Pearls or Swine? Another Death Possibly Related to "To Train Up a Child"

The New York Times this morning reported on the front page a third child death among apparent followers of the evangelical ministers Michael and Debi Pearl (http://www.nytimes.com/2011/11/07/us/deaths_put_focus_on_pastors_advocacy_of_spanking.html). Mr. and Mrs. Pearl are the authors of “To Train Up a Child” (posted in its entirety at www.achristianhome.org/to_train_up_a_child.htm), a document that advocates not what most of us would call spanking, but practices like whipping of 6-month-olds with plastic plumbing supply line. I have written about the Pearls in the past (Mercer, J. [2007]. Destructive trends in alternative infant mental health practices. Scientific Review of Mental Health Practice, 5(2), 44-58), but this third death report makes me feel that there is plenty more to say.

The Pearls are evangelicals living in Tennessee and associated with an organization called the Church at Cane Creek. According to the Times, there are 670,000 copies of their self-published book in circulation (an interesting fact when the book is readily available on line). The Pearls share an intensely Calvinistic belief system in which obedience to God is the essential correlate of salvation. Human beings are naturally “froward” or disobedient and rebellious, and those sins are the deeply serious ones that caused Lucifer to be hurled from heaven. Parents are responsible for their children’s salvation, and the first step they must take is to “break the spirit” and stamp out all rebelliousness expressed against the parents themselves. Without this step, children will not be meek and obedient before God, and therefore will be damned eternally. (There appears to be no room in this system for mercy or grace-- and Unitarians or Quakers need not apply!) The experience of pain is the natural tool for breaking a rebellious tendency, and although it may be uncomfortable for parents to cause this, it is their job to do so and rescue the child from an eternity in the torments of Hell.

In one anecdote in “To Train Up a Child”, the Pearls tell of a visit from a toddler who had never seen Mrs. Pearl before but was left with her for some hours. As he appeared unhappy, she offered him some roller skate wheels to play with-- but he “rebelliously” refused. Smiling at him, she whipped his leg with her plumbing supply line. This event was repeated ten times, at the end of which, according to the Pearls, the child played happily (I’m just reporting the news here, you know). Whipping was advised for a wide variety of early offenses like turning the head away when offered a spoonful of food or rolling off a blanket when placed there. The Pearls also approve of occasional withholding of food and of using a garden hose on a child who has had a toilet accident.

However appalling these practices may seem to many of us, it is unlikely though possible that they would ordinarily cause death or even serious injury. It is difficult to know whether the three child deaths-- all of adopted children, by the way-- can legitimately be attributed to the Pearls’ advice, although the parents in these cases are known to have been admirers of the Pearls’ practices. In each case, the parents’ behavior went far beyond the Pearls’ recommendations. To summarize from the Times article: The first death, that of Sean Paddock of Johnson County,NC, in 2006, involved suffocation of the 4-year-old child in a tight blanket wrap. The second, early in 2010, was that of Lydia Schatz, age 7, in California. She was whipped for hours, with pauses for prayer, and died from severe tissue damage, cut to ribbons by the lashing. The most recent death, last May, was that of 11-year-old Hana Williams in Washington State; according to the Times report, she “was found face down, naked and emaciated in the backyard; her death was caused by hypothermia and malnutrition… [she was] deprived of food for days at a time and [made to] sleep in a cold barn or a closet and shower outside with a garden hose.” The day she died, she was beaten with a link of plastic tubing as recommended by the Pearls.

Some questions come to mind, not so much about these pitiful children, who suffered unimaginably, but about the role of parenting advice and of religious belief in the United States . The First Amendment guarantees freedom of speech, but that freedom has its limits-- for example, it does not extend to yelling “fire!” in a crowded theater when there is no fire. Should there be limitations on advice that might be misused by parents whose mental health or intelligence limitations distort their understanding of appropriate parenting behavior? What should be the constraints placed on adoption caseworkers or other publicly-paid functionaries, whose instruction to parents may be out of line and lead to injury? Do parents’ religious beliefs allow authorities to waive the usual requirements about adherence to child abuse statutes? How do we, as a multicultural society, decide what laws to enforce for all families?

Simple and suitable though it may seem to just make the Pearls shut up and withdraw their book, and deplorable though the apparent results of their teachings may be, legislation may not be the answer here. However, the continuing silence of professional societies is of no help in this complex situation. The American Professional Society on Abuse of Children spoke out against attachment therapy in 2006. When will we see a task force addressing the intertwining of serious child abuse with religious and cultural beliefs? And when, particularly, will adoption organizations notice that it is dangerous to place older, foreign-adopted children with large families who concern themselves with “spirit-breaking”?

Lark Eshleman's "Becoming A Family": Approach With Caution

A Pennsylvania school psychologist, Lark Eshleman, published in 2003 a book called “Becoming a Family: Promoting Healthy Attachments With Your Adopted Child”. Although Ms. Eshleman is eager to be helpful and has written an enthusiastic volume, looking through the book unfortunately reveals misunderstandings that could easily lead to inappropriate treatment of adopted children.

Ms . Eshleman quickly focuses on the idea that adopted children are likely to suffer from Reactive Attachment Disorder and presents two definitions of “what RAD looks like”. She does not appear to notice that these “clinical definitions” (as she puts it) have little to do with each other.

Looking at discussion of Reactive Attachment Disorder in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, Eshleman quotes the following description:

“Reactive Attachment Disorder (RAD) is a complex psychiatric condition that affects a small number of children. It is characterized by problems with the formation of emotional attachments to others that are present before age five. A parent or physician may first notice problems in attachment with the caregiver that ordinarily forms in the latter part of the first year of the child’s life. The child with RAD may appear detached, unresponsive, inhibited or reluctant to engage in age-appropriate social interactions. Alternatively, some children with RAD may be overly or inappropriately social or familiar, even with strangers. The social and emotional problems associated with RAD may persist, as the child grows older.” [I haven’t checked for the accuracy of this quotation. It seems a bit clumsy, but nobody ever said psychiatrists had to be engaging writers.]

Next, apparently with the intention of reinforcing the comments above, Eshleman proceeds to quote the Association for Treatment and Training of Attachment in Children (ATTACh, a hybrid parent-professional group that has in recent years offered credentialing to those trained in their perspective on attachment issues):

“ Attachment disorder is a treatable condition in which there is a significant dysfunction in an individual’s ability to trust or engage in reciprocal, loving, lasting relationships. An attachment disorder occurs due to traumatic disruption or other interferences with the caregiver-child bond during the first years of life. It can distort future stages of development and impact a person’s cognitive, neurological, social and emotional functioning. It may also increase the risk of other serious emotional and behavioral problems.”

Let’s examine these two statements point by point and see to what extent they are in agreement with each other.
The APA statement refers to a specific diagnosis, Reactive Attachment Disorder, which has been listed in DSM for a couple of decades and which originally referred to a type of feeding problem of infants. The ATTACh statement speaks instead of “attachment disorder”, a general term that could be applied to less-than-ideal attachment styles that are nevertheless well within the normal range.
The APA statement makes no comment about treatability of RAD, while ATTACh introduces the idea of treatment before even describing the problem.
The APA statement describes observable behaviors that are part of the disorder and which presumably could be noted by parents and teachers as well as by psychiatrists, psychologists, or social workers. The ATTACh statement refers to vaguely-described problems such as the “ability to trust” or to “engage in reciprocal, loving, lasting relationships” which are not observable, but can only be inferred from behavior that is not described.
The APA statement refers to problems that can be observed beginning in the latter part of the first year of life. The ATTACh statement points to causation by events that occur in the first years (not otherwise specified), but does not cite behavior that occurs early.
The APA description notes that the social and emotional problems of concern, such as detachment and reluctance for social interaction, may persist rather than be “outgrown” as the child gets older. ATTACh warns that attachment disorder can “distort future stages of development”, a different and more serious matter than persistence of early problematic behavior. In addition, ATTACH speaks of impacts on “cognitive, neurological, social and emotional functioning”. The APA description is entirely focused on the social and emotional eccentricities that are the basis for a diagnosis of Reactive Attachment Disorder and never refers to either cognitive or neurological effects.

Following her quotations from APA and ATTACh, Eshleman goes on to add a description of a girl who is said to have some type of attachment disorder. This girl, in her early teens, is described as aggressive, destructive, jealous, and controlling, and steal from the family as well as shoplifting. At this point in her narrative, Eshleman introduces the idea that the girl shows “many of the typical features of RAD”, and cites these as lying, inability to trust, oppositional, acting-out behavior, engaging in dangerous behavior, apparent desire to keep others at a distance, and hypervigilance. None of these, please note, were mentioned as characteristic of Reactive Attachment Disorder in the APA description.

Eshleman appears to disagree on almost every point with the APA concept of Reactive Attachment Disorder. Between her quotation from ATTACh and the conclusions drawn from her case description, Eshleman has provided a view of Reactive Attachment Disorder that thoroughly contradicts that of the APA description.

Why, then, did she include the APA description to begin with? I can only attribute this to a sort of “showing the flag” by citing a conventional professional organization’s views. Or perhaps we might call it “sweetening the well” as the opposite of the persuasive technique of “poisoning the well”. By quoting the American Psychiatric Association, Eshleman claims for herself a modicum of orthodox authority and thus prepares the reader to accept her later statements. As Eshleman and similar authors well know, naïve or careless readers are not likely to say, “Wait… what? That’s not what you said before”, but are likely to read straight on and conflate the two contradictory statements with each other.

When a book displays so many contradictions in a few pages, readers need to be cautious about accepting the content. Even though some material is correct, it would be silly to assume that all of it can be trusted.

Moral Panics and Reactive Attachment Disorder

Some sociologists have a useful term for a kind of change in public attitude: moral panic. Moral panics are periods of agitation and concern about an issue that is not realistically of much importance (and by the way, the term has nothing to do with sexual morality, but is an old-fashioned way of saying that the panic exists for psychological reasons). Discussing these periods in a 1994 article (Goode & Ben-Yehuda, Moral panics: Culture, politics, and social construction. Annual Review of Sociology, 20,149-171), two sociologists defined moral panics as “explosions of fear and concern … about a specific perceived threat. In each case, a specific agent was felt to be responsible for the threat; in each case, a sober assessment of the evidence… forces the observer to the conclusion that the fear and concern were, in all likelihood, exaggerated or misplaced.” During moral panics, much attention is focused on the agent that is thought to cause the feared events, which incidentally need not be common and may even be nonexistent. Actions taken against the perceived agent can in themselves be far more dangerous than the feared events.

Moral panics have been common enough throughout history. The pervasive fear of witches in Europe and in the Massachusetts Bay Colony, the “Red Scares” of the last century, and the more recent preoccupation with “Satanic ritual abuse” are examples. Such panics may run their courses relatively quickly, but often leave traces in folk beliefs or even in institutions like laws that were originally established to deal with them. It can be argued that moral panic is responsible for some prevailing but unrealistic concerns of modern life and for some unnecessary and potentially dangerous steps taken in the hope of escaping a perceived threat.

I would suggest that for some episodes of moral panic over the last 60 years’ the perceived threat has been the same, although the agents thought to cause the threat have been different. The perceived threat is this: our children will hurt us.

In the 1950s, the psychiatrist Frederic Wertham invoked a moral panic by claiming that comic books depicting violence caused young people to behave violently. His beliefs remain institutionalized in comic book publishers’ “codes”. Both jazz and rock-and-roll music were subjects of moral panic in episodes when these forms of music were declared to loosen inhibitions and weaken morality, including resistance to violent impulses. Presently, moral panic is visible in intense concerns about violent screen games and the impulses to aggression they are said to foster ( a connection that is not supported by research on violent behavior and screen game-playing). While moral panics focus on factors that are considered agents of the threat, in these cases the threat remains the same: our children will hurt us.

Although I am far from claiming that moral panic is the sole reason for confusion, I would like to suggest that the continual misinterpretation of the symptoms of Reactive Attachment Disorder by the media and by a small number of professional and quasi-professional authors is also facilitated by the fear that our children will hurt us. Those experiencing moral panic about this issue look for agents that they believe contribute to the perceived threat. They do not imagine that their children will hurt them because they have hurt their children, or because they have modeled aggressive behavior for their children, or because they have failed to provide their children with non-violent strategies for dealing with others. Instead, encouraged by the work of a few authors and lecturers, people look to aspects of modern life which they think are the agents that can cause their children to hurt them--- abuse by other caregivers, their mothers’ thoughts about terminating the pregnancy, experiences in the NICU, difficulties with attachment, and of course adoption. To control these “agents” is their goal, because these factors are seen as the causes of the threat that creates moral panic.

Misunderstandings and false claims about the nature of Reactive Attachment Disorder focus on the violent nature and dangerous behavior posited for affected children-- in other words, in the probability that such children will hurt someone, and the likelihood that it will be a foster or adopted parent who is hurt. This focus links Reactive Attachment Disorder with the subject of moral panic, the fear that our children will hurt us. From that moral panic and pervasive references to the fear, misinterpretation of Reactive Attachment Disorder draws the energy that maintains it in the face of all evidence and arguments to the contrary. Institutionalization of Reactive Attachment Disorder as a focus of moral panic has occurred in the form of publication of misstatements by major publishers like Wiley and Academic Press and in payment for training of social services workers in related beliefs by some states (for example, Georgia).

Why do I say fears about being hurt by our children are a matter of moral panic-- a completely disproportionate reaction to the actual occurrence of any such events? The reason is that in fact youth violence has decreased rather than increased over the years when the supposed agents encouraging aggression have stayed constant or increased. Like any form of panic, moral panic makes it difficult for us to think clearly or make reasoned decisions. Under the impetus of moral panic, we may choose actions that are in fact harmful, like accepting and promulgating mistaken views of Reactive Attachment Disorder, or using treatment methods that are assumed to be harmful by child abuse researchers. Difficult though it may be, all of us-- and the media above all—need to breathe deeply and count to 100 before we allow moral panic to work through us and cause us to do harm while trying to escape an unlikely threat. Let’s not hurt our children out of our unrealistic fear that our children will hurt us.

Fallacies: Some Problems of Thinking About Infants and Children

It can be quite hard to think straight about child development, and even harder to think about practical child-related issues like parenting and teaching. One problem is that each of us individually (even teachers) can know only a limited number of children in our lifetimes--- yet we want to use that small number of children to generalize and come to conclusions about millions of children. Another problem is that even when we read about empirical research, or when we do it ourselves, so we have a lot of information, it still doesn’t work to make a prediction about an individual child on the basis of data summarized statistically. These problems make it awfully tempting to jump to conclusions from the information we have. Our jumps don’t always land us on solid ground.

I’m going to describe some fallacies, or errors in reasoning, that are all too easy to make when wrestling with complicated material about child development. Keep in mind that these have nothing to do with whether the basic facts are straight, although getting the facts wrong is obviously a problem too. Fallacies are mistakes we make in drawing conclusions even from correct information.

The ecological fallacy involves assuming that information about a large number of children can give us an accurate prediction about a single other individual. For example, in a recent series of articles, several psychologists have suggested that research work on the Strange Situation as a measure of attachment can justify using the Strange Situation to make a decision in a child custody conflict. Although no one would be justified in dismissing research evidence as a way to think about the family situation, it is fallacious to claim that what was found statistically in a study of a number of children will also be true of a single individual. The statistical findings were calculated from a set of measurements which were different from each other, and no single one of them may have been exactly equal to the calculated statistics. (But this does not mean that it is useless to compare an individual child to characteristics of a group, as is done in calculating the height or weight of a child relative to growth norms.)

The post hoc fallacy is the assumption that if one thing happened after another, the first thing to happen must have caused the second event. (In some cases, of course, the first did cause the second; the error is to think that it must have done so.) This is a common error of reasoning about child development. In its broadest form, it leads to the belief that because childhood happens first and everything else happens later, events in childhood must be the cause of all adult events such as happy or unhappy marriages, success or failure in school, and abusive or nonabusive treatment of one’s own children. By this reasoning, infancy and early childhood are of necessity more important periods than later childhood, as suggested by Bruce Perry and many others. A specific recent example of the post hoc fallacy is the belief that if adolescents who behave violently have been engaged in violent video games, the games are necessarily the cause of the violent behavior. (This idea was in fact shown in the syndicated comic strip “Funky Winkerbean” this morning, which suggests that it’s now something “everybody knows”.)

The misleading vividness fallacy involves the assumption that an event that is experienced, remembered, or imagined with many vivid details and strong emotional implications is more likely to cause an important outcome than events that are remembered or imagined vaguely or without much associated emotion. One special issue for child development discussions is that adults who would experience a strong reaction to an event right now are likely to attribute that same strong reaction to an infant who experienced a similar event. For example, an adult who can experience or imagine vividly a powerful reaction to abandonment or separation from a loved one may incorrectly attribute the same kind of reaction to a newborn baby; this attribution may lead the adult to assume that an experience of separation for a newborn was not only emotionally vivid but must of necessity be the cause of important life outcomes.

The genetic fallacy (nothing to do with heredity!) reasons that the origin of an idea provides the proof of its correctness. A common form of this fallacy looks at beliefs as proposed by one’s grandmother, a member of the clergy, or an experienced foster parent, and takes the sterling qualities of the sources to be evidence that what they say must always be correct. For example, when I was asked to discuss a problem with a young foster mother some years ago, I found she was far from interested in my attempts to re-frame a foster child’s bad behavior; she responded, “My grandmother says something different, and she goes to church every Sunday, so I think she’s right.” The genetic fallacy also applies to situations where people take a position because “I was always taught…” or “in my family they say…”. As in other fallacious reasoning, of course, the claim about child development may be correct, but it is not correct because of its origins--- other evidence must exist to show that it is correct.

If you are in an argument with somebody about a child development issue, don’t expect to be able to win by demonstrating a list of fallacies your opponent has committed! That strategy will just make them madder and more intransigent. The usefulness of looking for fallacious reasoning is really in our individual examinations of our own beliefs. It’s hard for most of us, including me, to ignore vivid experiences, for example, and there’s so much post hoc reasoning around that we can easily be sucked into it. But if we all examined our own beliefs more carefully--- well, we might be able to improve our thinking, and the world along with it.

What Is Child Abuse? Not Such an Easy Question

Most parents and teachers feel that, although they can’t necessarily define child abuse, they know it when they see it. Given anecdotes about several children’s experiences, they can readily identify each one as having been “abuse” or “not abuse”. Nevertheless, the term “child abuse” can be confusing. At times it’s used simply to mean that the speaker doesn’t like something, as in Richard Dawkins’ famous statement that religious instruction is child abuse. In addition, what is or is not abusive changes historically. I’ve been reminded of that recently by a communication from a distant relative of about my own age, to the effect that the person’s father used to punish his children by imprisoning them in a rabbit hutch. People now past middle age may remember that kind of punishment, or having their mouths washed out with laundry soap, or being sent to bed without supper-- not methods practiced by every family, but frequent enough to be known and recognized, and not widely perceived as abusive.

Even psychotherapists and other professionals may be unsure about whether a parent’s action constitute abuse or neglect, and they want to be sure because they are required to report to child protective services when they have knowledge of such actions. The other day, I was present at a discussion in which a therapist who works with parents was expressing her concern over a patient who had moved away. but had called to tell some things about her toddler’s life that had caught the therapist’s attention. Nothing had really happened, but the therapist was worried not only about the child but about her own obligations and the effect on her licensure if she made a mistake.

If we want a nice clear definition, can’t we just consider child abuse to be a matter of breaking laws about how children should or should not be treated? No, unfortunately that does not work very well. Statutes prohibiting abusive treatment are written as generally as possible for fear of omitting some unusual but undesirable action. There may be no very bright line between a permitted punishment and one that is regarded as abusive. If a child may legally be sent to her room as a punishment, does it matter how small the room is? Is being confined to a bathroom, or to a closet with a light in it, equivalent to being sent to her room? When does a structure become a large cage rather than a small room?

In day-to-day legal decisions, these matters are treated on a case-by-case basis, and considered within the context of factors like past history, the child’s age, and so on. But it would be impossible to do reliable research on child abuse if two cases that were counted in the same way actually had very different characteristics. Over a number of years, the four National Incidence Studies of Child Abuse and Neglect have worked out categories and definitions of child abuse events that are used for the purpose of describing samples of cases and extrapolating the frequencies of events in the United States. The most recent of these studies, NIS-4, is described at https://www.nis4.org/DOCS/ProjectSummary.pdf. The description discusses “sentinel agencies” which are asked to report to NIS-4, and notes that “the kinds of abusive and neglectful situations included in the NIS do not necessarily correspond to those covered by their state’s child abuse and neglect reporting statutes. The study guidelines should not be interpreted as indicating whether an official report is required or appropriate” (important points for professionals who are mandatory reporters of abusive treatment).

Other documents, such as http://www.nis4.org/NIS_History.pdf show the development over time of categories of child abuse. For example, failing to seek necessary medical care is one category of abuse and neglect, but the category was fine-tuned to exclude failure to provide even legally-mandated immunizations, unless the parent had received specific advice that this ought to be done. This decision is obviously arguable, but it involves recognition that failure to immunize, out of ignorance or because of religious objections, is a different matter from failing to have a child professionally treated for a broken leg. The History document shows steps in the development of current definitions, from the original telephone and in-person interviews with parents to more recent interviews with child protective services supervisors.

Does child abuse consist of actions that cause harm to a child? Generally speaking, behavior is likely to come to the attention of authorities only if some demonstrable harm has resulted. However, by NIS standards, there are actions that are so egregious that they are considered to be abusive even if no harm to the child can be demonstrated. These are shown in Table 6.2 of the History document and are described as having “assumed” harm. They include sexual penetration, abandonment, and failure to permit a runaway to return home. Also included are tying or binding of a child, but not confinement to close quarters (for which harm must be demonstrated).

The NIS definitions do not specifically mention (except as “other”) some forms of maltreatment that have been discussed on this blog. “Hot-saucing” (by putting stinging condiments on the child’s tongue) and restraining the child physically in the prone position are not discussed, possibly because they are quite rare or because they were little known at the time the NIS definitions were being developed.

Neither do the NIS definitions address the problem of the therapeutic use of actions that would ordinarily be defined as abusive or neglectful. If there were evidence that methods like prone restraint or food withholding are effective treatments for emotional disturbance, their use under appropriate circumstances could not be defined as abusive-- but of course there is no such evidence. And although there is evidence that aversive treatment like electric shock can be an effective way to stop severely disturbed children from mutilating themselves, there is no evidence that broad-scale, noncontingent use of such methods (as in the Judge Rotenberg Center cases) is a generally-effective disciplinary approach. Quasi-professionals or misguided professionals may advise parents to use such methods and may persuade child protective services or the courts that they are not abusive in spite of all evidence to the contrary. It would be wise if NIS efforts to come followed the thinking of reports like that of the American Professional Society on the Abuse of Children (APSAC; http://depts.washington.edu/hcsats/PDF/Attachment TaskForceAPSAC.pdf) and gave serious consideration to the problem of abuse in the guise of intervention.

Steve Jobs and That Primal Wound

Once a myth gets into circulation, it’s awfully hard to get it out again. What “everybody knows” comes to be regarded as just common sense, even though it’s actually common nonsense. A case in point: the recent discussion of Steve Jobs’ difficult personality and its attribution to his having been adopted.

Maureen Dowd’s op-ed column in the New York Times on October 26, entitled “Limits of Magical Thinking”, did not claim that Jobs’ conduct was caused by his adoption history, but did quote two other people who thought so. The mother of his more-or-less-abandoned oldest child stated that being adopted had left Jobs “full of broken glass”. His friend Andy Hertzfeld said that Jobs’ cruel behavior toward others “goes back to being abandoned at birth”. Although they did not use those words, both these people seem to be believers in the Primal Wound idea-- that separation from the birth mother, even in the early days of life, causes long-term misery, rage, and grief.

Given the Primal Wound concept, it’s easy to focus on a single possible factor and neglect to consider the thousands of other events that shape a personality. It’s particularly easy to confine oneself to looking at early childhood and to forget that the circumstances of adulthood also contribute to mood and behavior. It’s easy, too, to neglect to consider the Zeitgeist—the spirit of the times-- and the extent to which reprehensible behavior was excused or even admired.

Let’s have a look at the interpersonal behavior of some non-adopted people in the ‘70s, ‘80s, and even more recent times:

1. The famous Newt Gingrich hospital visit to tell his very sick wife he was divorcing her

2. The Roman Polanski drug ‘em and leave ‘em approach to a girl in her early teens

3. Woody Allen-- need I say more?

4. John Edwards and his out of-wedlock child

5. Jesse Jackson and his ditto

Without naming names, I can also mention personal acquaintances from the time when Jobs did his child-abandoning-- non-adopted, non-celebrity people who were enraged at the idea of child support, who insisted that a handicapped adopted child be “given back” as “too much trouble”, or who proposed that a handicapped 18-month-old alternate 6 months with the father and with a mentally-ill mother in another state.

There are a couple of important issues here. One is that there are plenty of non-adopted people who—whether or not they are “full of broken glass” (or any other substance)-- excel at making the world full of broken glass for those who are dependent on them. If Jobs’ sins are to be blamed on his adoption, what do we blame those people’s bad behavior on? Do both adoption and non-adoption create the same outcomes? If so, it’s hardly worth discussing the matter.

A second point is that fame and fortune provide opportunities for bad behavior that may not be available to those who are just soldiering on in ordinary life. Those who sport entourages can count on those entourages to cover their tracks. Those who live outside the rules of employment and family life can leave for distant spots and make sure their paths do not cross with those boring and annoying “exes” and children.

And a third point: there have been periods of time when “going with the flow” and “following your bliss” were widely-accepted goals. The ‘70s and ‘80s were periods when irresponsible behavior of men toward women and children was to some extent admired in the United States. Having shifted toward a greater emphasis on fathers’ responsibilities (for example, couples who say, with social if not biological accuracy, “we’re pregnant”), we find it shocking to look back at a not-so-distant period when that was not the situation. In considering Steve Jobs’ life, it’s easy to forget that he would have been influenced by the prevailing attitudes of the time, in addition to multiple other factors, not omitting his life with his adoptive family. The attitudes that prevailed during his youth may have helped shape his personality development in ways that conflict with today’s popular value system.

Children adopted in the early weeks or months of life have been shown to have no more and no fewer emotional problems than non-adopted children, by extensive research on large populations of children. It would be foolish to expect that no adopted child would behave badly, exhibit mood disturbances, or even have serious psychopathology. Non-adopted children have these problems too, and in about the same proportions as those adopted early in their lives. The two groups share these characteristics, so it makes no sense to say that in one group the problems are caused by adoption and in the other they are not. (Such an argument would require us to claim that the group of adopted children is genetically superior to the group of non-adopted children, and the adoptive parents are better parents than the non-adoptive parents, so that the only remaining cause of problems is the adoption itself. )

No doubt proponents of the Primal Wound myth will add Steve Jobs’ story to their repertoire of evidence that adoption is in itself harmful. Those who think through the facts of early development and of research on adopted children will reject that viewpoint, and will realize that Jobs’ behavior was comparable to that of many other famous, but non-adopted, people, as well as to actions of the less famous.

Incidentally, Nancy Verrier, the author who has drawn attention to the Primal Wound concept, has never answered the questions in my open letter of some time ago.

More About Reactive Attachment Disorder: "The Boarder" Movie

I’ve mentioned misconceptions about Reactive Attachment Disorder many times before on this blog. But it would seem that it’s possible to promulgate myths and misunderstandings on this topic a lot faster than I or anyone else can correct them.

A new example of the spread of misconceptions about Reactive Attachment Disorder is the movie “The Boarder”, created by Jane Ryan and based on her book “Broken Spirits, Lost Souls: Loving Children with Attachment and Bonding Difficulties” (iUniverse Star, 2004). (Incidentally, iUniverse is a “professional self-publishing” company rather than a traditional publisher that sends manuscripts for expert review before accepting them.) “Broken Spirits, Lost Souls” includes a foreword by Foster Cline, the well-known advocate of holding therapy and proponent of the belief that “all bonding is trauma bonding”; following the surrender of his medical license, Cline became a self-proclaimed expert on child psychopathology and effective parenting. “Broken Spirits” begins with unsubstantiated claims about the increasing incidence of Reactive Attachment Disorder and describes cases of teenagers planning Columbine-like massacres as if this behavior is caused by Reactive Attachment Disorder. It goes on to quote with approval the ideas of advocates of holding therapy like Martha Welch.

www.theboardermovie.com/what_is_rad.html provides a page that purports to offer definitions and descriptions of Reactive Attachment Disorder. In fact, its answers to the question “what is RAD?” are a mélange of accurate and inaccurate statements. Curiously, there is a link to http://en.wikipedia.org/wiki/Reactive_attachment_disorder, a Wikipedia featured article which in fact I wrote much of myself. But much of what is argued on the “Boarder” page is highly questionable. One inaccurate statement is that Reactive Attachment Disorder was once rare but is no longer so, as the number of children affected by neglect or abuse is rising “exponentially”; neither of these claims is supportable by evidence, nor is there necessarily a connection between them.

The author of the “what is RAD?” page-- presumably Ryan or a colleague—states that one possible cause of Reactive Attachment Disorder is separation from primary caregivers in the first 33 months of life, “including while in utero”. This is far from accurate, and is of special concern because of its implications about the developmental effects of adoption. While unpredictable and unresponsive care are factors in the development of Reactive Attachment Disorder and other problems like language delays, separation in the first six months does not appear to be problematic. Abrupt long-term separation after 6-8 months, when attachment emotions and behavior emerge, is associated with intense grief and other emotional reactions for a period of some months, but care by normally responsive and consistent caregivers facilitates recovery and the outcome does not involve Reactive Attachment Disorder.

Ryan (or her colleague) goes on to say that the “criteria for a diagnosis of Reactive Attachment Disorder are more severe and pronounced than the criteria used in the assessment or categorization of other Attachment Disorder styles such as insecure or disorganized attachment”. This statement shows a complete misunderstanding of the nature of Reactive Attachment Disorder and the concept of attachment styles (not Attachment Disorder styles). In “Broken Spirits”, Ryan makes it clear that she believes Reactive Attachment Disorder is shown through the checklist so often presented by proponents of holding therapy/Attachment Therapy-- the fascination with blood and gore, the “crazy lying”, fire-setting, animal torture, sexual molestation of other children, etc., etc.

These “symptoms” are completely non-overlapping with the description of Reactive Attachment Disorder given on the “what is RAD?” page, with any description in DSM or ICD, and certainly, as I can attest, with the linked Wikipedia article. Such child behaviors do occur, sad to say, but they are not aspects of Reactive Attachment Disorder. To claim them as signs of Reactive Attachment Disorder is like saying that because some (unimmunized) children do get an illness that involves swelling of glands in the neck, that kind of swelling should be called chickenpox. Understanding and treatment of mumps would be much lessened in effectiveness if the disease was assumed to be the same as chickenpox, and in the same way understanding and treatment of disorders like early-onset schizophrenia would be lessened by assuming that its symptoms were indications of Reactive Attachment Disorder.

Some readers may find it unimportant whether Ryan speaks of “Attachment Disorder styles” or “attachment styles”. In fact, the difference is an important one. To say “Attachment Disorder styles” implies incorrectly that a wide variety of psychopathologies are based on attachment problems, and that the standard Reactive Attachment Disorder is only one among them. Describing insecure attachment as an “attachment style” communicates corrrectly that this type of attachment behavior is in the normal range of development. Some have even argued that there may be social and family situations where insecure attachment is healthier and more appropriate than secure attachment. Disorganized attachment may be a normal response of toddlers to temporary family dysfunctions like divorce and custody disagreements, and a return to more stable relationships may enable the disorganized child to return to a better attachment style. (However, some methods of assessing attachment do not even use the “disorganized” concept, and it is not a basic part of Bowlby’s attachment theory.)

Will “The Boarder” ever be released? The web site indicates that contributions of money are needed to make this possible, and I have little doubt that it will occur. There are quite a number of quasi-professional therapists who benefit greatly from the spread of the inaccurate beliefs presented in Ryan’s book. Regrettably, there are also many parents-- especially those who have adopted-- who will rush to have their expectations confirmed by Ryan’s book and movie.

Meanwhile, those of us who know something about early development had better do our best to argue against these false and potentially harmful beliefs.

Babies and TV: Why Not Have Them Watch?

The American Academy of Pediatrics has again spoken against screen entertainment for children under two. They made their first policy statement about this in 1999, and they haven’t changed their minds. You can see a discussion of their position and thinking at http://www.nytimes.com/2011/10/19/health/19babies.html. When TV first became available, the cautionary joke was that if you watched too much your eyes would become square; the AAP today is seriously cautioning that young children’s mental development can be slowed by exposure to this kind of stimulation.

Is there clear evidence that television, videos, and computer displays do interfere with cognitive development in the first years of life? No, as a matter of fact, the evidence is not very clear, because it’s very difficult to establish. Because the first principle of research on human beings is to do no harm, and because that principle is especially important for the study of the very young, no one is going to do a randomized controlled trial (experimental) study of the effect of screen-watching on intelligence and academic ability. We’re left with nonrandomized studies, in which babies who ordinarily watch screens a great deal are compared with those who watch little or no screen entertainment. But although such evidence should certainly be given some weight, it’s important to remember that it involves confounded variables-- a confusion between the effects of screen-watching itself and other characteristics of families who do or do not expose their young children to screen-watching experiences.

It seems unlikely that chance alone determines the amount of screen exposure young children get, because on the whole they depend on their caregivers to set up a program, turn a device on, etc. Parents do or don’t do these things because of their own beliefs, motives, needs, and understanding of their children’s needs, and those beliefs and so on will also impact other aspects of their caregiving. For instance, parents who are exhausted or overwhelmed by problems may be more likely to want their children to be distracted and to leave the adults alone, but they may also talk to and look at the children less or be more irritable and difficult to communicate with. Parents whose poverty keeps them cooped up in a small apartment with their children, and whose dangerous neighborhood discourages them from going outside, may find screen-watching a lifesaver, but their children’s development may also be influenced by living in a poor and frightening place. When these children with a history of extensive screen-watching do poorly in school, we can’t know which of these factors really caused the problem-- or indeed whether it was caused by all the factors working together.

Nevertheless, all the major thinking of the last century about early mental development has emphasized the idea that children under the age of two are active rather than passive learners. They can learn some things by watching other people, but on the whole their understanding of the world develops through activity and interaction with the environment. They learn, for instance, that an object still exists when it’s hidden from view, and they learn this by crawling, reaching, grabbing, and mouthing objects, not just by observation (and certainly not by instruction).

Jean Piaget, the great Swiss theorist of cognitive development from birth into adulthood, referred to the period from birth to two years as the “sensorimotor” stage. He used this term to describe what he believed was the essential nature of early learning-- that it was based on a combination of information from the senses and from movement. He considered that toward the end of this stage toddlers became capable of symbolic thought and no longer were forced to learn solely through sensorimotor means, but that human beings continue throughout life to have a capacity for sensorimotor learning. Piaget’s theory of early development was based on a small number of direct observations of young children, and more recent work suggests that infants can learn some things by observation much earlier than Piaget believed. Nevertheless, it is a generally accepted idea among developmentalists that combined sensory and motor experience plays the major role in the early learning which forms a foundation for later school success. This view strongly suggests that much exposure to screen-watching will take away time from the needed sensorimotor experience from which young children learn most. The problem is not what screen-watching causes to happen, but what necessary experiences it interferes with.

A more recent thinker, the late Stanley Greenspan, the outstanding child psychiatrist and developmental theorist who founded Floortime/DIR as a treatment for autism and other problems, added an important concept to Piaget’s view of sensorimotor learning. Greenspan saw the senses and movement as essential to early learning, but in addition he emphasized that the most effective learning involved multisensory stimulation. In order to learn efficiently and to be interested, babies need to have a variety of senses stimulated at the same time-- not just vision, but hearing, touch, taste and smell, and movement senses of various kinds. What is most likely to provide excellent multisensory stimulation? It’s interaction with an interested, affectionate, engaged adult. That adult is not planning to give some planned form of instruction or purposely “teach” the baby, but because he or she is attentive and involved, whatever happens next helps the baby learn.

The affectionate caregiver provides the baby with two essential conditions for good learning. One is a combination of sensory experiences-- the warmth of touch, the rhythms of movement, the visual interest of facial expressions and eye positions, and speech or other sounds like humming and tongue-clicking. These are combined with each other into patterns that are more than the sum of their parts, as voice sounds follow the same rhythm as facial expressions and touch changes together with the movement of the adult body. These patterns offer powerful forms of sensory stimulation which draw the intense interest of the baby. In addition, the adult’s movements, speech, and gaze can all be instantly modulated in response to what the baby responds to-- what Greenspan, in talking about slightly older children, called “following the child’s lead”. The interested, caring adult provides multisensory stimulation that engages the baby’s interest and maintains it in ways impossible for any screen that offers entertainment to the passive baby. When babies spend much of their time in screen-watching, the opportunities for multisensory stimulation are limited.

There are other issues about screen entertainment or similar stimulation. One is that infants and toddlers have not yet achieved good control over attention (most of us are never perfect on this point). Where there is a great deal of noise or activity, young children find it difficult to focus mentally on everyday things they would otherwise learn about the world. The National Association for the Education of Young Children makes a point of this in their standards for early childhood education, in which they suggest that early childhood classrooms need to have low noise levels most of the time so that children can pay attention to speech or other sounds. Young children have trouble ignoring loud or distracting stimulation, which may draw them away from important sensory experiences. I recall visiting a foster home where a two-year-old boy was completely distracted by a television set and some music playing simultaneously. He stood between the two sounds and rocked back and forth from one foot to the other, and didn’t respond to his name being spoken. He was totally engaged with a sensory experience that was not meaningful in terms of the learning he needed to be doing--- in strong contrast to what he might have experienced if sitting on someone’s lap looking at a picture book.

The American Academy of Pediatrics and other interested groups are not concerned about what screen-watching does to children, but about what it prevents them from accomplishing. Because of the special nature of early childhood learning, watching passively does not give infants and toddlers the learning experiences that older human beings can achieve through observation. This is true no matter how carefully programming is claimed to have been designed for the very young.

How Does Maternal Depression Affect Young Babies?

When I’ve mentioned maternal depression on this blog, I’ve sometimes been quite surprised to have readers respond as if the condition was a moral failure rather than a mental illness. That attitude was especially common when the reference was to depression in adoptive mothers-- some seemed to think that such women were simply spoiled brats who changed their minds about what they wanted after they discovered that baby care was a challenge. I don’t think there’s much point to arguing about that belief. Depression is more common in women than in men, and is especially common during the child-bearing years. Although some women who are depressed while caring for young babies have been depressed earlier in their lives, it is also true that life-changing events-- even much-wanted ones-- can trigger depressive reactions, however counter-intuitive that may be.

Mood disorders in young mothers can exist for a variety of reasons. But it doesn’t really matter whether they occur because of moral turpitude or because of a genetically-determined emotional disturbance. In all cases, effective treatment is desirable, because a depressed caregiver cannot provide the foundation for a baby’s good cognitive and emotional development.

Why is this? How can a very young baby even know what a caregiver’s mood is? And as long as it’s fed, warm, and clean, why would the baby care?

To answer these questions, it’s important to look very closely at communications between caregivers and young babies-- communications that are quite subtle and occur very quickly, so a casual observer can notice only a few, if any, of them. Understanding such communications requires a microanalysis of videotaped movements and facial expressions. These can be examined in the order in which they occurred, so it’s possible to see how each member of the pair responded to changes in the other. (As an example of this, I’m going to summarize an article by Reck, Noe, Stefenelli, Fuchs, and others, “Interactive coordination of currently depressed inpatient mothers and their infants during the postpartum period”, Infant Mental Health Journal, 2011, Vol. 32, pp. 542-562.)

Ideally, we’d expect the baby and the caregiver to be coordinated in their behavior and mood, and to respond to each other by matching a communicated mood (what Edward Tronick calls mutual regulation). But we’d also expect that the two will occasionally make mistakes or “mismatches” and respond with a smile to a frown, or vice-versa. Normally, baby and caregiver fairly quickly notice their mistakes and “repair” the communication by moving to match the other’s mood more closely. Those repair events seem to be even more important than frequent accurate matches, because they teach the baby that moods can be changed and regulated, and that mistaken communications can be corrected with effort.

Reck and her co-authors looked at a group of mothers who were hospitalized together with their babies for treatment of serious depression, and compared them to a group of healthy mothers and their infants. They observed the frequency of positive matches (when both partners showed positive emotion) and negative matches (when both showed negative emotion such as crying, withdrawal, hostility, or intrusiveness). Because it has been reported that maternal depression interferes with the development of joint attention (looking at an object and then back at each other), shared looking at objects was also studied. There was particular interest in the pairs’ abilities to repair mismatches and come to similar positive states. The babies ranged from 1 to 8 months in age.

In order to encourage mothers and babies to show their social interactions, the researchers used the “face-to-face still-face” method. In this, mother and baby were seated opposite each other, with one video camera recording each face’s expressions and a single microphone between them. The mothers were instructed to begin just with a normal interaction, to get the babies’ attention and play with them without using toys or a pacifier. After two minutes of this play, the mothers were to do two minutes of an unresponsive “still face”, in which they simply stare into space toward the baby without responding to the baby’s bids for communication. For the final two minutes (the “reunion” phase), the mothers were to return to normal responsiveness and engage with the baby again.

Depressed mothers and their babies did behave somewhat differently from healthy mothers with their babies. When the mother was depressed, repair of mismatches took longer. Healthy mothers were quicker to repair mismatches in the reunion phase than in the initial play phase, as if they were “trying harder” after the difficult period of the still-face episode, but when mothers were depressed the difference was the opposite. There were also differences in the time it took the mother-baby pairs to come to a match. For the healthy mother-baby pairs, half of them got to a positive match in 3 seconds after they began, whereas in half of the cases with depressed mothers they needed 12 seconds to get to a positive match in the play episode and 18 seconds in the reunion episode.

The babies of depressed mothers thus had quite different experiences of social interactions than did those of healthy mothers-- and experiences of this kind would be repeated many thousands of times in the early months of life in ordinary caregiving. Slower development of communication skills would certainly be expectable for babies of depressed mothers. This would be only one of several reasons why treatment of maternal depression is important with respect to infant development. Babies don’t have to know their mothers’ moods, or to care about them-- they are affected by depression in their caregivers in ways that do not support the best development.

"Your Brain on Childhood": An Entertaining Book for Serious Parents

A good new book recently came across my desk-- Your Brain on Childhood: The Unexpected Side Effects of Classrooms, Ballparks, Family Rooms, and the Minivan, by Gabrielle Principe (Prometheus, 2011). I recommend this book to parents who are able and willing to confront the complicated realities of early development and to avoid the over-simplified strategies of Mozart and Baby Einstein. Your Brain on Childhood is clever and accessible-- but let’s face it, not everybody wants to do the hard work of understanding developmental change, and I don’t think this book is for anyone who wants a simple high-tech fix. (Unfortunately, the publisher has not provided an index or even a proper bibliography, so what might have been an excellent undergraduate course supplement is not very usable in that way.)

As some readers may know, Prometheus Books is associated with a skeptical and science-oriented publication policy (although I’d love to know why they continue to publish Arthur Janov the primal therapy man!). In line with that policy, Your Brain on Childhood questions a number of commercial ventures like the Your Baby Can Read system, and points out the power of placebo effects and the presentation of testimonials boasting that a given child can do things that are in fact in the normal range for his age. Advertising of this type is successful because many parents are unaware of confounding factors that operate together with supposedly “scientific” treatments, and may be very unclear about developmental milestones expectable at particular ages. Principe points out the commercially-manipulated confusion that tempts parents to pay high prices for products that in fact are not helpful to development.

Addressing the concerns of so many modern parents about their children’s brain development, Principe acknowledges that experience helps to drive brain growth and complexity. But she points out that not all environmental factors are relevant to brain functions. There really isn’t any evidence that Mozart-- or Beethoven, Sibelius, Elgar, or reggae-- has a predictable impact on the developing brain. In fact, it would be a pretty fatuous arrangement that would have organized normal human development so it required a kind of experience that was not present at the beginning of human evolution, in the environment of early adaptation. Could our remote ancestors have had a desperate need to hear stringed instruments in order to develop the normal intelligence and sharp senses that enabled them to survive a most challenging environment? Presumably not, because there were no stringed instruments, and they did survive, otherwise we would not be here.

As Principe points out, what we modern humans need to facilitate our development is similar to what our ancestors needed and must usually have gotten. A critical part of our brain plasticity (the capacity of the brain to be shaped by experience as well as by heredity) is what is called “experience-expectant plasticity”. This capacity involves an association between specific aspects of brain development and events that are very likely to occur during the first year or two after birth. Experience-expectant plasticity is generally a matter of fine-tuning abilities that are only generally governed by genetic factors. For example, good depth perception requires that information from the two eyes be put together appropriately by the brain, which has to taken into account the distance between the eyes. But that distance changes as the head grows during the first year, so the “formula” used by the brain cannot be the same at birth and at age 1. In addition, almost everyone has a slight difference between the distance from the right eye to the midline and from the left eye to the midline. The baby’s preferred head position molds the soft bones of the head so the face is a trifle asymmetrical, and the brain has to deal with this individual difference which is not genetically controlled.

Just as our ancestors 250,000 years ago responded to expectable experiences of this kind, we modern humans do too. And although it’s conceivable that by chance some experiences that were never present in that early environment could have an impact on modern babies’ development, it’s much more likely that present brain development is organized to be facilitated by the same kinds of experiences that made our ancestors’ babies develop normally. To think otherwise is like proposing that the diet our ancestors needed for good health has in some way been altered so that we now need to eat a substance that they did not need.

So, Principe asks, what did those ancestor babies need? What could they get? And what does this tell us about the experiences modern babies need for optimal development? Obviously, early human babies did not need battery-operated toys, DVDs, or flash cards in order to develop normal intelligence and abilities, or they would all have been starved because they couldn’t find food, or eaten because they were not bright enough to know they WERE food. What they needed, and what they had, was play-- play with things, and play with other people. Principe proposes that opportunities for play are exactly what drive the development of certain brain structures and their cognitive functions. When we prevent or interfere with play, we may also slow that development. Babies don’t need to be “entertained” or “stimulated” artificially; they do need the opportunities for play that are part of our evolutionary heritage.

A major reason that babies need to play is that playful manipulation of things and ideas remains an essential part of human life through childhood and adolescence, right on up through vibrant and successful adulthood. One important characteristic of humans is that, like the pet animals we love, we show neoteny-- the tendency to maintain certain child-like behaviors throughout life. (By the way, I haven’t found a page where Principe mentions this, but it may be there; oh for an index!) Play and exploration, not obviously connected with food or safety, are the foundations of our learning and are an important factor that determines our ongoing learning and the fact that it’s not all over at age 3. Play and exploration are also the foundations of science, invention, the arts, and all the other things that are positive achievements of human beings.

YourBrain on Childhood is full of really good stuff about things to do as well as things not to do. In many an aside, it punctures unverified assumptions like “learning styles”. I wish I had written it (but I would have fought for an index). Highly recommended for parents, and even more so for teachers!

Bring On the Taties, Bring on the Bread: Feeding, Eye Contact, and All That

“Bring on the taties, bring on the bread-- Won’t somebody get this baby fed!” Feeding hungry babies is a universal task of childrearing. Before they reach the toddler period, babies get frantically hungry and seem to think that only desperate crying will bring them anything to eat. Parents and other caregivers sometimes feel that they spend most of their time in feeding, and sympathize with mother and father birds confronted with wide-open beaks every time they return to the nest.

Obviously, feeding enough of the right things, in the right amounts and at the right times, is essentially to babies’ very survival, as well as to normal physical growth and development. The physical effects of feeding are so important and so obvious that it’s easy to forget that much happens during feeding other than transferring food from the outside of the baby to the inside. Studies of preterm infants have shown a number of factors that affect feeding and digestion even in very tiny babies who cannot suck and must be tube-fed-- these include the experience of smelling the mother’s milk, the experience of sucking a pacifier while being tube-fed, and the experience of being fed during a period of activity rather than when deeply asleep (all of these increase growth rate).

Even the youngest babies are actively engaged in the experience of feeding and are paying attention to events that they connect with being fed. This is a simple but powerful type of learning-- the kind Pavlov called classical conditioning-- in which the babies learn to expect one event to follow another one. More and more complicated learning builds on these early feeding experiences, until the hungry one-month-old who quieted when Mother began to undo her blouse becomes the one-year-old who tries to unbutton those buttons herself.

All those moments of learning are closely connected with social and emotional development. Except for the unlucky baby who has to make do with a propped bottle or pureed food in a bottle with a big hole in the nipple, infants almost always experience feeding as an interaction with another person. It’s an interactive experience of communication with a caregiver who does a lot of the physical work of providing food-- but who ideally does this in response to the baby’s communications of wanting to eat or wanting to stop. Both parent and baby use their best communicative skills to do this job. They both use their eyes to gaze at or look away from the other person or the food being offered, as well as putting out their hands to control a spoon or a bottle and their voices to show approval or protest. The baby wants food but may like some foods better than others, and prefers certain feeding rhythms; as he or she experiences a more satisfied appetite, there may be changes toward slower consumption or stronger preferences or avoidances.

These facts mean that ideally babies and caregivers have many sessions of practicing communicating with each other about a topic that is of great interest to both of them. It’s fun to eat when you’re hungry, and it’s fun to see your healthy baby consuming the food you’ve offered, so both of them are likely to find feeding time pleasurable and to associate that pleasure with their communication and social interaction. However, if a baby is sick or developmentally delayed, and if the caregiver is worried, depressed, afraid of wasting food, frightened, or exhausted, neither of them will have much fun in the feeding situation, and they will miss a major chance to learn to enjoy their interactions. They may not advance well in their abilities to communicate with each other, either about feeding or about other important things.

When parents and babies are not doing well together, they need support that pays attention to both adult and child needs and abilities, but they do not always get this even when intentions are good. A few years ago, I observed a program for adolescent mothers and their babies. There had been some concerns about neglect in the case of each participant, and the babies were receiving intervention in the form of supportive day care, while the mothers attended classes and discussion groups. The highlight of the day was supposed to be lunch, with each mother feeding her baby. The babies had high chairs and plenty of food provided. BUT--- nobody had remembered that it was important for the mothers and babies to be able to look at each other’s faces in order to communicate. There were no chairs for the mothers! Each young woman stood in front of her baby and bent over awkwardly to spoon the food into the baby’s mouth. The babies had to look up and away from the spoon to see their mothers’ faces, and even then saw only a tense-looking expression on a face held at an odd angle. What appeared to be a tiny detail actually caused a major impediment to the social and emotional interaction that’s a critical part of feeding.

It’s popular nowadays to emphasize early interactions, “skin-to-skin” experience, and so on, and I don’t dismiss those. But if we want to see how relationships, communication, and understanding of other people develop, I suggest we look at the thousands of feeding experiences that occur in the first year or so of a baby’s life. If someone invented feeding as a brand-new intervention, parents would rush to take workshops and learn how to do it. It doesn’t need to be invented, but parents need to understand its importance, and so do those who “coach” or support parents in other ways.

Authority versus Evidence: Arguing About Adoption and Psychological Interventions

Off and on for a couple of years, but especially in the last few months, I’ve found myself upholding the idea that there must be an evidence basis for treatment, against others who believe that statements by people who claim authority are the most powerful of all arguments. I’ve referred to this conflict as a “culture war”, and I am convinced that it is an argument between ideological, a priori assumptions about the world, on the one hand, and positions based on systematic observations and evidence, on the other-- same old Plato versus Aristotle, if you like.

Von and other adoption bloggers argue strongly for a Primal Wound, on the basis of their own experience and on the authority of Nancy Verrier (who, incidentally, has not yet answered the questions I asked a month or so ago). They reject the systematic research evidence provided by Michael Rutter and the English-Romanian Adoptees Project or by other investigators, showing that most adopted children, even those adopted late and after intense social deprivation, do quite well in the long run. For Von and friends, the vividness of personal experience and the statement of an authority establish a set of assumptions that do not need to be tested against other evidence. For Rutter and other researchers, evidence is to be explored carefully as a test of existing assumptions.

Valle Oberg, a proponent of Ronald Federici’s methods of dealing with post-institutionalized children, also appeals to authority as the foundation of her argument. She states (in comments on this blog) that Federici has worked with thousands of children (although the arithmetic on this does not seem to work out very well) and has “saved” them, and that her own children were among those. Therefore, she argues, what she says, and what Federici has said, must be correct. In addition, she proposes that peer-reviewed publication of outcome research is not evidence that methods are effective. Oberg dismisses the view that Federici needs to report his evidence to the public before his methods are said to be effective.

While mulling over these disagreements, I came across a letter to the editor published in Science in 2004 (a silent testimony to the number of papers on my desk). That LTE was in response to discussion at that time about hormone replacement therapy and the way it failed to provide the benefits to heart health that had been expected of it. The authors, Philip Guzelian and Christopher Guzelian, pointed out that it was not surprising or anomalous that the predicted results did not occur. They commented that the outcome was a “dramatic example of the difference between authority-based conclusions (arising from opinion, experience, intuition, judgment, and scientific inference)… and evidence-based conclusions (derived from an objective, unbiased, and systematic analysis of scientific knowledge)… The lesson is quite generalizable. Uncritical acceptance of authority-based opinions as conclusive evidence is pervasive, even though top authorities unsuccessfully predict what scientific knowledge will be preserved as ‘fact’ “. Guzelian and Guzelian noted that there are times when decisions need to be made without adequate scientific evidence, but warn against confusing them with evidence-based conclusions and propose that “the obvious solution is to explicitly acknowledge when shortcomings in the amounts or quality of evidence necessitate a reversion to authority”.

An important point in the contribution of Guzelian and Guzelian is the acknowledgment that evidence-based conclusions are not always available. Those authors were not talking about psychological interventions, but that acknowledgement is an important one in discussion of psychological treatment, where design and implementation of research can be extraordinarily challenging. Although Guzelian and Guzelian did not mention levels of evidence (the idea that some forms of research offer stronger arguments than others), they did imply the need to balance evidence and authority differently in different situations. When evidence is strong, it should be weighed far more heavily than authority; when evidence is weak or non-existent, authority and personal experience are better to rely on than flipping a coin or casting the I Ching.

Perhaps the most important message in the Guzelians’ letter is the need for explicit statement that in the absence of systematic evidence, one is appealing to authority for support of a claim. This is only appropriate, of course, if there is no evidence or if the existing evidence is weak or open to interpretation, and if the maker of the claim can show that this is the case. It is not sufficient to do as Von, Valle Oberg, and many others have done-- to ignore the existing evidence and put forward instead a contradictory claim based on authority, and not only authority, but the authority whose views are welcome.

But, of course, if your way of thinking is to appeal to authority, this will make sense to you only if stated by an authority of your choice.

You Can Pick Your Friends, But You Can't Pick Your Monkeys: Origins of Attachment Theory

One of the greatest temptations in the field of psychology is the urge to leap from research on animal behavior to a conclusion about human beings. Unfortunately, unless research about human beings substantiates the conclusion, the landing may be a bumpy and unreliable one. This danger does not always stop leapers; Alan Schore’s “modern attachment theory” is based on a number of such leaps, and as I have pointed out elsewhere, Schore does not make much of an effort to insure that readers realize which animals were the actual subjects of the research he cites.

The history of attachment theory, right back to John Bowlby’s time, has been characterized by generalization from animal behavior to human beings’ child care and early development. Bowlby originally compared human emotional attachment to the “imprinting” of ducks on the first moving objects they saw, and their later following of the imprinted object (usually the mother) and eventual courtship and mating with another member of their own species. Imprinting had an enormous impact on the duck’s life, determining that it might spend its early life following a toy train, or in adulthood “fall in love” with a human caretaker and ignore available mates of its own species. Considering the facts of duck behavior, Bowlby at first thought that human attachment would have similar mechanisms and effects, including “monotropy” (an inability to make an attachment to more than one human being). But further observation showed that attachment did not occur in the first days of life as imprinting did, that human beings had the ability to develop more than one attachment, and that a child who lost the first attachment relationship was capable, under the right circumstances, of developing a strong emotional attachment to a new caregiver.

Bowlby realized that the leap had gone too far and had landed on the wrong spot. Although human attachment was in some ways analogous to imprinting, it was not the same thing, and it was not possible to draw safe conclusions about human development simply from observations of duck behavior.

Bowlby and his colleagues then moved on to consider another type of animal behavior-- this time, an animal much more like human beings than ducks are. As is well known, Bowlby was much interested in the work of the comparative psychologist Harry Harlow on rhesus monkeys. Harlow demonstrated that rhesus babies, when separated from their mothers, sought out soft fabric model “mothers” and clung to them even though those “mothers” offered no nourishment. They would leave the soft mother to drink from a wire-framed “mother” that contained a bottle of milk, then scurry back to the soft model. Both Bowlby and Harlow were taken with the fact that the rhesus babies did not seem “attached” to the models that supplied milk; this result was in contradiction to Freud’s belief that the experience of feeding created emotional attachment, and it supported Bowlby’s argument that there was something in the social experience with the caregiver that triggered the development of attachment. Bowlby and Harlow were also interested in the later difficulties of the rhesus babies as adults, when they were reluctant to mate and did a very poor job of caring for their own infants if they had them. This outcome seemed to suggest that attachment experiences determined a great deal about personality development, an idea that was later built into Bowlby’s attachment theory and that has informed much of the later research on attachment.

Here’s an important question, though: What if Harlow had chosen some other kind of monkey? This was an issue which in fact received much attention from psychologists and zoologists in the couple of decades following Harlow’s reports and Bowlby’s adoption of the Harlow studies as evidence for attachment theory. The discussion at the time-- largely forgotten now that everyone has seen films of sad-looking rhesus babies on wire “mothers”-- focused on the fact that monkeys exhibit species differences in maternal-infant behavior. A monkey is not “just a monkey”, but a particular kind of monkey. (Much less work on these differences is done today because of the great expense of field studies and current concerns about the ethical treatment of lab animals.)

Harlow worked with rhesus monkeys, Macaca mulatta, a monkey that has frequently been employed in various types of research and which gave its common name to the Rh factor well-known to influence human reproductive success. But other researchers pointed out that the results of behavioral work with rhesus monkeys might not be the same as similar work with other types of monkeys. In one review article (Seay & Gottfried [1975]. A phylogenetic perspective for social behavior in primates. Journal of General Psychology, 75, 5-17), the authors described typical maternal-infant behavior and responses to separation in several monkey species in addition to Macaca mulatta.

Seay and Gottfried noted that in spite of the developmental difficulties of the “surrogate”-reared rhesus infants, rhesus monkeys who had somewhat less deprivation all eventually did well, whether they were reared in small groups of infants, reared alone but had a play period with other infants daily, were reared by brutal or abusive mothers, or had normal rearing by their mothers. They concluded that only an extremely unfavorable environment would alter these animals’ play, aggression, or sexual behavior. In addition, they stated that “even the organism maturing in an environment inadequate to support species-typical behavior will not develop unique techniques for coping with that environment. Rather, his behavioral repertoire will consist of fragments of the behavior patterns which ensure individual and species survival for most of his species-mates” (p. 10).

Comparing the rhesus monkey to other species, these authors noted that their own work on a different monkey, Macaca fascicularis, showed results rather similar to that on Macaca mulatta. However, the African red monkey (patas) showed a different pattern of social behavior. If rhesus monkeys were housed in cages such that the infants could go out to a central playground, when one came out, one or more others would join him. When an infant patas monkey came out, though, other patas infants did not join him—or, if one did, the first baby went back to his mother. As patas monkeys got older, they played chasing games, but unlike rhesus monkeys did not contact each other much.

Rhesus mothers object to physical disturbance from their infants, and will bite or hit an annoying baby. However, they will allow “strange” babies to come into the cage, as long as they “behave”. Patas mothers allow their babies to explore or play-attack them, and either do not respond or respond playfully-- but they will not allow a strange baby to come in. When nursing, rhesus babies are belly-to-belly with their mothers; patas babies do not have much of the body surface touching the mother. All monkey babies are disturbed by separation from the mother, but patas babies recover more quickly than rhesus babies do.

Who are we humans like? Should we accept a theory of personality development based on rhesus monkeys, or are we more like patas monkeys? The best guess is that we are like ourselves. Like other species, we have our own patterns of social interaction and of response to environmental changes. We may resemble other species, and their behavior may seem familiar and appealing to us. But when we come down to it, the behavior and development of other species can only provide a hint about what human beings might be like. We need to be cautious about our leaps from animal evidence to theories about humans--- however, cute, sad, and sympathetic those baby monkeys look to us.

What is Reactive Attachment Disorder? Further Discussion

I’ve made a number of statements to the effect that violent or aggressive behavior, lying, stealing, and so on, were not diagnostic of Reactive Attachment Disorder. Some readers disagree strongly with this perspective. Reader Valle Oberg, for example, has been arguing against my position for several days at http://childmyths.blogspot.com/2010/12/federici-v-mercer-story-behind-lawsuit.html.

I’d like to call people’s attention to a paper by Charles H. Zeanah and Anna Smyke from Tulane University, arguably the leading U.S authorities on Reactive Attachment Disorder (Zeanah, C.H., & Smyke, A.T. [2008]. Attachment disorders in family and social context. Infant Mental Health Journal, 29, 219-233). This paper discusses criteria for attachment disorders and compares the DSM and ICD-10 versions, as well as referring to categories suggested by Zeanah in previous work.

In none of this material is there any reference to violent or aggressive behavior, self-injury, lying, cheating , stealing, refusing eye contact, or any of these issues so much stressed by therapists and parent groups outside the mainstream of psychological and psychiatric thought. Zeanah and Smyke come no nearer to these issues than referring briefly to the possibility of risk-taking as one aspect of a RAD-like category.

Zeanah and Smyke discuss measures of inappropriate behavior suggesting a disorder of attachment. They point out three ways in which such measurement has been approached. One method looked at whether children wandered away from caregivers without becoming distressed, whether they approached strangers, whether they were never shy with new adults, whether they were friendly with new adults, and whether they would go off with strangers. A second approach considered whether children failed to differentiate among adults (that is, treated all adults the same way and did not have a preferred caregiver), readily went with a stranger, and failed to check back with a caregiver (i.e., by looking back to them or calling to them as distance between them increased or separation became likely). The third method looked at not having a preferred caregiver, lack of reticence with a stranger, failure to check back, and willingness to go with a stranger. (Once again, none of these methods looks at aggressive behavior, lying, self-injury, etc., etc.)

Zeanah and his colleagues several years ago wanted to develop a technique of assessing preschool children’s attachment to caregivers without depending on parent or teacher reports. They developed what they called the “Stranger at the Door” procedure. One of the researchers knocked at the door of the child’s home, and the caregiver and the child answered the door together. The stranger looked at the child and said, “My name is ____. What is your name? Let’s go for a walk.” Observers coded the child’s behavior in response (if the child was willing to go, they walked a few feet, then came back into the house). Children’s willingness to go with the stranger was greatest in the group who had been institutionalized, but there was also atypical willingness in a comparison group of children who had been in foster care.

The Zeanah and Smyke paper noted that in a group of children adopted from institutions, there were no cases of the inhibited form of RAD, but a “substantial minority” showed the disinhibited type, with less avoidance of strangers and less preference for familiar caregivers than is typical among family-reared children.

In discussing “self-endangering” behavior as an aspect of RAD (the nearest thing mentioned to the claims of aggression and self-injury made by some advocates of an unorthodox view of attachment disorders), Zeanah and Smyke emphasize the possibility that risk-taking is part of a “two person” disorder which is difficult to describe in present language. They raise the issue of possible relational attachment disorders (different from RAD as now defined) that are evident only in the context of the association between the child and a specific caregiver. I would add that this is a very interesting idea with respect to the claims made by members of ATTACh and similar groups that children with RAD behave angelically outside their homes, but are difficult or even dangerous in interaction with their mothers.

What Is Attachment?

What IS attachment, anyway? This word is used constantly by parents and teachers, attorneys and judges, as well as psychologists and social workers. What do they mean? Is attachment one of those things like obscenity, that we can’t define, but “we know it when we see it”?

Actually, one of the problems with understanding attachment is that many people don’t know it when they see it. As a discussion of attachment and child custody decisions pointed out a couple of years ago, “few custody evaluators recognized the distinction between a highly dependent or demonstratively affectionate relationship between a parent and a child and a secure attachment” (Calloway & Erard [2009]. Introduction to the special issue on attachment and child custody. Journal of Child Custody, 6, 1-7). Some quasi-professionals who emphasize attachment believe that the attachment of a child to a caregiver is indicated by physical demonstrations of affection, eye contact “on the parent’s terms”, obedience, and gratitude.

Many textbooks define attachment as an “emotional bond” or “tie” between two people, especially a parent and a child. The organization ATTACh (Association for the Treatment and Training of Attachment in Children) gives the following lengthier definition of attachment:
“Attachment is a reciprocal process by which an emotional connection develops between an infant and his/her primary caregiver. It influences the child’s physical, neurological, cognitive, and psychological development. It becomes the basis for development of basic trust or mistrust, and shapes how the child will relate to the world, learn, and form relationships throughout life.” (www.attach.org)

But let’s parse these definitions. Is it of any help to say that something is an “emotional bond”, without saying what an emotional bond is? Actual bonds involve close physical proximity, enforced by physical methods like ropes or handcuffs. Attachment, then, is being said to be like a bond in that it maintains proximity, but the way it does this is through emotional factors rather than with ropes. This is an analogy rather than a definition, and it is inadequate for two reasons. One is that although attachment does maintain a young child’s physical proximity to a caregiver, continuing development alters the way in which attachment is expressed. In any case, the seeking of proximity is not the same at all times, but occurs when the child feels threatened or uncomfortable. The other problem is that this description of attachment leaves it unclear whether both members of the pair behave in the same way or have the same emotions or motivations relative to maintaining proximity. In fact, in the course of development, parent and child trade several times the position of being the one that wants more proximity; the child who has a toddler clung to the parent who was leaving for work grows to the teenager whose parent is anxious to know where he is going and when he will be back

Now let’s look at the ATTACh version. It’s longer and more complicated, but is it any better? It begins by saying that “attachment is a … process”. No doubt there are processes leading to attachment, but if attachment is a process, it’s difficult to see how we can determine whether attachment is secure or even present. Surely attachment is some sort of end state, and not simply an ongoing process. Perhaps the “emotional connection” which is said to result from the attachment process is the actual attachment, but it too remains undefined.

ATTACh also says that attachment is not just a process, but a “reciprocal process”. I interpret this as meaning that attachment develops in the course of interactions with other people and could not exist in a social vacuum, and this is certainly correct. ATTACh may also intend to say that attachment (emotional connection?) in a child develops in tandem with some emotional change in the adult caregiver, which may be true, but seems to be irrelevant to the later emphasis placed on the child’s own development.

ATTACh speaks of connections between an infant and the primary caregiver and appears to be limiting attachment to this relationship. Here we encounter some problems, because all the evidence is that young children can have many attachment relationships, some more obvious than others, and that these relationships may or may not share qualities like security. On the other hand, caregivers tend to be monotropic and have one or two preferred infants, even if they work with a group of children of similar ages; perhaps the ATTACh authors were thinking of the adult’s connection with a “primary” baby when they wrote this.

ATTACh goes on to cite the various aspects of development that are influenced by attachment (although whether as a process or as a loosely-defined emotional connection is not clear). It is not stated how attachment affects the child’s physical development, or how psychological development is different from cognitive development, but even if these points are set aside, these remarks do not contribute to the definition of attachment, but simply say more about things that are related to the undefined process or end state. Similarly, in the last sentence, references to basic trust and to shaping relationships do nothing more than to say that something called attachment is involved here. (As to the statement about learning, it is far from clear what the authors meant.)

It would seem that neither the textbook definition nor the ATTACh effort is of much use in clarifying what attachment actually means. I’d like to offer an alternative definition that I believe cuts through some of the difficulties we’ve seen here.

I would suggest that attachment is best thought of as an attitude, or a readiness to behave in particular ways toward the object of the attitude. It is an attitude toward human beings that involves the readiness to behave differently toward familiar and unfamiliar people, but to do so in different ways when there is perceived threat than when there is not. Like other attitudes, attachment changes with development, and although young children show their attachment by seeking proximity to familiar people when uncomfortable, they gradually move toward other related behaviors. Also, like other attitudes, attachment involves characteristic emotional responses that may occur together with or instead of observable behavior, and these too change with development. Attachment attitudes vary with experience as well as with age and culminate in an internal working model of human relationships in general as well as the specific reaction to threat which is their foundation.

This may not be the perfect definition, but at least it actually is a definition. Comments and editing are invited.

Infant and Toddler Overnights: A Focus of Divorce Disagreements

When couples have children of infant and toddler age, the breakdown of marriage is often followed by intense and bitter argument over allowing the child to have an overnight visit and sleep away from the familiar home. In most cases, the mother is the custodial parent and continues to live in the marital home, while the father is more likely to be the one who moves out, lives elsewhere, and does the “visiting”.

Mothers are very likely to resist overnight visits for young children. They are concerned that the father is unaware of the child’s bedtime rituals or needs, that the child may be distressed by the experience, or even that a father who has behaved violently in the past may lose his temper if the child cries or fusses in the unfamiliar night-time setting. Fathers, on the other hand, may be concerned that the child spends less time with them than with the mothers and may therefore be less attached to the fathers. They may also believe that if the child does not form a strong attachment to the father in the first couple of years, no real relationship will ever be possible.

However the estranged couple work things out, this problem will pass (and of course will be replaced by different issues). The child will get older and reasons to resist overnight visits will gradually disappear. At the beginning, though, the overnight issue seems to be of overwhelming importance. In a recent special issue of the journal Family Court Review (2011, Vol. 49), the issue editor noted that when she surveyed readers to ask what they wanted to know about attachment and child custody, 60% of them asked what to do about overnights.

Several well-known psychiatrists and psychologists who contributed to the issue made a point of commenting on the overnight question. And all of them said about the same thing: overnight visits are problematic for about the first two years of the child’s life. Depending on the child, it may be best to wait as late as age 4 before beginning overnights (George, Solomon & McIntosh [2011]. Divorce in the nursery: On infants and overnight care. Family Court Review, 49, 521-528). The reasoning behind this advice is that children have real individual differences in temperament (for instance, the ease with which they accept a new situation) and in language development (which allows them to understand what they are told about the length of a visit). Children who are easily distressed, who have little concept of time, and who are still immature in their understanding of language may interpret an overnight visit as permanent abandonment by the custodial parent and may not be able to communicate their fears to the other parent-- who may have no wish to hear of the child’s longing for the divorced spouse. When children have handicapping conditions that affect communication and cognition, their level of development may be much more important than their chronological age.

But what if there are no overnights? Does this mean that the child’s relationship to the noncustodial parent is negated from the beginning? Charles Zeanah, the well-known attachment researcher, commented about this: “it’s not necessary for both parents to have attachment relationships with the child in the early years. That can happen later, when the child has more sophisticated abilities to sustain attachment relationships over time and place. Where it is possible, it does make sense for the child to keep contact at the level of comfort and familiarity until they are ready for more” (Lieberman, Zeanah, & McIntosh [2011]. Attachment perspectives on domestic violence and the law. Family Court Review,49, 529-538). Alan Sroufe, another leading attachment researcher, said, “I think that if parents, judges, lawyers, and so on took the view that attachment is a gradual building process, and that each relationship is built on its own terms, there would be less paranoia about this… even if they had no overnights for the first 2 years” (Sroufe & McIntosh [2011]. Divorce and attachment relationships: The longitudinal journey. Family Court Review, 49, 464-473).

These commentators are stressing the best interests of the child, a vague standard indeed, but one which we can clearly distinguish from an emphasis on parents’ rights. They seem to agree that it’s in the child’s best interest to have as calm an infancy and toddlerhood as possible and not to be asked to adjust to unnecessary changes and transitions. They also agree that two caring parents-- even if separated-- are better than one, but that there is no natural process that demands that both sets of relationships must develop simultaneously and early on. The fact that no “window of attachment” closes at age 2 means that it’s possible both to preserve family connections and to support a child’s early needs for a peaceful life.

Separated parents with very young children would do well to take these cautions to heart, but at the same time they may want to consider whether they want to try out visits with an eye to overnights. A gradual approach, including nap-time at the noncustodial residence, may give them an idea whether a child is ready to take the step to an overnight stay. If the child copes well with one overnight visit, it is wise to wait a while for the next one rather than rushing to a new schedule of frequent changes and risking overwhelming him or her. But none of this will work well unless the parents are able to concentrate on the child’s needs and reactions rather than hurrying to blame each other for any distress the child shows.

When overnight visits begin, one point that can be difficult for separated parents to deal with is co-sleeping. Plenty of parents let infants and toddlers sleep with them part or all of the time (and I am far from criticizing this practice). In addition, if a father leaves the household, the mother is likely to respond to the child’s distress and her own by letting the child sleep in her bed. What happens, then, if the child stays overnight with the father? Can the co-sleeping mother deal with having the child share a bed with the father, or will this trigger concerns about sexual behavior? How does the father comfort the child who is accustomed to sharing a bed, except by co-sleeping? This highly emotional situation is one in which straightforward discussion with neutral parties is essential in order to avoid distress, fears, and accusations that are in the great majority of cases completely unrealistic.

P.S. The comments of Alan Sroufe about attachment as a gradual building process are also highly relevant to adoption issues.

P.P. S. The issue of Family Court Review I'm referring to is available for free on line. Google the journal name and you'll see how to get to the articles.