of them put forward by occupational therapists.

The use of “wet packs”  for the mentally ill probably originated in their use (appropriate for the time) in treating fevers. With minimal pharmaceutical knowledge or resources, physicians of the 18^th century and before used “packing” as a treatment for the high and dangerous fevers associated with typhoid and other serious infections. The agitation and  restless activity that may be associated with fever were easily confused with the agitation and activity that may characterize manic episodes, autism, or other mental disturbances. Just as John Hughlings Jackson later took the regression of function resulting from brain damage and supplied it as a metaphor for cognitive or emotional dysfunctions, physicians treating the mentally ill thought of physical illness as a model for their treatment. Dr. Willis, George III’s physician and “mad doctor”, used hydrotherapy in the form of both warm and cold packs, a cold pack on the chest being expected to calm the action of the heart. According to Joseph Whorton’s book Nature Cures, a “wet-sheet” technique was thought  by 19^th-century hydropaths to draw off impurities that disturbed both physical and mental functioning.

The use of “packing” in mental hospitals continued well into the 20^th century. Mary Jane Ward’s semi-autobiographical novel The Snake Pit, in the 1940s, depicted its heroine’s experiences of wrapping in wet sheets, the “wet pack” treatment. (Incidentally, when this novel was issued in paperback in the 1960s, it was supplementary reading in many a psychology class; I have to wonder how many students of that time came to accept “packing” as a legitimate treatment. Just goes to show, you have to watch what reading you assign--- someone might actually do it!) Tubs full of hot water were also used by some practitioners, leading to the scalding death caused under the supervision of the egregious Jacqui Schiff of Transactional Analysis fame.

An issue related to the use of “packing” was the employment of restraints for calming purposes. George III was restrained in a special chair when agitated. The idea of restraint as a treatment in addition to a safety measure has remained with us, and it’s only recently that the use of restraint and seclusion has been considered to need careful regulation. Restraint in the form of physical pressure was advocated by chiropractors and similar practitioners from the 19^th century on (by the way, there were chiropractic mental hospitals up until about 1960).

In the 1960s, the occupational therapist A. Jean Ayres posited individual variations in sensitivity to sensory stimulation, including both light and deep pressure, and argued that developmental problems of children could be treated by a program of carefully balanced sensory stimulation—a “sensory diet” that might include regulation of light and sound, deep and light massage, and vestibular stimulation. (These ideas were also associated with programs designed for handicapped children by French educators like Itard and Seguin.) A connection between physical pressure and autism was suggested by the high-functioning autistic Temple Grandin, who described how as a child she longed for the pressure of the “squeezer” that held her grandmother’s calves for medical treatment; in her most recent book, Animals Make Us Human, Grandin refers to placing an animal in a box and filling the box with grain to provide all-over pressure and calm the creature. All of these claims lent support to the idea that physical pressure is calming and beneficial.

There are common practices that use pressure to have a soothing effect. For example, swaddling young babies is a world-wide method, and in Russia and some other places used to be continued until the child was a year old. The babies were so carefully wrapped that it was said you could pick one up by the legs and wave it around like a package without its body bending at all (I doubt that this was advised, however!). But although swaddling of young babies is still recommended as a calming method, not all uses of restraint and pressure are so harmless. For example, at www.sptimes.com/2006/12/15/Tampabay/letter_explains_schoo.shtml, there is a description of the use of stretchy bags called  “Body Sox” as a substitute for “timeout” for preschoolers. The practice of the complimentary and alternative psychotherapy called Holding Therapy or Attachment Therapy also involves physical restraint of a child in the form of an extended embrace by a parent or therapist, sometimes in spite of the child’s struggles to get away. Neither Body Sox nor Holding Therapy is based on evidence of efficacy, and the latter has well-demonstrated dangers in the form of injuries and deaths resulting from restraint and from related practices.

Physical restraint of the kind exemplified by “packing” is a practice left over from previous centuries--  what we might call the “trailing edge” of an idea. Historically, a variety of related beliefs have melded with the original treatments for fever and agitation to extend the lifespan of restraint intended as therapy. However, it is more than time for these practices to come to an end. They are without therapeutic merit, and they are potentially dangerous both mentally and physically. It’s time for us to follow the recommendations of Michael Rutter and Simon Baron-Cohen, about “packing”, and to question carefully all other practices based on similar ideas.

  

If It Isn't Spanking That's a Problem, What Else Could It Be?

Recently I’ve spent quite a bit of time in discussion with Jeff of punishmentmadeobsoletebypsychology.blogspot.com. Jeff maintains that even mild physical punishment is a risk factor for child development and is the cause of later violent behavior. I point out that there is no evidence that, other things being equal, mild physical punishment distorts personality development, although there is good evidence for an association between experience of physical abuse (as defined in law and for research purposes) and later antisocial behavior.

In all candor, of course, I have to acknowledge that the evidence we need would be very hard to establish, no matter what the outcome. Parenting practices don’t exist independent of other family characteristics. Education, family income, marital status, and certainly ethnicity are all strongly associated with the parenting methods someone uses. In the real world, all those characteristics of a family are confounded/confused with each other, so it becomes impossible to tell what causes what--   especially if the effects of each factor on the children are small ones. In addition, logic tells us that it is not possible to prove that an effect does NOT exist under any circumstances; even if it’s never been seen or reported, it might very infrequently be there.

What I’ve just said--   that a cause for an outcome may be very hard or impossible to demonstrate--  naturally goes for all kinds of parenting, not just for spanking. You have to have a major effect, like that shown for genuine abuse, before it shows up strongly. Nevertheless, it’s of interest to consider some parenting events other than physical punishment that may be risk factors for personality and behavioral development.

I’m going to talk about a few of those in a minute, but first let me point out that not everything I’m going to mention happens in early childhood. It’s an important tenet of psychoanalytic thought that events in infancy and early childhood have special formative power, which later events lack, and this view has been accepted in popular thought….  but, no, it ain’t necessarily so. If we’re going to think about factors that may cause antisocial behavior or other problems, we need to look at all of development. This is not to say that infancy and toddlerhood are not important periods--  maybe even the most important periods--  but it is to say that they are not the only important periods.

So, what are some aspects of experience, with parents or other people, which may mark children with undesirable personality and behavioral traits? The first one I want to mention is maternal depression. Perinatal mood disorders interfere with the ordinary sensitivity and responsiveness to a baby’s signals that are displayed by the majority of adult caregivers. That interference means that a baby with a depressed caregiver experiences constant frustration of its efforts at active communication of its needs, and also fails to experience the joyful communication “just for fun” that characterizes a healthy adult-child relationship. The baby also begins to act depressed and apathetic;  a vicious circle of cause and effect makes the child less appealing to adults, who become even less likely to be attentive to communications or to “woo” the baby into a satisfying relationship. An obvious early outcome of these experiences is a delay in speech and in other earlier communicative techniques like facial expression and hand gestures. (Incidentally, the irritability that often accompanies adult depression may mean that the child also receives more physical punishment than usual.)

Let’s look at emotional abuse--  not as obvious to the outside observer as physical abuse, but possibly as influential. The psychologist James Garbarino has described clusters of emotionally abusive behaviors, some of which may begin in very early life, others of which are likely only later in childhood. To list Garbarino’s suggestions briefly: Rejecting is denying the child’s value and the importance of his or her needs; this can begin in infancy with failure to smile back at the child’s smiles or answer her babbling, and it can continue into childhood as constant verbal abuse and criticism or “scapegoating” in which one child in the family is treated badly and others are not. Terrorizing is creating an atmosphere of fear by constant threats and intimidation, including deliberate teasing and scaring, often followed by punishing the child for being a “sissy” or a “poor sport”. (I often think of this when I hear the line, “I brought you into this world, I can take you out of it.”) Ignoring includes failing to respond to the child’s speech, but it also can involve failing to engage in the child’s schooling needs and failing to provide necessary supervision and care. Isolating is the process by which parents gradually prevent children from making friends or associating with outsiders, speaking to neighbors, joining groups for play, or having any experiences that would provide either a variety of role models or possible help for an abused child. (Homeschooling parents need to be careful that they consider the possible results of their decision in terms of the child’s isolation.) Finally, Garbarino suggests that a form of emotional abuse is corrupting. Corrupting parents intentionally teach antisocial behavior, involve the child in criminal activities, or act toward the child in ways like introducing him to drug use “because somebody else is going to do it”. Corrupting may begin in toddlerhood through deliberately antagonizing the child and encouraging him to fight, but criminal behavior is obviously more likely as the child gets older.

My last candidate for a parenting practice that could cause personality and behavioral disorders is intrusive parenting (see B.K.Barber [2002]. Intrusive parenting: How psychological control affects children and adolescents. Washington, DC: American Psychological Association). This term refers to controlling and manipulative parental actions that demand not only behavioral compliance to parental desires, but psychological commitment to parents’ beliefs and wishes. Intrusive parenting attempts to counter the natural development of autonomy that is usually considered to be an aspect of healthy personality growth. Parents who are highly controlling psychologically may be more sensitive to hurt and less tolerant of negative emotion than others. In any case, children who experience much psychological control are likely to have increases in both internalizing and externalizing problems, as well as lower academic achievement.

Here we have several parenting factors that appear to have a negative impact on development and behavior, but none of them necessarily involve physical punishment, either mild or severe. I point this out simply to show that the single factor of physical punishment is not likely to be the whole cause of undesirable adult behavior. In fact, I’d suggest that even the negative outcomes of experiencing abusive treatment may well result from other, accompanying factors like terrorizing and ignoring. To speculate further, the psychological ill effects of physical abuse may have nothing to do with its physical side, but with other experiences that are present or absent in abusive families.

Once again, it’s not rocket science. It’s more complicated than that.

  

The Regression Myth versus Developmentally Appropriate Practice

A disturbing report about a family in Snohomish, WA (www.heraldnet.com/article/20120121/NEWS01/701219927) states that a college-age adopted daughter has confronted her father with accusations of sexual assault, and that investigation has shown that a “therapist” concerned with attachment issues recommended years ago that the family share a bed. The intention behind this advice was to correct the daughter’s posited problems resulting from abandonment and lack of emotional attachment.

The details of the sexual relationship were outlined in the news report, but they are not the real point of this post. My guess would be that an adoptive father who was strongly tempted to be sexual with a young girl under his care would probably find some way to do this, shared bed or  no shared bed. However wrong-headed the therapist’s approach, her advice probably had little to do with the sexual misconduct, other than possibly offering an increased level of temptation.

Sorry as I am that the girl had repeated experiences of unwanted sexual approaches from one who should have protected her, what concerns me in a broader way is the belief system that made the practitioner (and note that I am not calling her a psychologist--  I doubt that she was one) think her advice was appropriate. That belief system must have included the idea that through regression a person can rework earlier experiences and resolve problems resulting from her early history, such as problems about emotional attachment to caregivers. The system is likely also to have involved the belief that regression can be brought about by behaving like a young child, or being treated like a young child. This view, which is common among advocates of rebirthing, patterning, primal therapy, and similar unconventional treatments, suggests that the cure for any problems that may date from early life is to re-enact early life events--  but, this time, make sure the experiences are right.

How does this link up with having the family share a bed? There is a popular set of beliefs (not usually necessarily associated with the idea of regression), advocated by William Sears and his family, and often called “attachment parenting”. Attachment parenting focuses on the idea that infants need intensive and extensive social and physical contact with their caregivers in order for attachment to develop. “Kangaroo care”, skin-to-skin contact, breastfeeding, and the “family bed” are all part of this approach. As a general comment, I’d say these activities are harmless but unnecessary; the development of attachment is a robust phenomenon that will occur if it’s given half a chance and does not need this kind of artificial cultivation. (By the way, if you wonder how people maintain a sex life while doing the family bed routine: some friends of mine used to give their 5-year-old a quarter to keep his little sister downstairs while Mom and Dad got it on--  necessity as the mother of invention!)

But surely the Searses do not say 15-year-old adoptees should be in the family bed? No, indeed they don’t. And this is where our so-called therapist fell prey to the regression myth. She knew that co-sleeping was supposed to encourage attachment; she knew the girl had a history of separation and loss, as well as a new relationship with adoptive parents whom she didn’t know well. If the girl would have developed an attachment to parents in her early childhood, given a chance---  and if co-sleeping was a way to develop an attachment--- and if regression through re-enactment of experiences typical of early childhood was a way to rework early personality development—voila! Put the girl in bed with the parents, she will regress to early childhood because of this experience, because she is co-sleeping she will become attached to the parents , and that attachment will dissolve any personality problems she has developed because of her lack of attachment. It’s all so simple, really.

Except…. Except that these things aren’t true. People can’t regress to earlier stages of life, although of course they can behave in immature ways and may do so particularly under emotional stress. Treating people as if they are infants or young children is a pointless “magic” ritual that cannot actually cause them to return to early development (and if it did, would you expect them to return to maturity immediately, or would they have to repeat years of normal development?). Co-sleeping is not necessary or sufficient for the development of attachment. And, an individual who is already 15 years old has a vastly different perspective on emotional attachment than an infant is capable of having; she doesn’t form attachments as an infant does, and she doesn’t show them through an infant’s attachment behavior when she does form them.

The therapist and the parents fell for some common myths about personality development. In addition, they forgot an important theme of childhood interventions for emotional, physical, or cognitive problems: treatments need to be developmentally appropriate if they’re to be effective. We feed a tiny infant milk, an older baby strained food, a five-year-old most of what adults eat. Giving the five-year-old an all-milk diet will cause malnutrition, and so will feeding the three-month-old barbecue. Treating an infant or toddler who is grieving over separation and loss may well require staying with her a lot of the time, but treating a teenager who has experienced many separations requires a much more complex treatment approach.

We can’t expect most parents to be aware of developmentally appropriate practice, but we surely should expect, even demand, that therapists working with children and families will know this concept. Regrettably, training and licensing in many related fields (like marriage and family therapy) may completely ignore this and other important ideas. We seem to have a long way to go before we can be sure that all psychological treatments are either effective or safe, let alone both.  The therapist in this case made mistake after mistake because she misunderstood some basic concepts, although her mistakes may not have been the cause of the sexual mistreatment that will probably be the focus of any discussion.  

What About Alice Miller?

Reader Neil Samuels has queried my unwillingness to accept Alice Miller’s views on physical punishment as necessarily correct, and has asked what I mean by the “Alice Miller belief system.” Before I go on to talk about these matters, let me state once more my position that mild physical punishment (open hand, one or two smacks on buttocks or upper legs) for preschool children may be effective and harmless when used very occasionally to enforce important rules. I have argued in an earlier post that there is no support for the claim that this parental behavior models a general tendency to violence. I have also argued for many years against genuinely abusive practices like those recommended by the Pearls and the “Babywise” books.

So, why do I not accept Alice Miller’s statements as unarguably correct? My reasoning is that those statements are based on a series of abstractions that lack empirical support, rather than on systematically-collected information about parenting practices and child development outcomes.

Alice Miller was a European lay-analyst and shared the attitudes and views of many such people, who have tended to reason from what they regard as first principles rather than to consider the necessity of working with reliable information. Much of Miller’s work resembles closely that of Marguerite Sechehaye and of Frieda Fromm-Reichmann. Like those authors, Miller emphasized the psychoanalytic principles of repression and regression, and by doing so placed the essential events in personality formation early in childhood and outside of consciousness. In addition, her view completely ignored the concept of transactional processes by which changing interactions between a specific child and a specific adult have developmental outcomes that would be different if either individual were different.

The psychoanalytic concept of repression claims that memories of disturbing experiences can be removed from conscious awareness and inaccessible to the individual except through psychoanalytic treatment, but can continue to influence mood, behavior, and motivation in ways that feel foreign to the personality. Although this idea has become almost universally accepted in Western popular culture, there is in fact no empirical support for such a mechanism. As Susan Clancy and Richard McNally have pointed out, ordinary mechanisms of memory and forgetting are perfectly adequate explanations of events that have been categorized as repression (for example, Clancy, McNally, Schachter, Lenzenweger, Pitman. [2002]. Memory distortion in people reporting abduction by aliens. Journal of Abnormal Psychology, 111, 455-461).

The psychoanalytic concept of regression claims that earlier versions of personality and experience can be re-accessed through psychoanalytic techniques, and that such re-accessing allows the individual to change a developmental trajectory that went wrong at a given time. In fact, as I have shown in my own work (Mercer [2011]. The concept of psychological regression: Metaphors, mapping, Queen Square, and Tavistock Square. History of Psychology, 14, 174-196), the idea of personality regression is a metaphor drawn from 19th century work on the results of physical damage to the nervous system. Although psychoanalytically-oriented practitioners over the years encouraged the acting-out of apparent regression (and this was especially true of proponents of “wild psychoanalysis” like Ferenczi), there is no empirical support for the existence of such a mechanism.

Thus, there is no evidence for the existence of Miller’s two major personality mechanisms repression and regression, and I believe this is a strong argument against the general accuracy of her claims. However, there are additional problems in her thinking. As is well known, Miller spent some years of involvement with and commitment to primal therapy, a form of treatment suggesting that psychological treatment must depend on regression to very early stages and intense acting-out of pain and distress posited to have been part of those stages ( an idea associated with Otto Rank’s and later with Wilhelm Reich’s views of development). Primal-related thinkers such as the “psychohistorian” Lloyd DeMause; David Chamberlain,who claims that all babies remember their births; and William Emerson, who massages babies until they cry as a way of working through the notional birth trauma, are all enthusiasts of Miller’s beliefs.

I see two major problems in this association. The first is that the concepts of early development espoused by primal therapists are based on adult experiences under LSD or hyperventilation rather than any systematic and replicable evidence about infancy and early childhood. When there are conflicts between LSD-based ideas and those derived from systematic study (for example, our understanding of infants’ memory and forgetting), I would hold that the latter source is more trustworthy, and I don’t believe it’s necessary to spell out why I take that position.

A second problem has to do with the assumption of the primal group, shared by Miller, that mechanisms characteristic of the individual (and speculative mechanisms at that) are sufficient to explain behavior of a group-- for example, that repressed anger and fear, were they in existence in members of a group, would be the reason for abusing children, going to war, etc. This belief ignores decades of work on, for example, economic factors in racial conflict, and fails to note that there must be some way in which such notional individual mechanisms would be translated into coordinated behavior of a group. Like the primal therapists, Miller chooses to ignore the complexities of social behavior in favor of discussion of the poorly-documented personal backgrounds of a few historical figures. Although this makes for entertaining reading, it is a very weak basis for a world-view.

These are the reasons that I do not accept Miller’s broad prohibition on all forms of physical punishment as necessarily correct. Her position is not in any way empirically based. Her thinking in general has the Platonic form so appealing to those who would prefer not to engage deeply with a topic, but instead are attracted to statements of what “must be”. I would suggest that people who are genuinely interested in how disciplinary methods influence children’s development should seek out the work of Grace Kochanska, who has shown how child personality differences interact with parental behavior to produce predictable outcomes.

Comments I Can't Respond To

There have been several comments in the last couple of days that I'd like to answer, but blogspot doesn't seem to let me. This has happened before and I hope it will be fixed soon-- otherwise I'll just make a post that responds to each.

Physical Punishment Tales from the Memory Vault

All this discussion of physical punishment has brought back memories from the long ago, and I want to recount one just to show how complicated these things really are.
Years and years and years ago, my older son was about three years old. I decided that it would be nice for him to have a blackboard in his room, because he always liked to write on the board if he came to class with me. I got some blackboard paint and painted a section of wall, got colored chalk, even fixed up a little chalk tray with a piece of quarter-round, and painted the rest of the wall a nice clean white. [Parents who are more experienced than I was at the time will see what’s coming.] I did all that, then left the room for half an hour-- and when I came back my firstborn had climbed up on some shelves, studiously avoiding the blackboard, and chalked all over the nice white wall. I was infuriated, which was really quite unreasonable because I hadn’t thought to tell him not to do this. I told him off thoroughly and delivered a couple of swats on the bottom.

A few hours later, this conversation took place.

CHILD: (firmly) Mom! I don’t like all that screaming and spanking.

ME: Well… what do you think I should do when you’re naughty?

CHILD: (thinks a minute) Tell me quietly, and clean it up.

ME: Oh. Well, if I did that, would you stop doing it?

CHILD: No.


It just goes to show-- as the saying goes, the camel driver he has his opinion; the camel he has his. But the family caravan still needs to keep lumbering along and usually manages to do so to the best of everyone’s imperfect ability.

More Mulling on Physical Punishment

Boy, I never thought I’d be arguing against people who argue against physical punishment for children. However, I think and have always thought that blanket prohibitions or admonitions either require some evidence or, as an alternative, need to be stated on moral grounds. If anyone wants to say they simply think it’s wrong to use physical punishment, I can’t argue with their belief. But when a belief is disguised as a statement of evidence-- I can’t go along with that without a response.

There are three issues about physical punishment that I want to noodle about for a bit. One is the fact that if punishment is to be used, mild physical punishment has certain advantages. Another is an alternative way of thinking about the idea that parents who spank are acting as inappropriate role models and teach their children to use violence. The last involves the belief that it’s all right for parents to use physical punishment, but not for schools or day care centers to do so.

1. When I refer to mild physical punishment, I’m referring to one or two smacks with an open hand on the clothed buttocks or backs of the legs of a preschool child. If punishment is needed to bring about behavior change favorable to the health and safety of all concerned, mild physical punishment has some real advantages. It’s well established that punishment works when it is given concurrently with an unwanted behavior; it actually works best when it occurs just as the child prepares for the behavior; the longer after the behavior the punishment comes, the less effective it is. Punishment is quite ineffective when it’s delayed “until Daddy gets home”, or when it involves deprivation of some future treat like dessert tonight or a birthday party on Saturday. Mild physical punishment can be performed more or less on the instant. Note, though, that if it isn’t done right away, you might as well not do it at all, as it will not later be connected with the unwanted behavior, but instead will be associated with whatever has gone on just before. (Any thoughts about our correctional system, by the way?)


2. Now, this role model thing: everybody and their brother states with certainty that a parent who uses physical punishment is acting as a role model to encourage violent behavior. But is that actually true? Not everything parents do serves as a role model for their child’s general behavior. For example, single mothers regularly teach their toddler and preschool sons to pee standing up, even though the little boys, in their frequent invasions of the bathroom, always see Mom sitting down on the toilet. Mothers can wear high heels; little children don’t except for playing “dress-up”. Fathers and mothers too are heard to say selected words which children aren’t supposed to say.

In addition, much of our instruction and modeling of behavior for children is a matter of teaching time, manner, and place. We don’t, in fact, usually teach children that violence is never acceptable. We accept and even approve of it in sports, in defense of a person under attack, in self-defense, and so on. A football player who is highly aggressive on the field is admired, but if he beats up his girlfriend later there will be some people (not enough, though) who will disapprove deeply. Children are socialized by their experiences with their parents into an understanding of the times, manners, and places in which violent behavior is permitted (or even required). Learning that it is acceptable for an adult to spank a child for repeated dangerous behavior does not involve the same time, manner, or place rules as learning that it is acceptable to mug old ladies or participate in gang warfare. To think so is to over-generalize--- what Jerome Kagan has called the “seductive idea” of abstractionism.

3. Our society’s great confusion about physical punishment is exemplified in the idea that parents may spank or smack, but day care centers and preschools may not. (I omit discussion of physical punishment in elementary and high schools, which when permitted has often gone far beyond the “mild” level, and which should not be necessary at those ages for children who are less impulsive and better self-regulated than younger children.)

We seem to have two conflicting ideas about spanking. One is that it’s a bad thing to do, and that’s why teachers aren’t allowed to do it. The other is that parents have a right to do things to their children as they choose, and if they don’t spank their children the children will run wild (and be annoying to the rest of us, I suppose is the real concern). Logically, of course, if it’s a bad thing, nobody should be doing it, although we can probably stop teachers a lot more easily than we can parents; if it’s an acceptable thing for parents, why shouldn’t teachers do it too?

I think it’s possible that this conflict is based on the assumption that because parents love their children and know them well, they will not let physical punishment get out of hand, and they will comfort a child who is upset--- but that teachers do not love the child and are likely to turn the Kiddie Academy into Dotheboys Hall if given any opportunity. In reality, the opposite might well be true, as teachers are less likely to experience the fatigue and frustration of daily and nightly child care, or conflict with a co-parent who focuses on relationship problems in connection with childrearing.


A [temporary] final thought on these matters: as for myself, as long as parents are hot-saucing children, keeping them in cages, limiting their food, making them sleep outdoor without blankets in winter, or whipping them with plumbing supply line, I am not going to worry too much about a limited and possibly appropriate use of mild physical punishment. My energies are going to be directed toward stopping treatment that is, frankly, torture. Admirers of Alice Miller’s position can either join me or continue to enjoy their ideological purity. I hope it will be the former, because there is a lot of thinking and a lot of work to be done.

Alice Miller, Physical Punishment, Ideology, and Reasoned Approaches to Parenting

On a number of recent occasions, I’ve come up against statements and ideas ascribed to Alice Miller, the late Swiss psychoanalyst. As Neil Samuels noted in a comment on one of my posts about physical punishment, Miller attributed war and other distressing actions and propensities of adults to their childhood experiences of punishment. I haven’t read all of Miller’s work, most of which is popularized and non-empirical in nature, but my impression from what I have read is that she argues strongly against all forms of physical punishment and categorizes together everything from a smack with the open hand onward, considering all of these behaviors to be deleterious. (If I’m wrong about this, no doubt I will receive speedy correction.)

I think there are many reasons to keep physical punishment to a minimum. An obvious one is that an incensed parent with an angry child may lose control and do physical harm. A less obvious one is that physical punishment may simply escalate everyone’s anger and make it more difficult to get the situation under control. Physical punishment may also substitute ineffectively for explanations and advice about how to behave. (There are a dozen more good reasons, but that’s not my topic just now.)

My concern in this post is to focus on the outcomes for parent and child of choosing one or another among the range of disciplinary methods, including both rewards and punishments of various kinds. (Negative reinforcement is not the same as punishment and does not lend itself well to use in everyday situations.) I think it is possible to consider what methods work best in specific circumstances and to use a reasoned approach to choice.

Miller, on the other hand, is primarily an ideologue. Her claims are based on a belief system that lacks empirical support, as are the claims of her companion-in-ideology, Lloyd DeMause, one of the founders of the “psychohistory” school that claims profound, although undemonstrated, effects of prenatal events. DeMause, Miller, and others have concluded that cause-and-effect relationships are plausible, not in the light of empirical work about families, but on the basis of statements by people like Frank Lake and Stanislav Grof, whose understanding of early development is founded on experiences with LSD. (These people were also strong though perhaps indirect influences on Nancy Verrier.)

I argue that an empirical, pragmatic approach is a more desirable way to think how people should act toward children, than an ideological one is. My reasoning is that there are multiple factors that help determine the outcome of any adult actions toward children, so it is unlikely that we can name a single factor and a single mechanism that have the same outcome for all children in all circumstances. An ideological approach argues that the truth is the same for all.

Here are some factors that seem to make a difference to children’s reactions to physical punishment:

1. Cultural differences: A smack on the bottom has a different meaning and therefore effect on children who have often seen other children get smacked than it does for those who have never seen such a thing and/or have heard it mentioned in discreet, horrified tones. There are great differences between cultural groups in the use of and attitudes toward physical punishment. Some groups would never dream of striking a child or using any other physical approach. Others, like many African-Americans, believe it is the obligation of parents, grandparents, and close family friends to employ physical punishment regularly. When a social group approves of the use of physical punishment, the children of that group do not respond as negatively to their experiences of mild punishment as do children whose group strongly disapproves.


2. Age: As a general rule, Europeans and North Americans believe that physical punishment is inappropriate for infants under a year of age and for older children and adolescents, but that well-thought-out physical punishments may be effective and suitable for many children from about age 2 to age 5. The reasoning about infants is that these children are too young to understand rules or to be expected to control their own behavior much, and that punishment may teach them to avoid adults at a time in development when their socialization depends on a lot of contact. The thinking about older children and adolescents is that physical punishment offers them challenges to physical fighting such that the child may win, or the combat become so serious that someone is hurt or the child runs away from home; in addition, many laws about child abuse would classify physical punishment of adolescents as abusive in itself.

Preschoolers, on the other hand, are capable of learning rules and regulating their behavior within reason, but are impulsive, over-confident, and able to hurt themselves and others unless carefully trained. Careful supervision and cue-ing of behavior can do a great deal, but many preschoolers show undesirable behaviors (like running into the street, or hitting each other, pets, baby brothers or sisters, or their parents) that are quite difficult to correct without the use of physical punishment. Balancing the possible consequences of those present behaviors against the long-term effect of punishment suggests that for everyone’s health and safety, brief, mild physical punishment may be an excellent choice. Many parents today attempt to use “time-out” methods but are unable to keep the child in the “time-out” chair or room; physical punishment as a back-up on a few occasions is likely to make it possible to transition to “time-out” alone.


3. Temperament: Children’s constitutionally-determined personalities may have strong influences on their responses to physical punishment. Some children have relatively little response to pain or other strong stimuli, and in my opinion should NOT be physically punished because of the temptation the adult may feel to escalate the punishment until the child seems to notice it. Others are extremely sensitive, and in fact are so overwhelmed by almost any kind of punishment that they forget what they are being punished for. However, some are attentive to physical sensations, but at the same time can notice and understand the adult’s admonitions and learn effectively what to do or not to do.

I believe these differences in children’ s responses to physical punishment, when coupled with the complete lack of anything but proof by assertion that physical punishment experiences are responsible for war and other social evils, lead us to only one sensible conclusion. That conclusion is that no single rule about punishment of children is applicable across the board. Parents need to consider carefully the characteristics of a child, the family’s social group and attitudes, and the goals they are trying to achieve through punishment or any other action. (This consideration, of course, has to happen during a calm time, not as the child pulls away from the parent and heads into traffic again.) The sense of righteousness one receives from ideology is much stronger than a reasoned approach can give, but I would suggest that a pragmatic, reasoned parenting mode is far more likely to produce happy children, families, and societies.

Those Empathic Rats: Take Two

I jumped the gun the other day by trying to comment on a research report as it was described on an NPR interview and in the Science Times. As a result, I missed an important factor (although I stand by my remarks about the role of empathy and altruism in rats’ daily lives). Now my copy of Science has come and I can comment more constructively on the article by Bartal, Decety, and Mason, “ Empathy and pro-social behavior in rats”, Science, 9 December 2011, pp 1427-1430.

The basic study involved observing laboratory rats (the usual little Sprague-Dawley guys with the white fur and beady red eyes) to see whether they would work to open a door and release a familiar cagemate from a container. To be able to claim that rats were motivated to release a trapped rat, the authors also needed to show that the door releasing a trapped rat was opened more often than the door to an empty container or the door to a container with a toy rat in it. The rats were tested daily over several weeks, and on the average managed to open the door and let the trapped rat out after about a week. Twenty-three of 30 rats eventually opened the door for a trapped rat, and 5 out of 40 opened the door when there was no trapped rat. All 6 of the female rats who saw a trapped rat opened the door, but only 17 of 24 males did so. The authors concluded that the rats showed motivation by empathy when they released the trapped cage mate.

In an additional study, where the free rats could choose between opening a container that held chocolate chips and releasing a trapped cage mate, they did the two things about equally. In addition, they ate fewer of the chocolate chips when they had released another rat than they did when they were alone with the chips (these animals had free access to food and water and were not especially hungry). The authors referred to this as “sharing” with the other rat.

The general conclusion of the article was that the free rats were “not simply empathically sensitive to another rat’s distress but acted intentionally to liberate a trapped conspecific”. I believe this conclusion raises many questions, as does the use of the term “share” with respect to eating fewer chocolate chips. I don’t reject the idea that empathy might be part of rat psychology, but I consider the study to suggest as many questions as it answers.

One of my questions comes from watching the video of one of the rats at work, to be seen at www.sciencemag.org/cgi/content/full/334/6061/1427/DC1. As the free rat succeeds in opening the door to the container, it does not step aside and let the trapped rat out. Instead, it squeezes past the trapped rat into the container so they are both briefly inside; when the trapped rat emerges, the free rat explores the container for a moment, then finally comes out and follows the formerly-trapped rat closely, sometimes appearing to mount it briefly (not an unusual thing for a rat to do). My question is, what was the exploration of the container about? Did rats other than the one selected for the video also show this activity? To what extent would it be appropriate to say that a more parsimonious explanation--- that the container and the other rat are interesting-- may be more appropriate than the “empathy” conclusion?

A second set of questions has to do with the role of the trapped rat in triggering its “rescue”. The authors refer to the possibility that high-pitched distress cries were annoying to the free rat, who might have released the cagemate in order to stop all that crying. However, they used a bat-cry detector to record the calls, and reported that such calls were infrequent. This assumes that the pitch of the cries was the disturbing part, whereas human infants’ cries differ in many ways other than pitch during different emotional states, and the same may be true of rats. Although the report alluded in a note to the role of smell in rat emotional contagion, and although the container and “arena” were carefully washed between observations, there seems to have been no attention paid to the role of airborne pheromones in possible distress of the free rat. Finally, although the researchers reported the sexes of the free rats, they did not specifically state this about the trapped rats. Because the trapped rats were said to be cagemates of the free rats, and because normal procedure would be to cage males and females separately, it seems likely that male free rats were with male trapped rats, and females with females. This raises the question whether the “unhelpful” 7 out of 24 males would have been helpful to trapped females, and conversely whether the helpful females would not have helped trapped males. Again, it may be more parsimonious to consider environmental factors that led to the door-opening rather than assuming that some form of empathy was in operation.

A curious thing about empathy is that it may be just as important in negotiating hostility as it is in causing prosocial, helping behavior. Empathic responses are a matter of identifying and even experiencing another individual’s emotions, and are easy to recognize when we are sorry for a sad person and want to help him or her. But what about situations where someone may be angry at us, or frightened and ready for self-defense? To recognize those feelings before the other acts on them allows us to escape, to placate the other, or even to attack first--- all possibly related to survival of the individual and of the group, but not prosocial in the usual sense. And a mixed picture is surely possible. What if the rats had been confronted with a human hand restraining their cagemate? Would biting the hand be prosocial or hostile behavior? Like oxytocin, which can be involved in both maternal care and fighting, empathy has a complex function. We may reach some wrong conclusions when we assume that behavior must be empathically motivated.

Those Empathic Rats: Motivation and a Missing Measure

N.B.-- 12/14: I may have been wrong in my remarks here. Read the comments that follow, too.

On NPR, in blogs, in Science, in the New York Times' Science Times, everybody’s talking about a study reported by Peggy Mason of the University of Chicago and her co-authors. To people’s surprise, these researchers reported that rats would make a lot of effort to open a door that would release a confined fellow-rat, and they would do this even if the other rat was beyond a barrier and they could not play together. The free rats opened the door to release the confined one as much as they opened it to get chocolate chips.

Quite a few people have interpreted the free rat’s “jailbreak” behavior as due to empathy with the confined one-- that the free rat feels unhappy when he or she perceives the displeasure of the rat in the container, and feels better when the other rat is happier, just as many human beings feel relieved when they can help a suffering human. Others have asked whether there might be an alternative explanation. Could it be that the confined rat squeals in distress, at frequencies higher than humans can hear, and that the free rat works to get rid of that awful squeaking? No, it seems that most of the confined rats did not squeal, so that explanation cannot replace empathy as a reason for the behavior.

Several bloggers have been extremely interested in the implications of the idea that rats, like humans, might be motivated by empathy. Some have argued that this is a blow for human exceptionalism and suggests that humans are not qualitatively different from other species.

Before we go to town on the implications of the study, though, it might be a good idea to consider whether avoidance of painful squeals is the only explanatory alternative to rat empathy. (I have no objection to the idea that rats could have empathic responses, but I don’t like conclusion-jumping.) As far as I can see, the study did not include an important comparison measure that might offer a better explanation for the behavior: it did not test what the rats did if given the chance to open a container with nothing in it. As a result, it confounded opening containers in and of itself, with opening containers and getting an outcome that might be gratifying.

Why would a rat open a container “for nothing”? Why, for that matter, do toddlers carry large objects from place to place? Why does my cat meow outside every closed door until it is opened, then walk away without going in? Why do I shut a drawer left open by a 16th of an inch? All of these actions can be considered in terms of mastery motivation, a tendency found across species and across ages to behave in ways that control the environment, even when there is no evident advantage to exerting that kind of control.

Jerome Kagan, in his book Three seductive ideas, criticized what he called the “pleasure principle”, the idea that all behavior comes down to a search for gratification of needs. Of course much of what any organism does is associated with needs and satisfactions, but this does not mean that everything is motivated in exactly the same way. Like humans, rats may do things simply in order to do them, and this is probably especially true of lab rats in cages. They ordinarily exist in a boring environment that offers them none of the usual activities of their species’ normal habitats. They don’t get to tunnel, gnaw different kinds of things (they do gnaw at the cage’s wire mesh), catch and eat bugs or other small animals, court, or mate. Occasionally some clumsy student reaches in to pick them up the wrong way and they get to bite that person, but that’s about the sum of the drama in their lives. Now, in the study we’re discussing, they get an opportunity to deal with exciting new technology. It’s time to be motivated by the need for mastery of the environment... maybe. I’m not saying that mastery motivation explains it all-- just that there is at least one alternative to interpreting the free rat’s behavior as empathic in nature.

The NPR “Science Friday” discussion of the study alluded to maternal care as the foundation of empathy, and so it may be, but anyone who has observed a breeding colony of lab rats is not likely to think of these animals as displaying much empathy. When babies get out of the nest, get cold, and squeal, the mother retrieves them and brings them back in, but that’s about it. They can find nipples and latch on by themselves (and they are so tiny, pink and hairless that you can actually see the bubble of milk in each stomach). The mother doesn’t do much more except lick them clean. And let one be sick, or injured, or die-- well, Mom tidies up the nest by eating the pup. If a male rat gets into the area, he’ll often tidy up further by eating the live pups too.

Could be that assisting in the jailbreak has some cause other than empathy.

Invisible England is Back and Talking About Holding Therapy

I want to make sure everyone knows that Invisible England, a blog commenting on semi- officially-sanctioned Holding Therapy in the United Kingdom, is back after a short hiatus, at http://invisibleengland2.wordpress.com. The blog includes a personal statement and description of Holding Therapy by a young man who was subjected to the treatment. Another unique post on this blog is a videotaped interview with Dr. Edzard Ernst, the well-known critic of complementary and alternative medicine, who comments on Holding Therapy as an example of CAM psychotherapy. The blog also has a link for advance access to my paper in British Social Work Journal, responding to recent efforts to rehabilitate Holding Therapy; these efforts ignore the treatment's rejection by a task force of the American Professional Society on the Abuse of Children in 2006.

Faith-Based Child Abuse

I want to call attention to two interesting comments on my post from several days ago, http://childmyths.blogspot.com/2011/12/prevention-v-cure-in-adoption-service.html. One contributor brought up the death of Kairissa Mark of Mt. Juliet, TN, within 90 days after her adoption from China by a pediatrician, Deborah Mark, and her husband, Steven, with the help of Bethany Christian Services. The contributor noted that Steven Mark had called Kairissa a “demon child” and had not made arrangements for family counseling as he might have. The child was beaten to death.

A second anonymous contributor reported that she (I think) knows the Marks and that they are not evil people. She believed that they must have been praying for a “miraculous cure” (she did not state what needed to be cured), but should have called in an exorcist or deliverer. I am assuming, based on this contributor’s remarks, that the Marks believed the child to be possessed by a demon and beat her as part of their efforts to end the possession. There was presumably some behavior or mood unsatisfactory to the adoptive parents which they believed indicated the presence of a demon.

When people come across the idea that religious beliefs can be associated with abusive treatment of children, they often think in terms of sexual abuse by Roman Catholic and other clergy. Disturbing as those events are, I suggest that in fact there are two other religious factors that create greater dangers for children. One of these involves a high degree of authoritarianism and the belief that absolute obedience to parents is a forerunner of absolute obedience to God, and that such absolute obedience is necessary for the salvation of the soul following the death of the body. A second risk factor is present when parents and religious groups believe that child behavior is caused by demons.

I have written about the authoritarian approach in several places, including a paper in the Scientific Review of Mental Health Practice (“Destructive trend in alternative infant mental health approaches”, Vol. 5, 2007, pp. 44-58). One relevant issue is the use of the Ezzo and Bucknam book On becoming babywise, discussed at http://www.gfi.org/. This book, and others in the “Babywise” program, date from the 1990s and emphasize the needs of adults. The program offers methods described as training the child to obedience and facilitating the parents’ relationship by preventing the child from making demands on the mother. The original version of the Babywise program advised moving the infant quickly to a reduced feeding schedule, with 6-month-olds receiving three meals a day and one liquid feeding at bedtime. (Writing for the American Academy of Pediatrics in 1998, M.T. Arney pointed out problems of dehydration and malnutrition that had been caused by the Babywise plan.) The goal of this program appeared to be to place the marital relationship (and perhaps above all the gratification of the father) as a priority, and to justify this in terms of the importance of learning obedience and humility.

A similar goal has more recently been set in the book To train up a child, by Michael and Debi Pearl, which has been widely discussed in various blogs including this one. The Pearls’ authoritarian approach involves physical punishment that is potentially severe and has even been fatal.

Question and answer material presented by Michael Pearl’s church includes belief in demonic possession, but I have not found any references to children’s behavior as caused by demons. However, the belief that a child can be demonically-possessed, and sometimes that painful treatment may be required to end the possession, is rather common among Christian fundamentalist groups. Doris Wagner’s book How to cast out demons (2000; Ventura, CA: Renew Books) states that demon possession is increasingly likely for children who are adopted, have had difficult births, or who fail to be “bonded at birth” (not defined by the author). [Incidentally, this book includes an informed consent document to be used by exorcists!] Other sources suggest that a child who has been sexually molested is more easily possessed by demons.

“Conventional exorcists”, if I may use that term, appear to address demonic possession by prayer. Fasting is also mentioned, although it is not clear whether the exorcist or deliverer is to fast, or the possessed person, or both (see http://www.stmichael.pair.com/laitydeliverance.html); it would be interesting if fasting as a form of purification ritual were related to the limitation of food used in some unconventional child psychotherapies. Nevertheless, there may be rituals that use physically-painful and injurious methods, or there may simply be frequent misunderstandings among adults who seek to change their child’s behavior by exorcism, because deaths as a result of exorcism rituals are frequently reported (http://www.tylerpaper.com/apps/pbcs.dll/article?AID=/20081203/NEWS01/812030289/0/FRONTPAGE; http://www.tldm.org/news8/possession2.htm; http://www.journalgazette.net/article/20110528/LOCAL03/305289976).

Adoption agencies, including Bethany Christian Services, make a point of screening adoptive parents for health, education, financial security, and so on. Isn’t it time that we screened for faith-based risk factors like beliefs in absolute obedience to parents, and in demonic possession as a cause of behavior problems? My anonymous correspondent was quite right when she said there are a lot of whackos out there. Screening for these beliefs would be a way of keeping adopted children out of their hands.

When Superstition Claims to Be Science: The Conscious Conception and Peace Lark

A reader recently called my attention to the forthcoming publication “Parenting for Peace” by Marcy Axness. This book, and Axness’s website www.quantumparenting.com/ , claim to integrate science (“quantum”, right?) with spiritual insight, and stress neurobiology as a major source of information. In reality, though, much of the material Axness promulgates is nothing more nor less than superstition. If she wants to present her views as a matter of faith, well and good-- but to state that they are based on science is incorrect.

Here is one example from the quantumparenting site:

In discussing fertility issues, Axness quotes Laura Uplinger’s description of her beliefs about becoming pregnant. “My husband and I sent out a call to the universe—as if posting an ad on a galactic website—stating who we were and what we could offer to a soul who wished to join us. We carried on our daily activities in a mood of solemn expectation and profound surrender; was a soul going to be drawn to us?” In commenting on this and similar ideas, Axness refers to the idea of thought as an organizing principle that can influence even conception and development.

Are these views correct? Do souls wait in some nonmaterial world until they join bodies at the time of conception? Do our thoughts shape our physical structure and function? Those who believe these things don’t want or need systematic evidence to support their beliefs, and I don’t want to argue with their universe of discourse. However, I can say that those beliefs aren’t science. Science as a modern human endeavor is based on certain assumptions that are contrary to the ideas Axness promulgates. Science is mechanistic, assuming that even the most complex human functions are based on the same physical and chemical events that occur in the non-human, non-living world. Axness’s views are vitalistic-- she assumes that living organisms contain some factor that is absent from non-living substances, a factor that may be thought of as a spirit or soul. She also appears to assume that the soul is not just an animating principle, but is instead a personality with intention and power to make decisions, and one that can at all times be influenced by thought (cf. the “primal wound”). These assumptions are by definition not scientific, and ideas based on them are not scientific, no matter how many tidbits of neurobiology they are bolstered with.

Axness has a strong tendency to try to shape material from scientific study so it matches her vitalistic and transcendentalist view, with its characteristic tone of the 19th century’s New Thought. For example, in a statement on http://icpa4kids.org/ (website of a chiropractic organization), she says this: “A child who is securely attached to his parents is deeply motivated to behave in harmony with them.” Now, certainly it is true that conduct disorders, extreme risk-taking, and age-inappropriate oppositionalism can all be associated with a poor attachment history or with other evidence of insecure relationships. But this does not mean that secure attachment is characterized by “easy” relationships in which little discipline is required-- which is what seems to be implied by “deeply motivated to behave in harmony” and by other comments Axness has made about children who are brought up according to her principles. Axness assumes, and presumably believes, that easy and desirable outcomes can be produced by thinking in the right ways. (Is this part of that “idealization of motherhood” that can be so problematic?)

Here again we have statements that do not follow a basic rule of science, the rule that all information must be considered unless there is a very good reason for omitting it. What Axness omits is the fact that failing to “behave in harmony” with parents may be an essential step in a child’s development. Bowlby’s attachment theory describes a set of events that do not stop with parent-child affection and commitment. Attachment is about learning to deal with other people, knowing whom to trust, knowing what to expect, and these lessons must eventually be applied to persons outside the family. A big portion of that learning has to do with the practice of negotiation and compromise, a major emphasis of development in the preschool years and again in early adolescence. When parents are helping children learn to negotiate, negative feelings can run high on both sides; Indeed, this may be a desirable situation, as it helps the child learn that people can be very mad at each other but still work out a satisfactory compromise. The child is deeply motivated to move along its own developmental pathway-- which includes autonomy--- but this really cannot be seen as behaving “in harmony”.

The First Amendment permits Axness to make what statements she prefers about early development, but the fact is that there is no science involved in her views. Neither, by the way, is she a leading figure in child development circles, as some websites say. Axness has a Ph.D degree from the Union Institute in Ohio, an intermittently-accredited organization that as far as I know allows students to choose the academic field where they feel a dissertation belongs and to have the degree granted in that field. (Other alums are Lark Eshleman, a therapist involved in the Nathaniel Craver case; Gregory Keck, a Ohio attachment therapist whose degree is said to be in criminology, and Bill Goble, who diagnosed Candace Newmaker over the telephone before recommending that she be taken to the Colorado therapists at whose hands she died.) Although her website suggests that she does some form of therapeutic work, I do not see a California license verification for Axness as either a psychologist or any kind of counselor; she refers to her work as “psychoeducational”, so perhaps she doesn’t need a license.

Whatever Axness is, she isn’t a scientist. Whatever her beliefs are, and however often she mentions brains, her principles aren’t based on science. Is it even pseudoscientific to claim that thought shapes the physical world? Frankly, I’d call it superstition.

Addendum, 12/10/11: The statements about the Union doctorate in the following are presumably also true about Axness's degree claims: www.signorile.com/2011/07/what-kind-of-doctor-is-marcus-bachmann.html.

Prevention v. Cure in Adoption Services

In a recent publication, the Evan B. Donaldson Adoption Institute commented on the need for post-adoption services, and cited the comments of parents and professionals in two focus groups (http://adoptioninstitute.org/publications/ParentFocusGroup2.pdf and http://adoptioninstitute.org/publications/ProfessionalFocusGroup.pdf). These focus group summaries make interesting reading and make it clear that in spite of hybrid parent-professional organizations like ATTACh, the goals and attitudes of parents and professionals overlap only partially.

One parent is quoted as saying, “It’s very difficult because there’s a lot of biases built into how the professionals see our children. One of the things I’ve often seen is that the first thing that is asked when the child has a problem is ‘What’s going on in your home?’ There’s no thought given to this child’s history, the child’s background. There’s got to be something wrong with you in your home, and it’s a frustrating situation to be in when you’re trying to get assistance for the children.” It’s not surprising that parents resent feeling “blamed” for children’s problems, and they appear to find it very hard to see the situation from the professional’s perspective. What if the caseworker immediately focused on the child’s history, and neglected to ask whether there had been a change in the family-- to find out later that it was the family’s alteration that had triggered the child’s problem behavior? Finding out first what is happening right now is common sense, especially because the present events may be open to change, as the past cannot be. A well-known case in the infant mental health field involved a child’s inexplicable behavior that turned out to result from a conflict between a grandfather and grandmother, and the resulting changes in the family system.

One of the real – possibly insoluble-- problems with adoption services is that parents and professionals do have different goals and viewpoints. The parent focuses on personal experience and wants to settle into life with a family as he or she expects it to be (and these expectations may or may not be realistic, as Rachel Stryker and others have pointed out). The professional has many other families to consider, and wants to minimize both adoption disruptions and abuse of any kind, even though there may be a paradoxical relationship between these two events. In addition to these differences in perspective, parents and professionals are different in the power they are perceived to have and actually do have. The adoption professional has the power to disrupt an adoption under certain circumstances and to require parents to follow directives in order to avoid disruption or to get the services the parents ask for; the parents have no similar powers, but if they do not do well as a group, the caseworker does not look good either. The relationship between the parent and the professional thus has the makings of a sort of mini-Stockholm syndrome, or alternatively various levels of conflict and resentment.

It’s possible that adoption services will not be genuinely effective until the ambivalence and conflict between parents and professionals is settled. I would speculate-- without any real evidence-- that this may not occur as long as parent support groups are encouraged. These groups, like all that have spun off various 12-step programs, are much loved by their members, but may serve primarily to establish a perception of the parent group as supportive and knowledgeable in comparison with professionals, thus worsening the existing conflict.

The unfortunate conclusion to be drawn here is that until such time as parents and professionals can work out their differences, the chances are that post-adoption services may not be very effective. This leaves us with two possible ways to improve the experiences of adopted children and adoptive families. Both are preventative approaches rather than “cures”: pre-adoption services like parent education, and improved screening of adoption applicants.

A good deal is known about the process of adoption and the important characteristics of both parents and children. But both the Evan B. Donaldson focus groups express pessimism about the possibility of training adoptive parents before the child comes into the family. One professional said, “Although we give parents a lot of information in preparation, obviously they don’t hear it because they’re thinking about their goal of having a child.” People in the parent focus group agreed with this: “Yes, I went through training, but it wasn’t the right training, and I don’t think it was really the right time, because when you’re [becoming] an adoptive parent, you’re excited, you have these children…” “Let’s face it. When you’re just coming into being a foster or adoptive parent, you don’t know anything, so you’re all excited and you only remember a quarter of what’s being said in that training. It’s too much information all crammed into one, and you’re just thinking about getting that cute little child.”

We seem to be left with improved screening of adoptive parents as a possible preventative of some problematic adoption situations. This approach, of course, will be abhorrent to many adoptive parents-- in particular those who might be excluded by screening. Increased screening may not be welcomed by some adoption professionals, either, as they are often much concerned with getting children placed in homes. However, as it happens, there is a good deal of relevant information that might help a screening process.

Some of this information contradicts common assumptions about the kind of person who would make a good adoptive parent. For instance, the developmental psychologist Mary Dozier’s work has demonstrated that people who have fostered many children are less capable of forming an attachment relationship with a child than those with fewer of these experiences. Other work (like the suggestions by St-Andre and Keren [Infant Mental Health Journal, 2011, pp. 694-706] that I mentioned a few days ago) emphasizes not only problems of the individual like a history of depression, but also the social environment-- depression or bipolar disorder in the adoptive parent’s family, and a lack of social support existing even before the adoption. (As the Evan B. Donaldson parent focus group indicates, social support is often lost after the adoption has occurred and difficulties are manifested.) St-Andre and Keren also note the force of the interaction between existing parent characteristics and problems associated with the child, such as multiple simultaneous adoptions. Screening to prevent parents with certain histories from adopting more than one child at a time (or perhaps even successively) might be a service of great help to a child’s developmental outcome.

St-Andre and Keren made another suggestion that is of great interest, but not necessarily supportable. They referred to the use of the Adult Attachment Interview as a way of predicting the capacity of applicants to function well as adoptive parents. The AAI is a structured interview that classifies adults as secure or troubled in their own attachment concepts. St-Andre and Keren described a woman applicant as appearing “pleasant and motivated for the adoption”, but as giving contradictory statements about her childhood and becoming “derailed” when talking about the early loss of a child. As a result of these responses on the AAI, she was excluded as a candidate for adoptive parenthood. However (and this is my comment, not St-Andre’s), the AAI, like many tests of its kind, was designed for research purposes and for guidance of treatment, not as a way to predict an individual’s personal life.

Adoption Risk Factors and "Strong Idealization of Motherhood"

A recent publication discusses the emotional difficulties associated with adoption and takes a much more complex view than the Primal Wound approach advocated by Nancy Verrier. The paper (St.-Andre, M., & Keren, M. [2011]. Clinical challenges of adoption: Views from Montreal and Tel Aviv. Infant Mental Health Journal, 32, 694-706) examines a variety of risk factors and recognizes that no single problem determines a good or bad developmental outcome for the adopted child.

Among other issues, St.-Andre and Keren consider the effect of post-adoption depression (PAD), a problem that has received little study but that probably occurs at least as often as post-natal or post-partum depression (PND or PPD-- also called perinatal mood disorder, PMD). They point out a number of reasons why PAD may have received so little attention, including the view of adoption as a happy ending to a sad story of infertility, the fact that there are no obstetrical problems to deal with, and the apparent absence of the abrupt hormonal changes that follow childbirth. There may also be an assumption that an adopted older child will be less “trouble” to take care of than a newborn, and that the adoptive family can thus just go on with its life without missing a step. Whatever the actual causes of depression following birth or adoption, there is no question that maternal depression contributes to developmental problems.

St. Andre and Keren suggest that, just as birth mothers should be screened for PND, adoptive mothers should also be screened for factors that make PAD likely-- and that the factors contributing to the two forms of depression are quite similar. They list among the risk factors a past history of depression or anxiety, a family history of depression or bipolar disorder, low social support, and early relationship difficulties. To these, they add a risk factor that I find very interesting: “strong idealization of motherhood”.

To the best of my knowledge, there has been no systematic investigation of the role of “idealization of motherhood” in postpartum depression or in problems of adoptive families. It’s not even clear how such an attitude would be measured or detected. From a purely speculative viewpoint, though, I must say it rings a bell.

Idealization of motherhood has been mentioned in two popular books (Estela Welldon’s 1992 Mother, Madonna, whore: The idealization and denigration of motherhood, and Susan Douglas and Meredith Michaels’ 2003 The mommy myth: The idealization of motherhood and how it has undermined all women). As well as discussing other feminist issues, these two volumes touch on the idealization of motherhood in the sense that I think St-Andre and Keren intend-- the belief that being a mother is woman’s highest calling, the crowning achievement of life, and a state of nobility and virtue. This kind of idealization is also much to be met with on web sites that specialize in what we might call “motherhood porn”, sentimental descriptions of mothers’ love and sacrifice in the face of their children’s indifference or even hostility. These approaches are nothing new, going back to Victorian times and before; when seriously annoyed with me, my own mother once sent me a verse that described how a mother was the only person who refused to believe that her child had committed murder (and he actually had!).

Why would idealization of motherhood be a factor in the development of post-adoption depression? Motherhood (and fatherhood too) in reality involve a tangled skein of joys, pains, boredom, overexcitement, social isolation, financial terrors, and exhaustion. The adoptive family additionally experiences both praise and criticism from outsiders, fears about the nature of the “stranger child”, and the impact of being observed by agency staff. They have had a roller-coaster ride of timing, sometimes having to “hurry up and wait” for long periods and sometimes being told that the baby is here right now. To represent this life stage as a crowning achievement is about the same as suggesting that having your appendix out is a transcendental experience. (It’s much better than not having it out when you need the operation, of course.)

I don’t mean to downplay the wonderful things about having children. But parenthood is real, not ideal. It has all the gritty, dirty, discouraging aspects of any part of real life, and however well we manage it we cannot realistically consider later on that we did everything right. As a Massachusetts DMV worker once told me, “we’re doin’ the best we can”. If we’ve idealized what it means to be a mother, and can’t accept that all we can do is “the best we can”, the meeting with reality may trigger depression in people who are vulnerable to that emotional problem-- whether it’s labeled PND or PAD. On the other hand, if nobody idealized motherhood at all, how many people would adopt?

Of course we can’t completely prevent depression by reminding people of the realities of parenthood and arguing against idealization of motherhood. And there is more to the picture than parents’ mood disorders, wherever they come from. In thinking about the potential problems of adoption, St-Andre and Keren emphasize the importance of taking a transactional view-- looking not only at multiple factors, but considering how parents and children influence each other, and how those influences change over time. Although a mother’s vulnerability to depression is of great importance, characteristics of the adopted child also contribute to the risk of problems. For instance, difficulties are more likely if the child has experienced extreme deprivation of care in the first two years or when adoptions are later in the child’s life. Multiple simultaneous adoptions are problematic (and unfortunately appear to be encouraged by Russian orphanages).

The Nathaniel Craver Case: Many Dissatisfactions With Decisions

If you have been following the trial of the adoptive parents of Nathaniel Craver in York, PA, you know some of the details of the case. Nathaniel (Ivan Skorobogatov) was adopted from Russia in 2003 and died as the result of multiple injuries and malnutrition in 2009. The parents, Michael and Nanette Craver, were recently convicted of involuntary manslaughter and given a sentence which allowed them to be released for time served. Their defense had argued that Nathaniel’s injuries were self-inflicted.

Russian representatives have stated strong objections to this mild sentence, as has been reported by the New York Times (http://www.nytimes.com/2011/11/20/world/europe/russia-angry-at-penalty-against-dead-adopted-boys-parents.html) and also by the English-language version of Pravda (http://english.pravda.ru/russia/politics/22-11-2011/119704-cravers_russian_boy-0/). Pravda reported a statement addressed to Secretary of State Hillary Clinton and Attorney General Eric Holder by the Russian Ombudsman for Children’s Rights Pavel Astakhov. Astakhov remonstrated about the inappropriateness of the sentence and asked for an appeal to be filed. In addition, Vladimir Markin, spokesman of the Investigation Committee of the Russian Federation, stated that documents about the case have been forwarded to the National Central Bureau of Interpol, a step that according to Markin placed the Cravers’ names on an international wanted list with the goal of arresting them and bringing them to Russia for prosecution.

I too am dissatisfied with the results of this trial, but I acknowledge that without far more evidence a death penalty decision would have been profoundly questionable. My concern is directed to the failure of the state of Pennsylvania to discipline persons who were either active or passive accessories to the child’s death. This situation was a regrettable example of similar failures that have occurred in case after case of deaths and injuries of children in the last 15 years. Individuals who were mandatory reporters of child abuse (required by law as members of their professions to bring abusive situations to the attention of child protective services agencies) did not report and were apparently inattentive to indications of trouble. Others who were not mandatory reporters but observed problems failed to take the responsibility they should have taken.

Again and again, therapists and counselors have come forward to testify that children who have been harmed are themselves guilty of their injuries. The two-year-old Russian adoptee David Polreis, who died of injuries in 1996, was said to have beaten himself to death with a wooden spoon. An older Russian boy (State v. Salvetti, North Carolina Court of Appeals 2010) who was poorly nourished and had been kept in isolation was said by a therapist to have refused food offered by his adoptive parents. Staff of the Institute for Children and Families, who were involved with treatment of Nathaniel Craver, stated that Nathaniel knew how to push his mother to the breaking point. One staff member, a school psychologist with a degree from a sometimes-accredited institution, testified that the child’s condition might have been worsened by a period in foster care, apparently implying that his condition was the factor that led to his death.

Where were these people when the harm was being done? If they believed that the children self-injured or precipitated injury by other people, why did they not monitor what was happening more closely? Why not help the parents engage in training programs to help them deal with risk-taking or self-injuring children? If the parents were seen as potential threats to provocative children, why not guide them into counseling that would help them control their own impulses? If a child is refusing to eat or is known to have feeding difficulties, why not enlist the family physician and keep growth records to make sure that growth stays within normal limits? Although legal restraints come into the picture only after harm is done, good practice for mental health professionals includes anticipating problems and helping to prevent them by supplying appropriate interventions.

The First Amendment permits therapists and parent educators to state their opinions to parents, even when those opinions are not supported by systematic evidence. Making mistakes in their practice, advice, even testimony, does not make these professionals liable to prosecution. However, the state of Pennsylvania, like other states, has the option of disciplining mental health and other practitioners through state licensing boards. These boards can investigate professionals for ethical and practice errors and can discipline them in a variety of ways, including license revocation. But a look at the on-line records of state boards shows that investigation and discipline are rare except where there was an injury caused directly by the practitioner, or where there was sexual misconduct, or where drugs and alcohol were involved. Failure to follow up injury or malnutrition is rarely a disciplinary matter-- even when the practitioner later testifies that the child’s own behavior (the practitioner’s presumable focus) caused the problems. State licensing boards justify their disengagement by pointing to their low budgets-- but cases that culminate in physical injury or death of children surely deserve priorities even higher than cases of sexual contact with an adult patient.

It has become abundantly clear in recent years that Russian adoptees are especially likely to be injured, killed, or abandoned. Whether this is due to the problems the children have to start with, to the nature of the adoptive parents, or to both, is unclear. Anecdotes about Russian institutions suggest that there may be pressure for adoptive parents to “take” more children than they had planned for, and this may also be a risk factor. But whatever the causes or mechanism, everyone with an interest in adoption has already heard about the tragic outcomes for some of these arrangements. Doesn’t this suggest that therapists, counselors, caseworkers, teachers, and pediatricians should all be especially alert to signs of trouble in adoptions from Russia? Lark Eshleman, one of the Cravers’ therapists, notes on her website the many years in which she has worked with foreign adoptions; did it not occur to her that a Russian adoptee with unexplained or self-inflicted injuries should receive extra attention, and that his parents needed more careful guidance than most adoptive families? Did not the fact of a previous abuse investigation alert anyone to the need for an appropriate care plan that would not punish the parents but would guide them to safe and effective child-rearing approaches?

If professionals working with foreign adoptions can’t keep these issues in mind, and state licensing boards are indifferent-- well, perhaps the Russians are right in turning to Interpol, but they need to add some names other than the parents’.