Holding Therapy as an International Problem

Some readers of this blog will be aware of my years-long concern about Holding Therapy (also called Attachment Therapy, Z-therapy, soul therapy, rage-reduction therapy, etc.). Holding Therapy, which I’m going to abbreviate as HT, is an alternative psychotherapy---  the psychological version of  complementary and alternative medicine (CAM). By this I mean that it is based on implausible assumptions, at odds with conventional understanding of personality and early development, and is also without a systematic evidence basis with a foundation of randomized controlled trials or well-designed nonrandomized trials. HT is used primarily with children, although some of the “sexual conversion” proponents have employed it, and its practitioners are more often social workers or licensed mental health professionals than they are psychologists or physicians. Child injuries and deaths have been associated with HT.

When most people see the word “psychotherapy”, they assume that the treatment in question is some form of talking therapy. They may think of highly-directed cognitive therapies or of psychodynamic approaches that seek basic motivations and may explore memories of early life, but they have in mind an intervention that relies on discussion between the therapist and the client. Even when people consider treatment of young children, they expect psychotherapies to focus on communication, perhaps through play methods rather than through speech.

HT, however, is a talk therapy only in the most minimal sense. It has strong physical components, including physical restraint of the child, demands that the child kick on command or do push-ups or jumping-jacks, and painful grasping and prodding of the child’s body. Children in treatment are required to shout statements like “I hate my mother! I want to kill her!” at the command of the therapist. The originator of this treatment, one Robert M. Zaslow, a California psychologist whose professional license was revoked after he injured an adult patient, suggested that clients sign a waiver noting that bruising was to be expected from the treatment.

Discussions of HT have often attributed the practice to a sort of American backwoods mentality, associated with religious fundamentalism and an approval of the use of force to achieve desired ends. In fact, people outside the United States have essentially said “it can’t happen here”.

But in the last few years it has become plain that although HT is not common, it does happen in England, as has been described at http://invisibleengland2.wordpress.com and in the book Invisible England. In fact, HT has a long history in Great Britain, as I have described in a paper recently accepted by the British journal Adoption & Fostering.

A recent e-mail from the Czech Republic alerted me to the fact that the HT practitioner Jirina Prekopova , who had practiced for many years in Germany, has returned to her homeland and is advocating and practicing HT. Here are two videos of the proceedings:

http://www.youtube.com/watch?v=dHI1hvBEKo4

http://www.youtube.com/watch?v=jqj_mLYKmxo

{Note-- 10/16/12-- these videos now come up as unavailable. If you want to see them, try searching Jirina Prekopova youtube, because there were a number that could be seen yesterday.}

But BE WARNED: THESE ARE VERY DISTURBING! ON NO ACCOUNT PLAY THEM WHEN CHILDREN CAN HEAR THE AUDIO. The language is Czech, but you will get the picture all too well without understanding the words.

One of my correspondents has said that Prekopova uses these methods with children who have tantrums, including, according to her, an infant under a year of age. The correspondent has complained to the Association of Czech and Moravian Psychologists but has received no answer.

Prekopova lectures widely, and groups using her methods have been formed in several European countries and in Latin America.

How Prekopova developed her HT methods, and how she received encouragement, is an interesting story with several clear morals. The story goes back to the 1980s, when the New York psychiatrist Martha Welch visited the town of Evergreen, Colorado--  usually thought of as the nursery of HT—and developed her own version of the treatment, which she initially called “holding time” but today refers to as “prolonged parent-child embrace” (PPCE). Welch’s method involved face to face contact in which a small child was held on the mother’s lap, and older children lay supine with the mother lying on top of them, supporting some of her weight on her elbows. Children resisted this strongly and fought to get away, while the mother shouted and cried in expression of her own negative feelings. Eventually, both were expected to calm down and to express tender affection for each other. Welch originally presented this as a treatment for autism.

In the early ‘80s, Welch  met Elisabeth Tinbergen, the educationalist wife of Nikolaas Tinbergen who had received the Nobel Prize for Medicine or Physiology in 1973, together with Konrad Lorenz and Karl von Frisch. Tinbergen’s work involved instinctive responses of animals to specific stimuli, and in his Nobel speech he attempted to bridge that work to work on human behavior and especially on the problem of autism. Mrs. Tinbergen introduced her friend to the Nobelist, who was impressed with the connections between “holding time” and his own ideas about early development and autism. The Tinbergens wrote a book about autism and holding, and although they noted that there was no systematic evidence to show that Welch’s method was effective, they also included a lengthy appendix by Welch, with many photographs. The support from the famous Niko Tinbergen was one of the factors that led to the publication of Welch’s own book, Holding time, and her tour of Great Britain, publicized by the BBC in films that show her guiding groups of mothers to restrain their crying autistic children. (One of the morals here is, just because a person gets the Nobel prize for one thing, that doesn’t mean he knows a whole lot about other things--  cf. Linus Pauling and vitamin C.)

Jirina Prekopova met with Tinbergen and Welch and adopted the Welch method. Apparently also present at this meeting was Bert Hellinger, a German therapist. Hellinger has a method he calls systemic family therapy. Hellinger’s approach includes the idea that one’s soul may be “entangled” with those of ancestors in ways that cause the individual to act out ancestral issues. For example, a boy may be homosexual because of the desires of a deceased sister. Similarly, when incestuous relationships occur, perhaps between father and daughter, both partners are responsible, and the daughter must forgive and respect her father. Prekopova refers to and supports Hellinger’s system, although it is not clear to me in what way she actually uses it.

So, there we are. As a result of various personal contacts, and a lack of guidance from professional and licensing organizations in Europe and elsewhere, HT has spread and continues to do so. Is it not time for an international conference to discuss what can be done about this? “Anya Chaika”, author of Invisible England, what do you suggest?  

Starving and Beating Adoptees in Allegheny County: Some Speculations

Has everybody breathed a sigh of relief that the State Department has got everything fixed for Russian adoptees? No more starvation, no more restraint? Great, let’s move along to the Ethiopian children. No Ethiopian Pavel Astrakhov has yet appeared on the scene, but one is needed.

Last  week, adoptive parents of two young Ethiopian children were arrested in Allegheny County, PA (http://pittsburgh.cbslocal.com/2012/10/04/deputy-attorney-general-wife-charged-with-abusing-adopted-children). One child, a boy of 6, was badly malnourished, and an 18-month-old girl had skull fractures that may leave her blind. The children, who were adopted through a church organization, had been since March in the home of the adoptive parents, Douglas and Kristey Barbour. Mr. Barbour is a Pennsylvania deputy attorney general.

What was happening here? Very little has been revealed so far. I’ve seen considerable Internet speculation that the elite adoptive parents were deliberately cruel to the black children, and although I acknowledge that the children’s ethnicity did not stop the parents from abusing them, there are too many cases of “white-on-white” abuse for me to think that the parents were especially motivated to abuse by the children’s skin color.

There are other possible explanations---  and I don’t bring these forward in an attempt to excuse the Barbours, but because understanding these situations can help us to prevent them from occurring again. Neither do I suggest that a single explanation can do the entire job, so more than one possibility needs to be considered here.

1. The first possibility I want to consider is that the Barbours were in fact encouraged to use certain “tools” in dealing with the children, and that this encouragement gave them permission to go much too far. There are groups like the “No Greater Joy” ministries that advise physical punishment for disobedience for children as young as 4 months (yes, months ). There have been some deaths associated with that sort of treatment, but they have involved shock from being whipped severely, rather than the skull fractures in the Barbours’ case. The key to understanding this will be to find out whether the Barbours were committed to the idea that instant cheerful obedience must be obtained at all costs, and failing to achieve this easily, they turned to blows.

In addition to the physical punishment “tool”, there are various sources for the recommendation that a child’s diet be restricted in order to display the authority that these people claim is the cause of emotional attachment (see the beliefs of Nancy Thomas, for instance). I have discussed this before at http://childmyths/blogspot.com/2010/12/federici-v-mercer-story-behind-lawsuit.html.  To the best of my knowledge, practitioners do not advise parents not to feed a child at all, but just as a mild spanking can turn into a beating when an adult feels the need to escalate, so can food restriction become a starvation situation.

2. A second possible explanation for the Barbours’ abusive behavior is the Post Adoption Depression that has recently been discussed on this blog. Depression in many adults involves irritability and shortness of temper as well as the characteristic sadness. Irritability adds to the potential for physical lashing-out against a child whose normal behaviors are found annoying, who perhaps does not go to sleep as instructed or who drops food by accident. Although maternal depression has often been attributed to hormone changes following pregnancy, it’s pretty clear that it can also depend on the challenge of life with young children. (A reader recently pointed out that adoptive parents tend to be older than biological parents and may have life difficulties associated with their greater age--  perhaps responsibility for care for elderly parents rather than a younger person’s expectation that their own parents may be helpful. Adoptive parents may also have very high standards for themselves and feel depressed at their failure to live up to an unrealistic level of performance.)

3. I have no explanation to offer for the battering of the little girl, beyond what I’ve said so far. But I have to wonder whether starving the boy was associated with poor understanding of the eating habits and nutritional needs of children from other cultures. A 6-year-old is old enough to have strong habits and expectations of what food should be like and how you eat it (hands versus forks, plates versus a communal pot). Adults from the United States suddenly shifted to an Ethiopian diet (delicious but spicy by our standards) might well suffer stomachaches and be reluctant to eat. What was this child’s experience? How did he respond? Did the Barbours take his reluctance as disobedience that had to be nipped in the bud? For other adoptive parents dealing with this kind of situation, I’d like to point out the enormous help that the SPOON foundation (www.spoonfoundation.org) can be in understanding what a child’s past diet and eating habits probably were, and how to make a dietary transition and ensure that nutritional needs are met.

I am hoping that information about these points will emerge in the course of the trial. I would not be surprised to find that all the points mentioned above worked together to cause the terrible outcome. If any reader knows more about this case than has so far appeared in the news, I would like to hear from you.

Adoption and Post-Adoption: A Guest Post

Attachment Therapy Makes Strange Bedfellows

A news story from Washington State raises a multitude of questions in reference to people’s beliefs about attachment. According to this story, the adoptive parents of a 15-year-old girl who had been removed from a polygamous group in Utah were advised to share a bed with her so they could “bond” (http://www.heraldnet.com/article/20120904/NEWS01/709049844#Snohomish-man-sentenced-to-6-years-for-rape-of-girl). The therapist felt the girl had “abandonment and attachment” issues and advised attachment therapy. Somewhere all these good intentions were turned into the proverbial paving stones on the way to hell, though, as the father soon turned the bed-sharing into an even more intimate connection. When the girl resisted, he threatened her with being returned to her biological family and married off polygamously. She complied while living with the adoptive parents, but filed a complaint when she went away to college.

What the father was up to was no doubt largely a matter of letting the little head do the thinking. One hopes that the adoption agency is now a little more sophisticated about some of the possibilities of this kind.

My question is, what did the therapist imagine she was doing when she gave this advice? Where did this misch-masch of ideas about attachment come from?

The therapist (so-called) told investigators that she advised “attachment therapy”.  Although there is no “official” definition of this term, it’s usually used to describe an unorthodox treatment that purports to switch an adopted child’s emotional attachment from a biological parent to and adoptive parent. According to www.attach.org, an organization that promotes the treatment, attachment therapy involves physical holding of the child by therapists and parents; past history shows that some practitioners use a coercive and painful form of holding that has caused injuries and deaths, but presumably others do not. (In neither case is there evidence that these treatments are effective approaches to emotional disturbance.)

It’s possible that the Snohomish County therapist also recommended attachment therapy when she suggested that the adoptive parents and the 15-year-old share a bed. Ordinarily, attachment therapy would not be associated with bedsharing, and for all the serious problems associated with attachment therapy, I have never heard of sexual abuse occurring in the context of that treatment.  Attachment therapists do suggest a great deal of physical contact, rocking, hugging, and so on, and push this beyond what might be developmentally appropriate because of their unconventional beliefs about emotional development, but this would not necessarily imply or lead to overt sexual activity. In any case, such practitioners tend to stress the mother’s relationship with the child much more than the father’s.

So, we have a therapist who’s talking about attachment therapy, but she seems to be recommending something unrelated, whether instead of or in addition to attachment therapy. Where did she get the bedsharing idea?

My guess is that the therapist has become intrigued with some of the beliefs often called Attachment Parenting--  beliefs originally proposed by William Sears, and stressing physical and emotional interactions between parents and children during infancy and toddlerhood. Suggestions made by Sears and others have included an emphasis on skin-to-skin contact, on long breastfeeding, and on the “family bed” shared by parents and children. Fans of Attachment Parenting hold that these activities (which are not part of the “standard culture” of the United States) are needed in order to create a strong emotional attachment of parents and children, to provide an optimal foundation for the children’s later development, and to avoid developmental problems. Proponents of Attachment Parenting don’t regard attachment as a very robust phenomenon, an opinion in which they disagree with developmental scientists.

A small number of advocates of Attachment Parenting may approve of continuing to share a bed with the older children who have slept with their parents since birth. As far as I know, however, none of these advocates, even the most enthusiastic, has proposed that an adopted adolescent be brought into the “family bed”.

That suggestion, made by the Washington State therapist, seems to have been based on a misunderstanding common among those who  practice attachment therapy or derive their understanding of attachment from a few workshops--  the supposition that events that have a particular effect in infancy and toddlerhood will have the same effect on older children or even teenagers. This idea flies in the face of the concept of developmentally appropriate practice, which stresses the differing needs and reactions of children at different stages of development.

Attachment therapists in general--  and perhaps the Washington State therapist in particular—believe that an individual who has had problems in early development (for example, in attachment) will have those problems corrected  in the present if exposed to the kinds of situations that would have produced good development if experienced in the past. This is somewhat analogous to thinking that a 16-year-old whose growth was stunted by a lack of protein during infancy can be returned to a normal growth trajectory by having the diet limited to milk for a while.  Even if bedsharing were needed for attachment in the very young (which it isn’t), this would not be evidence that adolescent attitudes and relationships can be manipulated in the same way.

The therapist in the present case seems to have made two big mistakes. The first was to assume that she could or should make a 15-year-old “attached” to adoptive parents, in the same sense that a toddler is attached to familiar caregivers. The second was to think that the methods used by advocates of Attachment Parenting could harmlessly be generalized from infants to adolescents. Unfortunately, the person most harmed by these mistakes was the girl, with the adoptive mother next in line--  and we  might think that even the father might have behaved better and not be in prison if he did not feel some sort of permission from the therapist for “bonding”.  But, there’s no law against giving bad advice, and that’s how this therapist and others get off without punishment after contributing to family train wrecks like this one.

I just have to wonder, though--  did the therapist advise skin-to-skin contact?

Seclusion and Special Education: The Lichtenstein Papers

Following the publication of an op-ed piece by Bill Lichtenstein in the New York Times a couple of weeks ago, describing the subjection of a 5-year-old special needs child to seclusion in a small, poorly-lit room as a behavior management tool, there has been a good deal of he-said, she-said, and they-said. The Times contributed to this an editorial note acknowledging that the child’s custodial parent, her mother, should have been consulted before the article by her father was published.

Lichtenstein, the father, is standing by his statements in spite of considerable criticism--  and I would point out that if any details of his narrative are inaccurate, that’s unfortunate, but the basic story is undeniably true and echoes similar tales from all over the United States. Those tales are predominantly about experiences of special needs students who are in theory protected from mistreatment under the Americans with Disabilities Act, but who in practice may be exposed to unacceptable efforts to manage their behavior.

At http://lexington.patch.com/articles/lps-superintendent-statement-challenges-nyt-oped-alleging-mistreatment-ofspecialneedsstudent#pdf-11299348, Lichtenstein has posted a number of documents that give further information about the events experienced by then-five-year-old Rose. (Some of these appear to me to have agreed to confidentiality, but then I’m not a lawyer.)

I’ll summarize some of the information in those documents. One document, prepared by the Commonwealth of Massachusetts Department of Education Bureau of Special Education Appeals, gives further information about Rose and clarifies that she did have special educational needs and that these had been apparent years before she entered the Lexington public schools. She had had difficulty at age two and a half in a Montessori classroom, where she did not tolerate frustration well and would hit or throw things in response—not unheard-of characteristics in a two-year-old, but intense enough to be noticed by her teachers. Some of the same difficulties were seen in a later preschool and in a Lexington preschool program.

When Rose entered the Lexington school, she had an IEP (Individual Educational Plan) that recognized her delays in both receptive and expressive language and difficulties with self-regulation. (Language delays are well known to be accompanied by age-inappropriate behavior, as children with these problems may fail to understand information and directions adults give them, and may experience extreme frustration when they have difficulty asking for help or communicating other problems.) However, she was mainstreamed into a regular education class and pulled out for occupational therapy and speech/language work.

After a few months, Rose was assigned a 1:1 aide whose previous experience had been with a child who was restrained much of the time.  The aide did not know that Rose had an IEP, had no training about seclusion, and did not see school policies about restraint or seclusion. It appears to have been the aide’s job to take Rose to one of two seclusion rooms, which she did in response to actions like yelling or not following directions, rather than in response to situations which threatened safety (the acceptable reason for use of restraint or seclusion). Rose’s parents were notified that she had been taken out of the classroom to a “quiet room”, but the rooms were not described. Neither did school team meetings discuss the use of seclusion as any part of Rose’s IEP.

When Rose was placed in a seclusion room, the apparent plan was that she would be allowed out when at the end of a five-minute period she could calmly say that she was ready to come out. Because of her receptive language problems, she might not have understood this; because of her expressive language problems, she may not have been able to make the required statement. In any case, it appears that she frequently experienced multiple five-minute periods adding up to as much as an hour, although the school principal stated that the limit was to be 15 minutes in total.

It is difficult to argue that five minutes of seclusion could never, ever be a suitable response to a child’s behavioral difficulties--  although seclusion becomes a wholly different matter if the room is frighteningly dark or if the child does not know an adult is near. The problem here was not necessarily the simple use of seclusion, but seems to have been what Oscar Wilde called “officialism”.  Administrators felt that rules had been established, but did not manage to give appropriate training to those who would actually be in contact with the child or with the parents, or to supervise and be aware of how a “plan” was being applied. This scenario has become so horribly familiar in the many stories of social workers who did not see the foster child they were to monitor and were surprised when the child died at the hands of the foster parents or others.

In the Ohio seclusion cases and elsewhere, failure to supervise or train aides has been the cause of harm to children through inappropriate use of restraint and seclusion. As I pointed out several days ago, organizations that offer restraint training do not teach about seclusion (which someone presumably thinks is harmless). My crystal ball says that at this very moment people across the country are cobbling together seclusion training programs that they will advertise as evidence-based when they see that a few groups report that they liked the training. Please, school administrators, pay attention to what’s going on! Don’t just assume that if you’ve paid out public funds to train teachers and aides about seclusion, and you’ve got policies in place, that you can just forget the whole issue. You yourselves need to know what should be happening as well as what IS happening. Don’t succumb to officialism any longer.

More About Post Adoption Depression

Some recent correspondence I’ve had with an adoptive mother has made me more concerned than ever about the possibility of depression following adoption and its potential impact on the adoptive family as a whole, as well as on the developing adopted child. My correspondent describes her experience with depression as “a living hell” with “three monsters” and states that “I did things then that I would never even consider doing now” (following treatment). She sent the children to her mother’s house because she knew they were not safe at home; she reports that “most of my thoughts were about being overwhelmed, running away, and wanting to die”.

When I searched Academic Search Complete for material on Post Adoption Depression, I was interested to see that many of the papers that came up were on depression in adopted children rather than in adoptive parents. It was over 15 years ago that the term Post Adoption Depression was first used, but a clear description and explanation of the phenomenon are still very much in the works. The common belief that hormonal changes cause post-partum mood disorders made it—and still makes it--  difficult for many people to accept that a post-adoption problem can also exist. A 1999 paper (Gair, S.[1999]. Distress and depression in new motherhood: Research with adoptive mothers highlights contributing factors. Child and Family Social Work, 4, 55-66) reported that about 30% of the adoptive mothers studied scored high on a questionnaire used in assessment of depression. A number of the mothers spontaneously stated that what they had was “post-natal depression”. Interestingly, Gair noted that “Typically, in Western society, the source of discontent in mothering is not seen to have its origins in the tasks of caring and mothering… Rather the fault is seen to lie with individual mothers”--  a belief that minimizes the actual stress of caring for children and may be a cause for depression when new mothers discover how demanding these tasks actually are. As Gair pointed out, this would be intensified by the lack of social support more common in adoption than in pregnancy and childbirth. Gair summarized the evidence that hormonal factors are not a major cause of post-partum depression and argued that the events that cause depression are similar in both birth mothers and adoptive mothers.

More recently (Payne et al., [2010]. Post adoption depression. Archives of Women’s Health, 13, 147-151), researchers concluded that “Significant depression symptoms were relatively common [about 30% of the group] in adoptive mothers within the first year after adoption and were associated with environmental stress”.  Most of the mothers in this study had adopted because of infertility, a condition associated with painful and intrusive treatment and with a sense of shame and loss of self-esteem, possibly making them more vulnerable to the effects of later environmental stress (my statement, not Payne’s—J.M.).  In another recent study (Foli, K., & Gibson, G.C. [2011] . Sad adoptive dads: Paternal depression in the post-adoptive period. International Journal of Men’s Health, 10, 153-162.), the researchers described the occurrence of depression—often expressed as anger--  in adoptive fathers, possibly in response to their wives’ depression.

As for the impact of parental depression on children, there has been an examination of this issue focused on adopted children (Natsuaki, M.N., et al. [2010]. Genetic liability, environment, and the development of fussiness in toddlers: The roles of maternal depression and parental responsiveness. Developmental Psychology, 46, 1147-1158). The concern of this study was of the role caregivers’ responsiveness can play in helping infants grow into toddlerhood with less negative emotion than they might otherwise show. Parents who were responsive to their 9-month-old babies’ signals were shown to have less irritable toddlers when the children were 18 months old. One major effect of depression is to reduce the adult’s responsiveness to child communications, especially when the signals are hard to understand, so depression is likely to be linked to unresponsiveness and later to child fussiness. This and much other evidence points to parental depression as playing an important role in children’s development--  treatment of depression is not just for the comfort of the adult, but for the development (and even the safety) of the child.

Unfortunately, as an article by Foli and Gibson has pointed out (2011; Training “adoption smart” professionals. Journal of Psychiatric and Mental Health Nursing, 18, 463-467), not only is there relatively little research on Post Adoption Depression (and that research has a number of problems that I haven’t mentioned here), but adoption caseworkers do not have much awareness of what is known on the subject, and adoptive parents receive little or no training about it.

I want to voice a particular concern about untreated depression in adoptive parents. I must ask, to what extent does depression create vulnerability to inaccurate statements about adoption--  for example, that even children adopted at birth are grieving for their birth mothers? To what extent does depression make adoptive parents ready to accept stern, repressive, even dangerous regimens claimed to “cure” their children? Does thinking about harming your children (as an aspect of depression) make you more likely to let someone else hurt or endanger them?  I once came across a description of “holding therapy” as what parents can choose when they want someone else to hurt their child for them. Do unconventional treatments like “holding therapy” exploit the undiagnosed and untreated depressions of some adoptive parents? I don’t know the answers, but I believe this topic is one that needs much further exploration. 

Seclusion and Schools: The Times Fact-Checks Lichtenstein's Op-Ed

A week ago, I posted a piece about an op-ed by Bill Lichtenstein that appeared in the New York Times on Sunday, Sept. 9, 2012. Lichtenstein described in his publication an event 6 years ago in which his kindergarten-age, language-delayed daughter was subjected to many episodes of seclusion in the Lexington, Mass public schools. Several readers queried the accuracy of Lichtenstein’s story, some in terms that I did not feel comfortable posting on this blog. I myself asked the Times public editor about the degree of fact-checking associated with op-eds and was told that they were scrutinizing the piece following its publication.

This morning, the “Week in Review” section of the Times includes an editor’s note, as follows:

“An opinion essay last Sunday criticizing the use of seclusion and restraint to discipline students described an episode on Jan.6, 2006, in which the writer’s daughter, then a kindergartner, was kept in an isolation room at her school in Lexington, Mass. Several details of that episode have since been disputed.

“The girl wet herself while being confined in a closet for misbehaving. But school officials, and a 2008 deposition by the girl’s mother, state that she was then cleaned up and dressed while her parents were notified--  and that it was not the case that the parents found her standing alone, unclothed, in her urine.

“The article incorrectly described the closet where the girl was confined. It was on a mezzanine between two classroom levels, not in the basement.

“While the girl’s parents sued the Lexington school district in 2007, and obtained a settlement in 2008, the writer did not notify two Massachusetts state agencies—the Department of Children and Families and the Department of Mental Health—“at the time” of the episode, according to state records.

“The girl’s parents divorced in 2007. If The Times had known before the article was published that the writer’s ex-wife was now the girl’s custodial parent, it would have contacted her.”

One reader had commented on my blog post that she thought there was “more to the story” than was being presented. There certainly seems to be less—only slightly less--  to it than Lichtenstein’s story says. Some details were exaggerated, whether for vividness or because the writer’s memory was inaccurate or because the writer realized that most readers would not put themselves in the child’s place unless forced to. The child was not left alone and wet, the closet was not in the basement.

It’s a shame that these exaggerations were included, because they give people a good excuse to ignore or downplay the whole story. And the story is a serious one. We have inappropriate use of seclusion, for matters other than safety. We have seclusion of a young and language-delayed child whose understanding of the situation must have been minimal. We have the petty officialism that deprives a distressed young child of toilet facilities. We have inaccurate reports to parents about the child’s conduct and achievement in her first year in school.

We also have all these points in the context of a nation-wide concern voiced by the U.S. Department of Education, the subject of legislation in Kansas, and the topic of an investigation in Ohio that revealed a complete lack of staff training in the use of seclusion.

The unregulated use of seclusion in schools is a genuine problem and far more important than Bill Lichtenstein’s apparent misreporting of a personal experience.   

Post Adoption Depression: "Real" or "Not Real"?

I received an e-mail this morning from a friend and colleague whom I generally respect, but who occasionally gives me the urge to beat him about the head and shoulders with a blunt instrument I keep for that very purpose. My friend had received an e-mail himself, from a third party who spoke of her experiences with depression following adoption of two children. His comments to me got up my nose, put my knickers in a twist, etc. (British readers, please fill in other colorful expressions.)

Here’s what Friend said to me about the e-mail he had received: “ a new “disorder” to fall back on: Post Adoption Depression! At least post-partum depression has some hormonal etiology, as I understand it, and can be considered as real. But PAD seems to me just another metaphor-as-reality that pervades… much of CAM”.

Let me anatomize this statement. First, I’d like to point out that the term post-adoption depression has been used for at least ten years in descriptions of women’s disturbed emotional states that sometimes follow adoption. Such descriptions have rarely been more than simple case reports, and as far as I know there are no estimates of the frequency of this problem. It’s not mentioned in DSM, and I would guess that it’s diagnosed and treated, quite properly, as depression without requiring any acronym or “syndrome” description. It’s clear that some women (and no doubt some men too) become depressed following adoption--  although whether their condition is because of adoption is another matter, since people become depressed under many circumstances. To say this is not “real” strikes me as simple avoidance. The adoptive mother feels sad and lacks energy, experiences insomnia, may be irritable, and has difficulty conducting her daily life, including her care of her children. No physical reason for these difficulties is apparent. … If that’s not real depression, I don’t know what is.

Second, what about perinatal mood disorders (post-partum depression is one)? Are these “real” because there are hormonal changes around the time of birth, but would not be “real” if there were none? In mood and behavior, women with perinatal mood disorders are very similar to those who are depressed following adoption, making the two situations equally “real”, it seems to me. In addition, it’s clear that hormonal change is only one factor in perinatal mood disorder—it’s more likely in women who have been depressed before, and may not come on for some weeks after childbirth, by which point any hormonal turmoil has been moderated. And by the way, it’s not treated by hormone supplements, which you would think would do the trick if hormonal changes were the main cause.

Treatment of depression can be effectively done for most people by a combination of medications and talk therapy. The special problem for women with perinatal mood disorders is the potential impact of medication on the baby’s prenatal development and, through breastfeeding, on its later condition. Except in the very rare circumstance of adoptive nursing, these issues are not present for adoptive parents, which may have diverted attention from depression that they may experience.

I think a real issue here is the continuing reluctance of people outside the mental health field to recognize that a mental illness may exist and have a drastic impact on lives without any clearly demonstrable biological reason being known. This is reflected in the emphasis on hormones with respect to perinatal mood disorders. If your hormones are messed up, your mood and behavior are not your fault and you deserve help. If your hormones are not messed up, the problem is your fault and you should pull your socks up and stop being such a whiner (you wanted that child, didn’t you? Well, then!). We see the same orientation when national mental health groups refer to mental illnesses as “brain disorders”. Of course, at bottom they do involve brain disorders in some form, and are no more under the patient’s control than Parkinsonism is, but the effects and treatment of mental illness are so different from those of, say, brain injuries, that the only reason for blurring the distinction seems to be to defuse public attitudes.

People adopt children. Subsequently, for whatever reason, some of them experience debilitating depression. I don’t see what’s not “real” about that.  I’d like to see the post-adoption problem more clearly recognized and studied. Adoptive parents need to understand that depression is possible for them as well as for biological parents, and is as harmful to their parenting abilities as it is for biological parents. I would also put forward the following questions: to what extent to difficulties in adoptive parenting stem from parental depression, which goes untreated as long as the mental health focus is on the child’s condition? Does untreated depression make adoptive parents unnecessarily vulnerable to the promises of unconventional psychotherapists, who propose to “fix” the child? Does untreated depression attract adoptive parents to the idea that adopted children are all grieving for their lost mother and unable to form a good relationship in the adoptive family? These questions can’t be answered until we recognize and study adoptive parents who experience unexpected depression soon after adopting.

Here’s an interesting tidbit that I can’t seem to fit in above. Frank A. Beach, the late, great, American researcher of reproductive behavior, found that being exposed to rat pups changes both hormones and behavior in male and virgin female rats. If they’re not experienced with pups,  the males are inclined to eat the pups and the females to ignore them when they squeal for help. Put them in a cage where they see and hear pups for a few days (but can’t eat them), and both will begin to retrieve a squealing pup the way a mother does when it gets out of the nest. AND guess what, their hormones change too. As far as I know, no one has tested post-adoptive hormone changes in humans, and of course different species can be different in most ways. Makes ya think, though.

     

  

Seclusion in Schools and the Failure of Imagination: What Oscar Wilde Had to Say

Several days ago, I began a series of posts based on the op-ed by Bill Lichtenstein in the New York Times on Sept. 9, 2012. Lichtenstein’s piece described the subjection of his then five-year-old, language-delayed daughter to behavior management by seclusion--  in the form of being locked up in a closet with one light bulb in the basement of her public school. Further investigation showed me that in spite of regulation of restraint and seclusion as used in psychiatric facilities, there is much less regulation of restraint in schools, and little or no discussion or training about the use of seclusion itself.

To me, the use of seclusion in a locked room for young children and those with developmental delays signals not so much cruelty as a failure of imagination--  an inability to put oneself in the place of a child left alone (to the best of his or her knowledge) and without the ability to communicate in case of either real or social danger (like needing to go to the bathroom). Five- and six-year-olds regularly demonstrate their fear of being alone and unable to contact a trusted adult. Going to bed every night involves ritual farewells and promises that parents will look in regularly, along with leaving the door ajar and checking the closet for monsters. Emotional empathy or imagination should surely enable us to generalize from those bedtime fears to the terror produced by being locked up alone.

As I thought about the child’s experience in seclusion, something was tugging at my mind--  something someone had written a long time ago that described a similar situation. And I found it: it’s a statement written to a newspaper by Oscar Wilde in 1897, describing his observation of children in prison. Here’s what he said (you can read the whole thing at www.oscarwildefanclub.com/oscar-wilde-prison-letters/):

“People nowadays do not understand what cruelty is. They regard it as a sort of terrible medieval passion [but]…. Ordinary cruelty is simply stupidity. It is the entire want of imagination. It is the result in our days of stereotyped systems, of hard-and-fast rules, and of stupidity. What is inhuman in modern life is officialism. Authority is as destructive to those who exercise it as to those on whom it is exercised….The people who uphold the system have excellent intentions. Those who carry it out are human in intention also. Responsibility is shifted onto disciplinary regulations. It is supposed that because a thing is the rule it is right…

“ The terror of a child in prison is quite limitless. I remember once in Reading… seeing in the dimly lit cell opposite mine a small boy. Two wardens—not unkindly men--  were talking to him, with some sternness apparently…One was in the cell with him, the other was standing outside. The child’s face was like a white wedge of sheer terror. There was in his eyes the terror of a hunted animal. The next morning I heard him at breakfast-time crying and calling to be let out. His cry was for his parents…”

Readers may point out, correctly, that seclusion in school is not prison, and that the child Wilde described was suffering from many other discomforts in addition to isolation. To the adult, it is clear that there are many differences between being locked for an hour into a basement closet and spending much longer times in Her Majesty’s prisons in 1897. Yes, that’s all true, but I ask you : Does the child know that? Does a five-year-old, who probably cannot tell time by the clock very well, and who has only fairly recently learned what “tomorrow” means, have the capacity to understand that being locked up for an hour does not mean that the isolation will go on all day and all night? Does a child in seclusion know that adults can see or hear her? Does she understand that if she were in extreme distress adults would, or at least could, come and help her? Is she aware that if she wet herself (having no access to a toilet) no one could possibly blame her?  

If the answers to these questions are “no”, which I believe they are, I submit that the experience of the young or handicapped child in seclusion is not substantially different than that described by Oscar Wilde. It is terror, and it is justified only by that officialism Wilde referred to, not by any evidence of a positive effect on later behavior.

  

Still Cross About the Cross-Crawl: Some Messages from Mother Nature

As I commented some months ago, there are still a number of Internet sites that promote what they call the “cross-crawl”--  treatment that encourages the use of crawling on all fours and other movements that use the two sides of the body reciprocally, and whose proponents claim that such movements recapitulate and improve on early brain development. (If this reminds anyone of the “patterning” method that has twice been rejected in policy statements by the American Academy of Pediatrics, that’s correct, it’s the same basic idea.) The “cross-crawl’ has been presented as a treatment for cerebral palsy, for autism, for dyslexia, and for all kinds of other problems that might be attributable to early brain damage.

There are two problems with the “cross-crawl” idea. One is that nobody has presented any systematic evidence (i.e., not anecdotes) that supports the effectiveness of such a treatment for anything. The second difficulty is that it’s simply implausible that years of brain development could be reversed in this way, whether they began with injury or not. The assumption made by “cross-crawl” advocates is that because certain motor and perceptual changes are associated with events in brain development, one must cause the other--   and that the motor events cause the brain development, not the other way around.

In spite of marvelous modern brain imaging techniques, we can’t observe events in children’s brains as they crawl, or for that matter events in the brains of child or adult patients as they go through “cross-crawl” treatment. Maybe, maybe, important events are happening there, and showing that would go a long way toward making outcome evidence less necessary. We don’t have either kind of evidence, though.

Is there anything about the development and behavior of other mammals that would help us accept or reject the claims put forward by “cross-crawl” proponents? Well, we can look around us and see that many animals do use that reciprocal movement, moving the front left and back right legs together, then the front right and back left legs together. This movement resembles what adult humans do in walking, as we counter-rotate the trunk to balance as we take a step, and make our left hands swing forward as the right legs go forward. Lions do this--  but tigers don’t. Instead of walking at a trot, like lions, tigers pace, with the two left legs working together, then the two right legs. It looks as though normal development and effective functioning can take place whether the right and left sides work in a “crossed” fashion or otherwise.

If you’ve ever gone to a trotting race, you probably know that some horses trot, using the “crossed” pattern. Others pace, with front and back legs working together like a tiger’s. These are not completely natural gaits for either one, and you may see pacers wearing “hopples” that  associate front and back legs on each side.

A recent article (www.nytimes.com/2012/09/11/sports/scientists-find-gene-could-explain-horses-ability-to-pace.html) suggests that specific genes, which are active in neurons in the spinal cord, determine what movement patterns are possible and their absence makes training of certain movements difficult or impossible. This is especially true of the trot, in which coordinated diagonal limb movements are essential (and which is comparable to the “cross-crawl”). The pace is not a naturally occurring gait for horses and must be trained; although the trot occurs naturally, horses must be trained to continue to use trot movements at high speeds and not to break into a gallop, which involves a “four-beat” move as each hoof strikes the ground at a separate time. In trotting races, horses are disqualified if they break from the trot to the gallop as they move faster, so their ability to control the movement pattern is important---and under genetic control. A genetic test can predict which horses have the genetic control of motor neurons that will enable the trained horse to trot or pace even at higher speeds. The genes and the nervous system control the movements, rather than the other way around, as “cross-crawl” therapists would claim.

I would be the first to point out that people are not horses, and that what is true of one species may not be generalizable to another. However, in the absence of other kinds of evidence, it does seem that we might pay attention to what Mother Nature has to show us--  and in this case it seems to be that other mammals can naturally either trot or pace, or be trained to do either,  rather than having normal development exclusively involving the “crossed” movement pattern. In addition, it seems to be a mistake to think that movement experience necessarily alters the brain. It’s the brain (actually, the spinal cord) that causes the movement and associated experience.

Hmm, maybe teaching people to pace will be the next big thing---    

Schools Using Seclusion: Not Just Lexington's Problem

My post about Bill Lichtenstein’s Times op-ed describing his young daughter’s experience of seclusion for behavior management in a Massachusetts public school drew a lot of comments. Some people said this could not possibly have happened, referring to Massachusetts laws in some cases and making ad hominem remarks in others. Other people referred to similar events known to them. It seems very possible that although schools try to regulate the use of restraint for behavior management, they may have neglected to set careful policy about seclusion--  and that this may be a nationwide problem.

Guidelines about the use of restraint and seclusion in residential psychiatric facilities have similar rules about each of these methods, including requirements for careful documentation (www.crisisprevention.com/CPI/media/Media/Resources/alignments/Joint-Commission-Restraint-Seclusion-Alignment-2011.pdf).  However, the guidelines do emphasize training in the risks of restraint and they do not refer to the stress placed by seclusion on younger or developmentally handicapped individuals.

Schools, of course, have as their primary responsibility work with children at different levels of development, including those with developmental delays or other handicapping conditions. That is, schools have a special concern with the possible impact of seclusion when used as a behavior management technique. Training of teachers and school staff in use of seclusion--  as well as in use of restraint--  is essential. Understandably, though, the training emphasis is generally on restraint techniques, which have the potential for causing physical harm or even death. Seclusion may be regarded as harmless or equated with “time-out”, even though the two are quite different, as recommendations of the U.S. Department of Education make clear.

An article by Molly Bloom in the Columbus, Ohio, Dispatch in August, 2012 (www.dispatch.com/content/stories/local/2012/08/06/teachers-get-little-training-on-seclusion.html) noted that Ohio teachers whose schools have seclusion rooms receive little training in how to use them, and their preparation includes little discussion of the use of seclusion with special needs children. Bloom reported an investigation showing that none of the schools examined had trained teachers for use of seclusion rooms, even though most of the schools using such rooms focused on children with disabilities. The company used for restraint and seclusion training in Ohio reported that it does not teach about the use of seclusion. Bloom’s article also stated that although restraint and seclusion are supposed to be limited to situations where physical harm is a likely outcome, other types of misbehavior were the most common precursors of seclusion. In addition, as one comment on my previous post pointed out, restraint may be involved in bringing children to a seclusion room. Bloom’s article referred to children who had scrapes and bruises following seclusion.

In Kansas, a bill before the legislature in 2011 would have mandated teacher training on the use of seclusion and would have required that lockable seclusion rooms “shall ensure that the lock automatically disengages when the teacher or attendant viewing the child walks away from the seclusion room or in cases of emergency, such as fire or severe weather “ (www.kslegislature.org/li/b2011_12/measures/documents/hb2444_00_0000.pdf). This bill died in committee. It was strongly opposed by Kansas school boards, who complained that these would be unfunded mandates and that training costs and increased litigation would need to be covered. (That last bit seems to me to indicate that the authors were aware of existing inappropriate use of seclusion, or why worry about increased litigation?) The school board association contribution (www.kasb.org/assets/Advocacy/test12/HB2444S.pdf) also argued that redress for people who suffered harm from either restraint or seclusion was already available under existing law--  for example, that parents can appeal the use of seclusion to a school hearing officer, and if dissatisfied to a district court, etc. This is no doubt true, but may be of little use to poor or ill-educated parents who don’t understand the laws and can’t afford an attorney, or even to those overwhelmed with work and responsibility for special needs children. In any case, harm may already have been done, as occurred with the Lichtenstein child, and correcting that harm may not be an easy matter.

Teachers need specific training about the use of seclusion rooms (by whatever name they are called--  it would appear that in Kansas they have been called Thinking Rooms and Opportunity Rooms). They need to understand the differences between time-out and seclusion. They need to know how a child’s perceptual and communicative abilities or disabilities can be factors in the impact of seclusion. Above all, they need to understand developmentally appropriate practice and the different responses to seclusion of children of different developmental levels. Although no doubt most teachers have some understanding of these things, the U.S. Department of Education’s recommendations are directed toward being sure that all teachers, aides, and school staff know what they are doing if and when they use seclusion. But this may not happen unless communities are alerted and demand policy and procedure changes.

  

Schools, Restraint, and Seclusion: Terror May Be Worse Than Spanking

Several organizations are working hard to prohibit the use of spanking as a punishment in U.S. schools, and for a variety of reasons they are probably right to do so. In my opinion, though, there are more common and more dangerous “disciplinary” methods than spanking used in schools, and these deserve our attention because they are so often directed toward special needs children.

Physical restraint in certain positions and for more than a brief period can be fatal, especially when the restrained person is being treated with certain medications. While that problem is well known, it is harder for most people to imagine that seclusion can be terrifying and damaging in its own way, especially for younger children or those with handicapping conditions.

In the New York Times  today, the journalist and filmmaker Bill Lichtenstein describes his young daughter’s experiences with seclusion as they occurred a few years ago in a public school in Lexington, MA (www.nytimes.com/2012/09/09/opinion/sunday/a-terrifying-way-to-discipline-children.html). Lichtenstein mentions that the five-year-old kindergartener, who had some language delays, began to have serious tantrums at home after starting school. Communications from the school suggested that she was doing well and did not mention any unusual disciplinary problems. Her parents had no idea that she was being punished by any method involving seclusion--  indeed, that she was being punished at all--  until they received a call saying they should come to get her because she had taken all her clothes off! When they got to the school, they found the little girl standing by herself in a basement mop closet with one light bulb. She had been locked in the closet five times that morning and could not get out when she needed to pee, so had taken off her clothes in order not to wet them.

What were the behaviors that led to her being locked up? Were they matters of safety for herself or others--  the approved purpose for use of seclusion? No, she had failed to follow directions. (Remember, this was a child with language delays.) She had been placed in seclusion almost every day for three months without any communication of this fact to her parents. The short-term result was tantrums; now, years later, she still has nightmares. A lawsuit, settled out of court, has forced the school system to pay for her ongoing treatment.

What is the story here? How can schools get away with this kind of treatment of children? It’s simply because they ARE schools. A set of HHS rules for psychiatric hospitals, residential treatment centers for children, and group homes, initiated in 1999 and finalized in 2007 (www.gao.gov/assets/230/228149.pdf) , restricted the use of restraint and seclusion in those places and required documentation of all restraint and seclusion events. But these rules did not apply to schools. In fact, one Seventh Day Adventist boarding school in West Virginia, which was the subject of complaints about restraint and seclusion several years ago, argued successfully that as it was a school and not a residential treatment center it was not subject to restrictions. (This school was and is a holding area for children adopted from abroad whose parents can’t cope with them.)

Meanwhile, efforts are being made by the U.S Department of Education to develop control over use of restraint and seclusion in schools. The publication Restraint and Seclusion: Research Document ( www2.ed.gov/policy/seclusion/restraints-and-seclusion-resources.pdf; May, 2012) describes a set of principles and procedures that States and school systems should consider when they establish their own policies about restraint and seclusion as disciplinary techniques. This document stresses that “Restraint and seclusion should not be used as routine school safety measures; that is, they should not be implemented except in situations where a child’s behavior poses imminent danger of serious physical harm to self or others and not as a routine  strategy implemented to address instructional problems or inappropriate behavior (e.g., disrespect, noncompliance, insubordination, out of seat), as a means of coercion or retaliation, or as a convenience”. The reference to using restraint or seclusion as coercion or retaliation resonates strongly with reports on their use in hospitals and RTCs in the past, when staff were observed to antagonize vulnerable individuals until their escalating actions “gave permission” for restraint.

According to the DE document, there are presently no Federal guidelines for the use of restraint and seclusion in schools, and like many other aspects of education in the United States, local policies vary enormously in both public and private schools. As the document implies, there is further variation that results from better or worse training of school staff and their understanding  of methods of behavior management.

One common confusion (and this is my point, not DE’s, although again it is implied in the document) is about the differences between time-out and seclusion; it may be that some poorly-trained or supervised school staff members fail to understand the distinction. Time-out (for all its faults) is an acceptable behavior management technique, it is intended to calm the child, and it is done in an observable, non-locked setting. Seclusion is leaving a child alone in a locked area where he or she may be able to be seen but may not be able to communicate with anyone. The experience of the Lichtenstein’s daughter was clearly not time-out--  time-outs do not involve being locked up alone in a small room for an hour, with daily repetitions.  

DE, under the leadership of Arne Duncan, is to be congratulated on starting a dialogue about schools’ use of seclusion as well as of restraint. However, I would think still better of the document if it addressed issues of developmentally appropriate practice and the fact that young or communication-impaired children are likely to be terrified by seclusion as older children may not be. It seems to me very possible that a five-year-old would find being physically restrained by a teacher less frightening than seclusion, because at least someone would be there (I’m not recommending restraint, of course).

The fact that seclusion does not in itself cause physical harm does not make it acceptable for school use, although unimaginative adults may think it of little concern. Terror does not support learning and can well cause long-term ill effects. I believe that getting this insidiously harmful practice under national control is a more pressing priority than prohibiting spanking. Requirements for documentation of seclusion events would be a good start toward regulation.

Grandparents Day, Sept. 9, 2012: "Do Something Grand"

I’m usually cynical about a day a year supposedly dedicated to a specific group of people, but it seems that Grandparents Day (on Sept. 9 this year) can be much more than a brainwave of the greeting card industry. The organization Grandparents United (www.grandparentsday.org) is proposing that grandparents celebrate their status by Doing Something Grand for children in their communities.

Grandparents United provides an infographic (http://www.gu.org/RESOURCES/publications/GrandparentsInfographic.aspx) that shows how many grandparents are already doing Grand Things for their own grandchildren, ranging from savings for college education and payment for medical and dental treatment to permanent day-to-day care. But their Take Action Guide suggests a wide range of activities for those who are geographically or otherwise separated from their grandchildren or who do not have any yet (or possibly ever). The guide addresses the importance of intergenerational connections for all older adults as well as the benefits to the community when older people turn their energy and experience to helping rising generations, to working for all children, not just “my child”.

As is so often the case, people in the grandparent generation can count on the satisfaction  of giving real help to others, but perhaps not on any other reward. They do not necessarily receive direct thanks or enjoy authority, unless they are children’s guardians and caregivers. Grandparenting in the United States is usually a very different matter from parenting, and grandparents may need to focus on the privilege of helping rather than on any rights that they might expect to be associated with their positions.  

The question of grandparents’ rights is a complicated one in the United States, where every state has different statutes about contact between grandchildren and grandparents when families are in disagreement. Grandparents have some stated rights for visitation with their grandchildren, but those rights are applicable only in terms of the best interests of the child, and there may be powerful arguments against grandparent contact in some cases. In addition, of course, many grandparents who are denied contact cannot afford the legal representation which would be needed to challenge the denial; others may simply decide that it’s better not to further raise the child’s stress level by fighting the situation.

The U.S Supreme Court in 2000 heard a case from Washington State, Troxel v. Granville, in which a state statute which gave third parties (not just grandparents) a right to file a request for visitation with children had been declared unconstitutional by the state supreme court. The U.S Supreme Court affirmed this decision and repeated the common position that fit parents are the appropriate people to make decisions because they can be presumed to know and act in their children’s best interests. (The term “fit parents” most often applies to a married couple.) In cases of divorce or death of a parent, or if the child was born to unmarried parents, grandparents are much more likely to petition successfully for contact with a grandchild. In February, 2012, the Court refused to hear an Alabama case that involved the denial of grandparent visitation by both of the children’s parents.

The important legal principles that apply in these cases have to do with a constitutional right to freedom from government interference in personal life and with the “family veil” principle that excludes government from intrusion into child-rearing unless there is evidence of harm to a child. Although there is every reason to think that involvement with a larger number of  interested and caring people is advantageous for children, and that stressed-out parents can benefit from knowing they have back-up from the older generation, it is difficult to argue that there is usually actual harm as a result of absence of grandparent contact. Disturbing as it may be to the estranged grandparent, denial of contact may not be contrary to the best interests of the child.  

As divorce and remarriage stay at high levels, and as the rate of births to unmarried couples rises, it may be necessary for more grandparents to accept philosophically a period of estrangement from their grandchildren. Perhaps the best way for all of us to go is to think in terms of Doing Something Grand for the future community and the future world--  perhaps through  baby-sitting our “own” grandchildren, perhaps through reading to “other people’s” children, perhaps through working to assure a clean and wholesome environment for all. Such acts are our privileges as older people and our ways of living on when we are gone from this world.