Tuesday, March 4, 2014
I was not a little surprised and somewhat puzzled (yikes, does this mean people read this blog??) when I received in my inbox this morning a message from Dr. Richard Warshak, sending along a copy of his recent article about parenting plans and referring to my post from three years ago, http://childmyths.blogspot.com/2011/09/infant-and-toddler-overnights-focus-of.html.
Dr. Warshak (whom some readers will recognize as the parental alienation man, and who has been working on issues strongly related to father custody since the beginning of his professional career) pointed out that the research I had cited was of questionable quality. His recent paper, “Social Science and Parenting Plans for Young Children: A Consensus Report” (Psychology, Public Policy, and Law, 20, 46-67) makes well-deserved hay of a number of research reports on matters relevant to overnight visits of young children to parents who do not share the households where the children live most of the time. It is all too true that the research in this field is exceedingly weak and does not provide a good foundation for practical decisions made in the best interests of children. This statement is not a condemnation of the researchers concerned, but just a recognition of the extreme difficulty of doing high-quality research when it is impossible to use a randomized design (not the random sample characteristic of some studies Warshak cites), when access to families is limited by their interest in cooperating (thus omitting from the studies a most interesting group of people), when there are no universally accepted assessment methods available, and when the existing assessment methods were developed to use for research with large groups rather than for prediction of an individual outcome. As a result of these problems, there is no high-quality research to support either the idea that overnight visits for young children are advisable, or the idea that they are inadvisable.
To make a decision about overnights based on the existing research, theory, and other relevant information is a judgment call, and Dr. Warshak, with the agreement of over a hundred well-known researchers and theorists, has judged that the information supporting the advantages of overnight visits for young children is more compelling than the information showing their disadvantages. In my own 2011 references to some existing research, I did not make such a general judgment, but used the evidence for distressing effects of overnights on some children as an introduction to some thoughts about individualizing plans, anticipating problems, and fine-tuning visits as child responses are observed.
I am concerned that general recommendations about overnights, if adopted as guidelines by courts, could make it more difficult for divorcing parents to work on individualizing their parenting plans with respect to children’s ages, developmental stages, temperaments, special needs, and situational variables. I anticipate difficulty in periods or relationships of high conflict when one parent says “this isn’t working well” and the other replies “the judge said we have to do it this way”. Just as there were problems created when the courts accepted the idea of monotropy in attachment (that is, that one parent is always much more important than the other), problems will be created either if courts assume that overnights are never indicated for young children or that they are always indicated, and it would be my prediction that some attorneys and some judges would take one of those simplistic views if encouraged.
One section of Dr. Warshak’s paper caught my particular interest, and I am delighted to see it stated in print. He says, “our recommendations apply to children who have relationships with both parents. If a child has a relationship with one parent and no prior relationship with the other parent, or a peripheral, at best, relationship, different plans will serve the goal of building the relationship versus strengthening and maintaining an existing relationship” (p.60). In other words, methods that facilitate maintenance of an established parent-child connection are different than those that help create a relationship between a child and a person who, though biologically related, is essentially a stranger.
This comment is in my opinion one of the most critical in a paper that is likely to be very influential, and I hope that those who take guidelines from Dr. Warshak’s article will read it through to the end. I am thinking of the mistaken application of good rules about ordinary parenting to situations where a parent has had little contact with a child, or perhaps not even known that there was a pregnancy or a child born. For example, in a case known to me recently, a woman who found she was pregnant by her employer, whom she had come to distrust and even fear, went away to her parents in another state. The employer sought her out, and learning that she was pregnant, denied paternity. A later test showed that he was the biological father. At that time, he petitioned for full custody of the child. Because of evidence of violent behavior in the past, he was given supervised monthly visitation during the first year, then unsupervised visitation during which he took the child back to his home state for weekends and had him cared for by a nanny during those visits. The child appears to have responded with distress to the visiting schedule and events--- a schedule and events that (except for the nanny and some experiences that may have occurred) might have been perfectly appropriate if there had been an existing relationship. (I say this with complete awareness of the fact that toddlers can be stressed by many ordinary changes; this child’s response went beyond the ordinary level even for an irritable or low-threshold child.) I hope that the statement about building relationships made by Dr. Warshak, and supported by a large group’s consensus, will be given full consideration by courts dealing with cases of this type.
Tuesday, February 18, 2014
In the United States (and in most other nations), laws prohibit deceptive commercial practices. If someone who sells refrigerators tells customers that a refrigerator is larger than it really is or that it keeps food colder, it’s possible for charges to be brought against that seller. When such charges are brought, it’s usually done by an annoyed customer-- and of course when the purchased object is a refrigerator, it’s possible for the buyer to ascertain whether the volume or the temperature are what they were claimed to be.
Laws about deceptive commercial practices apply to services as well as to goods, and to services sold by non-profit groups as well as by those that operate as for-profit organizations. However, it can be a lot harder to detect whether a service is what the seller has advertised. It can take a long time to see whether a service is effective, and in many cases a purchaser might not know exactly what the service should be like.
These problems are especially relevant to the sale of psychotherapy services. Although there are effective brief therapies, it’s traditionally—and not unrealistically-- thought that psychotherapies can take a long time to “work”. It’s also the case that most psychotherapy customers have no clear idea of what a treatment should be like, except perhaps that they’ve seen movies that included psychotherapy scenes. Therapy clients may be and remain quite confused about how they should be feeling or acting, whether a treatment is ineffective or whether their case is just much less tractable than they thought. If they feel distressed by the treatment or even think the problem is getting worse, they may believe that these are normal aspects of “healing”. They will probably not be aware if they have been attracted to a treatment as a result of deceptive material about it.
It will not surprise anyone when I say that the Internet is an ideal medium for the posting of deceptive material for commercial purposes. There are hundreds of websites advertising psychotherapies in deceptive fashions—and I am not even talking about attempting to pass off testimonials as equivalent to systematic research evidence. Some of these sites include specific claims that are easily recognized as untrue by anyone with a thorough background in psychology. When recommendations for treatment are derived from such false claims, I would say that the statements amount to deceptive commercial practices.
Let me provide an object lesson by examining a single website, http://instituteforattachment.org, belonging to the Institute for Attachment and Child Development in Colorado. Here are some statements on the home page about Reactive Attachment Disorder: “Traditional therapy only feeds it.” “Love infuriates it.”
Are these statements correct? Does traditional therapy exacerbate Reactive Attachment Disorder (whatever they mean by that, but that’s a separate issue)? There is absolutely no evidence to the effect that any “traditional” therapy-- by which I presume the authors of this material mean a cognitive or behavioral therapy—causes any childhood mental health disorder to become worse. This is a claim that has been made by proponents of Attachment Therapy/Holding Therapy for two decades. It is not only without foundation, but is a profoundly ethically questionable statement for mental health professionals to make, as it intentionally deceives potential clients. To quote the National Association of Social Workers code of ethics on the principle of integrity: “Social workers behave in an ethical manner. Social workers are continually aware of the profession’s mission, values, ethical principles, and ethical standards and practice in manner consistent with them. Social workers act honestly and responsibly and promote ethical practices on the part of the organizations with which they are affiliated.” Surely it cannot be argued that anyone is behaving honestly and responsibly by making unfounded statements that serve only for their own commercial advantage.
Now, how about “Love infuriates it” (Reactive Attachment Disorder)? To begin with, this really means nothing, as “love” is an abstract noun referring to an emotion or motivation, and it’s hard to see how a psychological disorder can be “infuriated”, any more than measles can. Presumably this really means that behavior usually interpreted as loving, like kissing, hugging, mutual gaze, or gift-giving, has a different effect on some children than some caregivers would expect or like it to have, and that if such affectionate advances are pressed in spite of the child’s obvious withdrawal, the result may be an angry interaction ending in a tantrum. But that’s not what is communicated by the website’s claim, which deceptively suggests that the fact of love for a child, not a parent’s behavior, causes the child (or perhaps the disorder, in a demonic fashion?) to become furious.
I think the deceptive aspects of this website are pretty clear already, but let’s soldier on and look at some specifics at http://instituteforattachment.org/learn-about-attachment-disorder/common-questions/#1. Hmm, this is interesting, isn’t it? The home page referred repeatedly to Reactive Attachment Disorder, which is an “official” DSM disorder, although with some redefinition in DSM-5. But here we see that the discussion is of something called attachment disorder, a term that is applied here to Reactive Attachment Disorder, oppositional defiant disorder, post-traumatic stress disorder, childhood trauma, Pervasive Developmental Disorders, and “pervasive developmental delay”. These are conventionally seen as different disorders, although more than one may be a problem for a particular individual. It is deceptive to present all of these as part of the same disorder, and especially to assign a purely speculative overarching category to them without explanation.
There are quite a few other points you may notice if you look at this page. But let me go on to one of particular interest with respect to the code of ethics mentioned earlier. Scroll down to the orange headline, “I’ve sought traditional therapy in the past. It didn’t work for me. Why?” The response is this: “In traditional therapy, the client with a maladaptive upbringing usually functions more from his frontal lobe-- the part of the brain that performs abstract reasoning. For them, traditional talk therapy tends to be more of a cognitive process. Basically, they never access and deal with their limbic-based emotions. The more intelligent the client, the better they are at defending their stored up feelings of inadequacy. As a result, they tend to get frustrated by traditional therapy.” Now, this is nothing but neurotrash talk. There is no evidence that any of this is true. In addition, it exposes this approach as a “parts” therapy that views human beings as collections of unintegrated entities (curious, because I expect the practitioners call themselves “holistic”).
One more bit, then I’ll rein myself in. Below the part just mentioned, you’ll see another orange headline: “Does my child have attachment disorder?” Here we have a good many of the same-old same-old “symptoms” of attachment disorders, promulgated by AT/HT practitioners for lo, these many years. “Lacks cause and effect thinking”! Have these people ever stopped to consider what someone would be like if they actually did not have this ability, which starts to develop a few months after birth? What they actually mean is that no matter how much people have been yelling at and punishing the kid, they have been unsuccessful in changing the behavior they find a problem. It is a deceptive practice to claim that any of the “symptoms” listed here are part of an attachment disorder, much less part of PDD, especially when by doing so the authors imply that their form of treatment can ameliorate the problem.
By the way, the outfit that has posted these deceptive statements is the one that has prevented “Eve Innocenti” (see http://childmyths.blogspot.com/2012/12/the-attachment-therapist-wears-two-hats.html) from seeing her children for some years now. As the organization sells its services to the county, perhaps there is more here than simply deceptive commercial practices that could lead to charges if a victim had legal help. Many states have “false claims” acts that punish the sale to governmental agencies of substandard goods or services. But a whistle-blower needs to report what is happening. Is there one out there?
Monday, February 10, 2014
Foster Care, Institutions, and International Adoption: Re-focusing on Developmentally Appropriate Practice
Eton, Harrow, Marlborough, Roedean; Lawrenceville, Andover, Hill, Hotchkiss, Miss Porter’s, Sacred Heart… these are all boarding schools, institutions if you will, to which affluent British and American parents have been sending their children for over a hundred and fifty years now, for the purposes of education and socialization into the culture of their class. Some people have had horrible experiences there (cf. George Orwell), but great national leaders have also emerged from such schools (cf. FDR and Winston Churchill).
Can knowing these facts help us decide whether all institutions that do congregate care for children of any age are either acceptable or unacceptable? I’m afraid not, because not only are such institutions different from each other, children of different ages and different backgrounds are also different in their needs and abilities.
However, the facts about the great independent schools do tell us that it is quite possible for an institution’s care to create excellent outcomes for some children. Similarly, Richard McKenzie’s recent piece, “Foster Care versus Modern Orphanages” (http://www.ncpa.org/pub/ib136) tells us about the successes of the Crossnore School in North Carolina-- an institution whose graduates have done well in spite of challenges rarely known to the students of Harrow or Hotchkiss.
Of course, none of this tells us that institutional care, even for adolescents, is uniformly good. To be aware of this, we need only look at the track record of the World Wide Association of Specialty Programs and Schools, quite a number of whose members have been charged with serious maltreatment of children in their care. Or we might have a glance at the Miracle Meadows School in West Virginia (www.miraclemeadows.org), where on line complaints suggest that at least some outcomes have been less than successful, in spite of-- or perhaps because of-- the school’s claim to have a policy not to expel any child, perhaps meaning that the school will act as a private prison at parents’ wishes until the child ages out. A document describing a state investigation of events at the school mentions isolation of a child in a small space and beating of another child with a board (www.caselaw.findlaw.com/wv-supreme-court-of-appeals/1042637.html). Parents who had sent children to the school evidently did not want an investigation to proceed. (Incidentally, I know of my own knowledge of a Russian girl who was placed at this school as an investigation into abuse by her adoptive parents in another state was about to begin-- this being her second set of adopters, the first having decided that they did not like her and that she was not being changed by holding therapy. I see on the school website the presence of other Russian and of Ethiopian children, who were presumably adopted, or at least I can’t picture Russian and Ethiopian parents planning their children’s education in West Virginia.)
Similar stories of excellent and of abysmal conditions and outcomes can easily be told for both foster families and international adoptions. Institutions, foster care, and adoption are equal in their capacities to facilitate or to discourage good development. The care method is not the important thing; the details of how children are treated are the essential factors, and those details have not been transparently reported in materials published about the Bucharest Early Intervention Project (BEIP), the “scientific foundation” for many current claims about care for parentless children. Neither are they made very clear in the epidemiological study by Kathryn Whetten and her colleagues, published in 2009, and concluding that health and well-being of children aged 6 to 12 are not negatively affected by institutional living (www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0008169). Whetten noted the need for clarity about these details, pointing out the need to “understand which characteristics of care promote child wellbeing”, and adding, “Such characteristics may transcend the structural definitions of institutions or family homes.”
What details of care should we look for in studies about care of parentless children? Beyond simple issues like appropriate food and medical care, this depends on the ages of the children being considered. And, I should point out, this fact makes “apples and oranges” of any attempt to set the BEIP study in direct contradiction to the Whetten report. The BEIP study dealt with an intervention that began when the children were toddlers; Whetten’s work focused on children who were already “school age” when studied.
Much is already known about the different developmental needs of children at different ages. Designing environments that satisfy these needs and foster good development is known as developmentally appropriate practice (DAP). DAP concepts have been used primarily in discussion of children in early childhood (including infancy and the toddler period), and they focus on the importance for good development of having a small number of sensitive, responsive adults as caregivers for a small group of children, with consistent rules and practices guiding children’s social development, and a stable but interesting physical environment. Although caregivers often resist this idea, it has been suggested many times that caregivers should remain with their group of children as they move “up” to more advanced classrooms and activities (this is actually practiced, I believe, in the Waldorf Schools).
Although less has been said about this point, “school age” children also have their DAP concerns, and different ones than were the case in early childhood. Familiar caregivers are preferred, but by this age children much more easily engage with new adults who are friendly and interesting. These children still benefit from the presence of familiar people at bedtime or when sick or frightened, but they can explore new activities and people without needing the frequent “emotional refueling” of their younger days. They are strongly interested and involved in their peers and benefit from having a stable group of friends. This is a period of learning to negotiate and compromise with others and of developing skills in making social and moral decisions in a safe environment where helpful adults can buffer the effects of mistakes. Schooling and learning some adult-like tasks are another focus during this age period.
DAP with adolescents is somewhat different, as teenagers are in the process of moving toward adult status. They still appreciate and benefit from adults who respond warmly and helpfully when they are sought, but they need to be working toward independent judgment and decision-making. The advent of sexuality and increased aggressive impulses means that help is needed with insight into emotions as well as with self-control. Adolescents are also preparing for adult lives in the sense of working toward further education and refining their ability to do adult tasks, in anticipation of independent living.
Care for parentless children thus needs to be different for each of these age groups, and it also needs to be fine-tuned with respect to the child’s age when entering the care placement. Good outcomes cannot result from “warehousing” at any of these stages, and it’s possible to see how either a good job or a poor one could be done at any stage by an institution, a foster home, or adoption.
As Richard McKenzie pointed out, a “full menu” of care options for parentless children is needed world-wide. Glorification of a single option probably has real political benefits for those who do this, but it entirely avoids consideration of the real needs of orphaned and abandoned children. We need to re-focus on a variety of needs and a variety of developmentally appropriate solutions.
Wednesday, February 5, 2014
I usually don’t look at Amazon reviews of my books, because most of them are intended as textbooks or supplementary texts. I doubt that too many people buy them because they see them advertised or critiqued on Amazon—they are more likely to be ordered because of publishers’ advertising or comments by publishers’ reps visiting campuses. However, this morning a friend called my attention to a series of “reviews” by the Virginia psychologist Ronald Federici, which you can see at http://www.amazon.com/gp/pdp/profile/AXNT5EBH90QQB/ref=cm_cr_rdp_pdp.
Anyone looking at a single book would see a review that would appear to be directed at that book alone, but Amazon happily makes it possible to see all of a reviewer’s reviews (as at the link above). Thus we can easily see that Federici has written almost identical comments on each book, and has complained in each case that I offered no solutions to parents. This is, of course, perfectly true, because most of the books were not addressed to parents particularly (although they may have been marketed as text/trade books in some cases). The infant development textbook and the “myths and misunderstandings” books that gave rise to this blog have sections that deal with parent beliefs and parent behaviors, but they are far from being books of advice. One of the reviews refers to my teaching at a community college, and I did indeed teach one course at such a college about 40 years ago-- but this is of course not an element of a review, but instead an ad feminam argument designed to distract the reader from the real point.
Federici is nothing if not consistent, as he has spent quite a few years cursing my positions and praising his own (note the laudatory review of his own book shown at the same link, apparently written under another name at one time but now reverting to its real author). He has been especially consistent in his use of proof by assertion, simply repeating the same points without any effort to bring evidence to his support. This is certainly what occurred the only time I ever spoke to him face to face, when he sued me in Small Claims Court in Fairfax, VA, claiming that he had lost clients because of what I had said about him on the Internet. He brought a pile of printouts of e-mails and placed them in evidence-- but provided no evidence that the writers were real people, or indeed that they were written by anyone but himself. As a result, the judge found in my favor. Within an hour after leaving the courtroom, I received an e-mail (and later a hard copy) inviting me to come and work with Federici! (If this bit appears inconsistent, just think of it as a consistent focus on “whatever works”).
That trial was in 2010, and a later suit (dismissed by a federal judge) was brought to court in 2011. I had not heard from Federici for quite a while. But now we have these repetitive reviews, the most recent written in late 2013, with a pause since the one before that in 2011. Federici has also been active in another sort of nuisance lately-- I hope to be able to talk about this when it is resolved, but it’s probably better not to comment just now.
It’s probably pointless to ask why Federici does not simply present data to support the claims he makes in his book about the use of methods like prone restraint of uncooperative children. If he had the data, he’d give them, no doubt. Nor is there much point in asking why he puts his energies into personal attacks; this is what he does, and I don’t suppose it will change now. But what has re-awakened Federici’s interest in me? Could it be that he wonders whether I was involved in discussions expressing concern about what role he might play in Russian decisions about adoption? Or is it that, having been thanked for his help in the recently published book by Nelson, Fox, and Zeanah, he feels he may share in some political benefits that might be forthcoming for supporters of international adoption, and therefore is entitled to throw his weight around? Could it be that a personal matter going back about two years has irritated him? Or could it just be that he is really consistent, and I am on his enemies list, so whatever little noodge he can provide is worth doing?
Seeing Federici’s “reviews”, and thinking a lot recently about the Bucharest Early Intervention Project, I went back to Roelie Post’s 2007 book, Romania, for Export Only: The untold story of the Romanian ‘orphans’. There’s no index to this daily journal kept by a Dutch employee of the European Commission, so it can be hard to find details, but I did find some references to Federici’s involvement in Romanian adoption affairs. This is a complicated story connecting international adoption with child trafficking, but what is especially interesting to me in terms of Federici’s consistency is an e-mail quoted on p. 79, one of a number sent by him to Post in 2001. My point in quoting this is to show Federici’s presentation of his own credentials ( a point on which I filed a complaint with his professional licensing board several years later). He said:
“Dear Madame, My name is Dr. Ronald Steven Federici , Neuropsychiatrist* in Washington DC area and specialist in the neuropsychiatric* evaluation and treatment of post-institutionalized children. They tell me I am regarded as one of the world’s experts in the most complicated cases of children who have been institutionalized, and I lecture all over the world with my medical* team from my international charity Care for Children International Inc. I am also Director of a large group medical-psychiatric* practice and Professor* of Child Development.” (* added by JM)
I have starred points on which Federici has consistently made claims that cannot be supported. By referring to himself as a neuropsychiatrist, he implied that he has a medical degree (as psychiatrists do), whereas in fact his degree is Psy.D., with original specialization in school psychology and later licensure in clinical psychology. He made the same suggestion by speaking of neuropsychiatric evaluation and treatment, neither of which he is qualified to do, and by referring to his medical team and medical-psychiatric practice. Incidentally, although he has been a “professor” in the sense of teaching a course as an adjunct, he does not hold the faculty rank of Professor at any college or university. (And of course, whether “they” really told him he was regarded as one of the world’s experts, I couldn’t possibly say.)
Federici is remarkably consistent, it’s true. He consistently does not want to respond to critics by arguing the evidence for the safety and effectiveness of the methods he advises in his self-published book, and he consistently does want to take whatever backdoor approach he can think of to attack those who are concerned about those methods. Isn’t it time for him to come out and discuss differences in a straightforward professional manner, as his real credentials suggest he should be able to do? I, as well as several others, would be happy to engage in a public debate with him.
Tuesday, January 14, 2014
When care for children without functional families has been discussed recently, a single perspective has been paramount. This is the belief that group care in institutions (orphanages) is “toxic” to good development, and that individualized foster care and adoption are the only acceptable choices. The proposed Children In Families First (CHIFF) legislation in the U.S., and the recommendations made by UNICEF about shifting from orphanages to foster homes, are both based on the claim that scientific evidence strongly supports the idea that institutional care is in and of itself harmful to children’s development.
However, the existing evidence is not nearly as strong as some proponents argue. Today, I want to present some sources of relevant information, including both older and more recent studies, and to look at their conclusions and the evidence that supports them.
Historically, it has been fairly common for children, even infants, to be cared for in groups. Valerie Fildes, in her fascinating book Wet Nursing, looked at the practice in France of sending infants to be breastfed in the countryside for the first two years of their lives. The mothers, who were usually skilled textile workers, could continue to contribute substantially to the family’s earnings, while the wet nurse did well for herself and her family by caring for multiple infants. The mothers might or might not visit their babies, and the children were badly distressed when suddenly transferred back to their family’s care and separated from the only caregiver they knew. This does not seem to us post-Bowlby readers as a very good idea, but in fact (as James Robertson was to point out much later), when the children were then cared for sympathetically, most of them did very well. A somewhat similar situation existed in World War II Britain, when quite young children were evacuated from London to unfamiliar places and multiple caregivers ( see Churchill’s Children, by John Welshman), or were cared for in group homes like Anna Freud’s Hampstead Nurseries. Again, good developmental outcomes were the rule, rather than a “toxic” effect lasting through the children’s lifetimes.
No one would claim that wet nursing or evacuation were interventions that we would expect to be beneficial to development, but they seem to have done very little harm, and along with ethnographic data suggest that human beings do not require a single, restricted set of experiences in order to thrive in early life.
Like other wars, World War II created many orphans, and institutions for their care were established. Even when the war orphans were close to adulthood, institutions continued to exist to help unmarried mothers to deal with pregnancy and to care for children after birth. As these institutions were in existence contemporaneously with John Bowlby’s formulation of attachment theory, and because their arrangements were in conflict with Bowlby’s (now discarded) tenet of monotropy (the need for an infant to form an attachment to a single caregiver), many questions were asked about the effects of institutionalization on early development.
One institution that received much early attention was the Metera, a Greek foundation for unmarried mothers and their babies. According to a 1960 article in a popular magazine (possibly not very accurate), an infant born in the Metera was assigned, along with two other young infants, to two caregivers who lived in the institution, and who moved along with their three infants to a different ward if a transfer was made. Family members could visit the children, but the emphasis was on the relationships with the caregivers; adoptions were to be arranged within a few months if possible. However, by 1979, practices in the Metera seem to have changed—or perhaps they were never as positive as previously indicated. Berry Brazelton and two colleagues examined neonatal behavior of Metera infants, as compared to other groups (Pediatrics, 63(2)), and found worse performance on the part of the Metera children at birth. They attributed these difficulties to the extreme disapproval of unmarried pregnancy in Greece, and the attempts of the mothers to starve themselves before they arrived at the Metera-- but also mentioned that the infants were in unstimulating white cubicles and fed on a strict 4-hour schedule. More recently, Vorria et al (“Early experiences and attachment relationships of Greek infants raised in residential group care”, Journal of Child Psychology and Psychiatry, 2003, 43 ,pp. 1208-1220) looked at the development of children who remained in the Metera for many months, and found that an unusually high number of them showed disorganized attachment (that is, atypical behavior when a caregiver returns after a separation in a strange place, for example, freezing in place or backing toward the adult). However, some showed secure attachment. The children, who had incidentally had much lower birth weights than a control group, were less advanced cognitively than home-reared controls. Vorria et al noted that although there were claims that the Metera babies had plenty of interaction with a small number of caregivers, in fact they had little interaction in the early months, and were later moved to a pavilion where the ratio of babies to caregivers was 4-6:1, a situation where the best-trained and best-motivated caregiver would have difficulty in being sensitive and responsive to all infant signals.
The interesting point about these studies of the Metera is that although there was little question that the institutional babies fared less well than home-reared babies did, the authors did not attribute the problems to any single factor, particularly not to institutionalization in and of itself. On the contrary, they looked at characteristics of the infants’ pre-birth experiences and at specific characteristics of the institution as possible causes of poor development.
The recent research on which CHIFF and the UNICEF recommendations depend is the Bucharest Early Intervention Project (BEIP), conducted by the eminent child psychiatrist Charles Zeanah and many collaborators, and reported in a growing number of publications. The BEIP research is unique among investigations of institutional effects on children in that it involved a randomized controlled trial (RTC), the highest level of research design, and one which does much to assure that outcomes are caused by the treatments the children experience, rather than by other unknown factors. As described by C.H. Zeanah, N.A. Fox, and C.A. Nelson in 2012 (“The Bucharest Early Intervention Project…”, Journal of Nervous and Mental Disease, 200, pp. 243-247), this project worked with 136 children 6-31 months old who were being cared for in Romanian orphanages. Children were assigned at random to remain in the institution where they already were or to go to a foster home.
BEIP authors have given clear descriptions of the resources poured into the foster homes. The work included establishment of a foster care network, as well as training of social workers who would oversee and encourage the development of relationships between the foster children and their caregivers. The social workers also received weekly consultations with expert psychologists in the U.S. It is notable, by the way, that the training and resources involved here were probably a good deal greater than those available to foster parents in the U.S. or the U.K.
Publications on the BEIP have given much less detail about the experiences of the children who were randomized to institutional care. It would be of much interest to know details of these experiences such as the ratio of infants to caregivers or the sizes of groups (these factors generally being considered to have strong effects on the outcomes of day care). The 2012 article by Zeanah et al references the well-publicized appalling conditions in Romanian institutions for children following the fall of the Ceasescu regime in 1989, but does not provide much information about ways in which orphanages might have changed (for better or worse) in the ensuing period. This lack of information about the experiences of the children randomized to the institutional treatment arm makes it difficult to know what factors actually differed between the two groups, and to what extent they were different.
An additional difficulty of design has been pointed out by Douglas Wassenaar, writing in Infant Mental Health Journal in 2006. Wassenaar noted a problem of scientific validity in the BEIP study: the fact that evaluators should have been, but were not, “blinded” to (unaware of) the treatment being received by each child, for “both the ‘soft’ psychosocial evaluations, which are notoriously subject to rater bias, and some of the more ‘objective’ physical evaluations”. Wassenaar also pointed out that this matter should have been discussed by Zeanah and other BEIP authors, as an important issue with respect to confidence in the conclusions, “particularly in view of their expressly stated bias favoring deinstitutionalization”.
In spite of these difficulties and criticisms, BEIP participants (and many others) have continued to state general conclusions that the project has shown the advantages of foster care over institutional care for young children. Fox et al, in the Journal of Child Psychology and Psychiatry in 2011, stated that children raised in institutions exhibit lower IQ scores than those raised in family settings.
However, even setting Wassenaar’s concern about blinding aside, it’s necessary to question what the BEIP data actually show. Is it not that children who were in high-quality, resource-rich foster care did better than children who were in institutions whose quality was not clearly described but may have been abysmal? Is the conclusion not that a particular group of children, in one set of conditions, did better than another group, in a specific other set of conditions? Those conclusions are a far cry from saying that institutions are “toxic”, and that all possible institutional variants are harmful in comparison to all possible variants of adoption or foster care (including, perhaps, “mega-families”). The latter statements smell strongly of the “expressly stated bias favoring deinstitutionalization” mentioned by Wassenaar and evident in CHIFF and other proposals.
What would have happened if the training and resources lavished on the foster homes were also provided for the Romanian institutions? That’s the question that must be answered as a step toward understanding whether institutions are “toxic” (and I would like to see that sensational “toxicity” metaphor abandoned, as it distracts from rational discussion). Until we have further information, it will not be time to say that science supports one view or another of care for children without parental care. When such statements are made, they should be recognized as the ideological positions they actually are.
Monday, January 13, 2014
After I commented on some recent discussions of breastfeeding for adopted children, Karleen Gribble, of the University of Western Sydney , responded and sent me a copy of her paper “Post institutionalized adopted children who seek breastfeeding from their new mothers” (Journal of Pre- and Perinatal Psychology and Health, 19(3), 217-235). I’m going to comment on Gribble’s paper today.
Let me say first that I’m thrilled to see more observational work on care events in infancy and childhood. I consider this to be a much-neglected topic, and exactly what happens during breastfeeding-- including the many variations-- is rarely given systematic attention. I attempted to do some data collection of my own some years ago, but unfortunately La Leche League (it was at one of their functions that I was observing) was not willing to give permission for this. I also vividly recall being roundly scolded by the journal editor Marc Bornstein for submitting a comment that proposed more such work. I confess that I have not been entirely evidence-based or free from speculation about breastfeeding interaction (www.psychologytoday.com/blog/child-myths/200906/breastfeeding-speculating-wildly), but this is an area where knowing what to observe depends partly on thinking through one’s own experiences and other people’s stories. Nonetheless, it’s the observation rather than the speculation that we need to attain.
In considering Gribble’s paper, it’s important to look first at the a priori assumptions it contains. The author refers frequently to breastfeeding as a causal factor in attachment and attunement, but at the same time concludes the paper by noting that attachment may need to precede breastfeeding. (It is not clear whether this implies that newborn infants who breastfeed must already be attached to their mothers.) In addition to Gribble’s statements in the paper, we need to look at the reference section and see what authors she considered to provide appropriate background for her work; these include Deborah Gray, Mary Hopkins-Best, Terry Levy and Michael Orlans, and Nancy Thomas--- all people committed to an alternative theory of attachment rather than to Bowlby’s conventional psychosocial approach. In line with this background, Gribble references the so-called “attachment cycle” as a series of experiences that cause emotional attachment (see http://thestudyofnonsense.blogspot.com/2012/08/parsing-attachment-cycle-fox-terrier-of.html for a discussion of this issue). Like other authors who publish in JPPPH, Gribble also references ideas about children’s memories of birth and early life. All of the assumptions displayed here suggest that Gribble is very ready to accept the belief that unconscious, biologically-driven motives and behavior patterns play powerful roles in children’s development even after the first few months of life have passed. She quotes a mother as saying that her child’s need to suck was ”primal”, exemplifying the belief I have just described, and suggesting strongly that some human maternal and child behaviors are best seen as instinctive.
The assumptions I have just described are in contradiction to established conventional views of early development (and of course such conventional views can turn out to be quite wrong, but it has yet to be shown that they are wrong). Conventionally, feeding modes are not considered to be important to development of parent-child relationships, although a parent’s sensitivity and responsiveness to infant feeding cues are important, just as they are in every other area of parent-child communication. Neither is skin-to-skin experience thought to play a strong role in establishing emotional relationships. Infants are not considered to have an attachment to anyone at the time of birth, nor are they thought to have memories of birth or of early life. Biologically-determined infant social reactions are thought to be paramount in the early months, but after that learning from social interactions begins to take over. While initially biological, modes of communication become a matter of learning and therefore are strongly culturally influenced rather than instinctive.
Understanding the assumptions of Gribble’s paper, and the ways they differ from the foundations of conventional approaches to early development, let’s go on to look at the information reported about adopted children wanting to breastfeed. Gribble reports information about 32 adopted children, of both sexes and a range of ages (ages at placement= 8 months to 12 years) and separation histories, whose adoptive mothers stated that the children asked for breastfeeding or signaled that they wanted to breastfeed. It is not clear how many of the mothers were actually interviewed by Gribble, as some of the cases were said to have been reported by social workers or drawn from published material. In addition, it is unclear what sex ratio was involved; of the five interviews reported by Gribble, four of the children were girls.
Gribble’s paper provides an interesting beginning for discussion of children’s motivation for adoptive nursing, but a much better context is needed before we can interpret this report. For example, the Wikipedia article on adoption in Australia states an average of 330 intercountry adoptions per year (the children in Gribble’s study were adopted from other countries). However, Gribble does not say over how many years her information was collected, so it is impossible to know whether the 32 children discussed were a very large or a very small proportion of similar adopted children.
In addition, Gribble does not state or even speculate upon the number of nonadopted children who, having been bottle-fed from the beginning, or having been weaned from the breast, later communicate to their mothers that they want to breastfeed. This is an important issue because of Gribble’s argument that adoptive breastfeeding facilitates attachment in children who have experienced separations. Nonadopted children have presumably had ideal opportunities to develop attachment and have not experienced serious separations, so if they signal their wish for later nursing in the same proportions as adopted children, it is hard to see what the emotional motivation for this behavior would be. A full understanding of the phenomena reported by Gribble awaits information that would permit this comparison.
Another important unanswered question is the role of the adoptive mother’s beliefs, expectations, and caregiving behavior in creating the child’s interest in breastfeeding. Gribble has pointed out elsewhere that mothers are not likely to provide information about the atypical behavior of adoptive breastfeeding unless they trust their confidant; this suggests that the mothers have a belief system that is not entirely shared by most other people. Gribble states a belief that skin-to-skin contact is important for attachment, and describes a mother who “used skin-to-skin contact via co-bathing and a cuddle time in the evening as a way of promoting attachment”. Mothers who share this belief provide opportunities for breast contact that would not occur in the Western world in most other situations or be presented by mothers who did not share the belief. Adoptive mothers who believe in the “skin-to-skin” and “attachment cycle” system may also accept the idea that breastfeeding is important for the mother-child relationship and therefore be exceptionally ready to read child behavior as a wish to nurse. (Gribble refers to sucking on clothing as such a signal, although mouthing and sucking objects is common childhood behavior, as often seen in school-age boys who like to chew on the necks of their t-shirts.) Interestingly, Gribble also describes children who sought to breastfeed as part of “birth games” played with their adoptive mothers, suggesting that she is focused on a group of adoptive parents who are committed to an alternative theory of early development-- not surprising in light of the journal in which the study was published.
The information Gribble presents is of great interest, and certainly should be kept in mind in cases where breast-touching by adopted children is regarded as “sexualized” behavior indicative of previous sexual abuse. (If Gribble’s reports are accurate, such behavior may not be an indication of sexual experience at all.) However, interpretation of the reported cases must await contextualization by information about other adopted children and about nonadopted children as well. Gribble’s extensive discussion of why adopted children seek breastfeeding is premature, because we have no idea whether they actually do so more than nonadopted children do, or whether their adoptive parents’ belief systems lead them to read child messages differently than they might otherwise do.
As a final comment, I want to turn to two sentences that Gribble places at the end of the article abstract and that she does not actually discuss in the body of the paper. The first sentence states that the “frequency of adopted children seeking breastfeeding is unknown, however adoption professionals should advise adoption applicants of the possibility”. Such advice, if it is being given, is certainly likely to increase the number of cases where mothers interpret ambiguous behavior as bids for breastfeeding.
In a second sentence at the end of the abstract, Gribble makes the following claim: “It may also be appropriate for adoptive mothers to pursue breastfeeding in the event that the child does not.” Nothing in the paper provides grounds for this claim, and it is most concerning to think that a group of parents who have already (as Gribble notes) experienced various disappointments and losses should be offered an additional challenge when there is no evidence that it is necessary.
Tuesday, December 31, 2013
Yesterday I discussed some issues about adoptive nursing-- breastfeeding a child who is in one’s care but who was born to a different mother. I concluded that adoptive nursing can be valuable for the health of very young babies or others who have poor immune reactions to infection, but that it is irrelevant to the social and emotional development of the child, and relevant to mothers’ emotions only in that they may expect it to influence their relationship with a child.
Today, I want to look further into advice about early emotional development as it is given by proponents of adoptive nursing like Alla Gordina and Karleen Gribble. These authors, as well as Gordina’s colleague Ronald Federici, propose that it is essential for adopted children to experience complete dependency on their new parents. For example, Gordina says in her PowerPoint presentation (www.wiziq.com/tutorial/693267-ADAPTIVE-NURSING-APC): “Promote dependency on you providing food for your child (hand/finger feeding by caregiver even for snacks, feeding/drinking in the breastfeeding position and/or on caregiver’s lap, bottle feeding, eye contact, etc”. She also says (without further explanation in the PPT): “Not to give such a child a sippy cup; use a bottle with the hole as large as the child needs, slowly decreasing the opening; straw cup or a regular cup can be used too”. Bottle-feeding for all ages is encouraged.
What is the reasoning here? Why would either breastfeeding, or continued bottle-feeding of an older child, be expected to benefit the child’s emotional development? This viewpoint, shared by Gordina, Gribble, Federici, and others, seems to be part of a naïve psychology that expects imitation or re-enactment of desirable events of early life to have positive effects, as if they had really occurred early on. This is a form of magical thinking in which symbolic actions are “mapped’ onto actual events, and the outcome of a ritual is expected to be the same as the outcome of the real occurrence. Similar thinking can be found in various alternative psychologies and psychotherapies like the screaming and convulsing of “primal therapy” and the apparently-painful infant massage done by people like William Emerson.
Specifically, the rationale for associating breast- or bottle-feeding with attachment would seem to be the following: Young infants who are breastfed or bottle-fed are completely dependent on their caregivers and indeed would not survive without adult care. Such infants are still completely dependent some months later, when they start to show signs of attachment behavior to their familiar caregivers. Therefore (and here’s the tricky part), the dependency must have caused the attachment-- so, if dependency can be fostered in an older child, that child will also show attachment as infants and toddlers do. In addition, if that child can be made to appear like a dependent young child by replicating breast- or bottle-feeding or other infant care routines, he or she will actually BE dependent, and therefore (again) become attached and show this as younger children do.
When the rationale is spelled out like this, it’s clear that it resembles the thinking behind rituals like the couvade or like spitting if someone compliments your child, so evil spirits won’t get interested.
But there’s more. Looking at remarks by Karleen Gribble (https://www.breastfeeding.ans.au/bf-info/adoption), we can see another reasoning problem behind some of the claims of adoptive nursing advocates. Gribble says: “…it is important to bear in mind that the emotional and developmental ages of a child may be very different from their chronological age and that breastfeeding can help nurture the baby inside the older body” (my italics-- JM). This view is common among “attachment therapists” and others whose work is not evidence-based, especially therapists who are focused on multiple personalities or dissociative conditions. The concept of independent entities within a personality has many sources, but the idea of the “Inner Child” was popularized in the 1970s as part of Transactional Analysis. The posited need to care for this entity goes back much further to “wild psychoanalysts” like Sandor Ferenczi.
The belief that some “inner baby” needs to receive care suitable for an infant is an aspect of a “parts” psychology that ignores the integration of components of any person. Of course a child may act in some ways as if he or she is younger than is chronologically the case, but this does not mean that the child has younger “parts” that need care different from what the whole child needs. To assume this ignores the whole nature of the child, and resembles thinking that a 20-year-old with an IQ of 50 would do well in a school class of 10-year-olds with IQs of 100, or that a 15-year-old who behaves “childishly” should be given a time-out.
An adopted 5-year-old may seem emotionally “young” or “immature” when he or she has trouble resisting temptation or tolerating frustration, but that child does not have an “inner baby” who needs special care. Instead, the child is a person with many typical 5-year-old abilities who is having difficulty mastering some emotional capacities. To treat such a child like a baby (unless this is what he asks for) is to dismiss his most mature capacities as if they did not exist, and thus to remove points of pride and the senses of autonomy and initiative that are characteristic of his developmental stage. This situation is similar to one in which the 5-year-old has difficulty using speech; high-pitched, repetitious infant-directed talk is suitable and useful for an infant to hear, but however poorly the older child may speak, he is beyond the stage when infant-directed talk will help him, and needs support that is appropriate for his entire developmental picture.
Again, I want to be clear that I am not rejecting adoptive breastfeeding, and I believe it can be very appropriate for babies with some medical conditions or with poor immune reactions. However, the social and emotional reasons claimed for it are without grounds.
One final point: Gordina’s PowerPoint gives one piece of advice which I wish could be given to all parents, adoptive or otherwise. She says, “Not to stare on your child, while he/she is eating unless you and he/she are ready to initiate the eye contact”. I’m not too sure what that last part means, or how you would know this readiness, but I’m convinced that the anxious stares of parents have exactly the opposite effect from what’s wanted. Babies don’t like blank or frightened-looking faces and are likely to avert their eyes and avoid looking at a staring adult. If you find you are staring, try “flirting” instead-- look away, glance back, look away again, and keep smiling until the baby gets interested in you. That’s how you get relationships rolling.
At the end of the war in Vietnam, there was some publicity about the fact that staff caring for babies who were to be airlifted to the U.S. took medications that caused them to lactate so they could feed infants in the absence of their usual food supplies. Over a number of years, there has been increasing emphasis on the idea that adoptive mothers can breastfeed their babies-- and that if at all possible they ought to do so. One person who has pressed this idea is Alla Gordina, a Russian physician who practices in New Jersey. A PowerPoint by Gordina can be seen at http://www.wiziq.com/tutorial/693267-ADAPTIVE-NURSING-APC.
Although she includes in the PPT instances where an adoptive mother was unsuccessful or unhappy with breastfeeding, Gordina stresses the benefits of adoptive nursing and focuses on social and emotional as well as biological factors. She refers to the practice as “adaptive nursing”, followed by “TM”, so it would appear that she has trademarked this term (?). Her PPT lists some of the advantages of adoptive nursing in the following order: promotes secure attachment and trust; augments their sensory and physical development; provides a therapeutic effect on the correction of oral deficits and/or aversions.
Gordina discusses a number of general practical issues about feeding children adopted from institutions where they might have received poor care, including fears they may have if they have been fed roughly or insensitively. These are important considerations, but my concern today is to discuss the statements she makes about the social and emotional aspects of breastfeeding.
- Breastfeeding and attachment. Emotional attachment of young children to their caregivers is based not on food but on the sharing of pleasant social interactions and play. For young infants, most of those interactions ordinarily center around physical care routines, including feeding. These are the events that happen most often in the infant’s day and are always a time when another person is present to socialize (except when people prop bottles, but let’s not think about that). They are also times when the caregiver is focused strongly on the infant and is not doing much else, although of course there may well be side activities, conversations with others and so on. Pleasant social interactions often occur during feeding, when the baby eats enthusiastically and the caregiver is pleased to see this.
However, it makes no difference to social interaction whether the young child is breastfed or not. Any feeding method or routine can be linked with pleasant shared experiences and communications. These are the real basis of attachment: attachment is not the “cupboard love” proposed in the past, but involves satisfaction of a hunger for social contact. Otherwise, young children would not become attached to their fathers, brothers, sisters, grandmothers and fathers, nannies, and child care providers-- which they do.
Initially, attachment is shown as a sense of safety and security associated with familiar people, and many authors, including Gordina, have jumped to the conclusion that attachment at all ages is shown by “staying near”. But as children get older, their attachment to adults is expressed in terms of new developmental needs such as needs for autonomy and the ability for independent actions. Pleasurable experiences with adults involve children’s pride in their new abilities, not the sense of happy dependency that was evident earlier. Bowlby’s attachment theory stresses the growth of a “goal-corrected partnership” in which the maturing child and the parent gradually shift their ways of interacting to satisfy the developing needs of both and to preserve their relationship-- not simply to preserve dependency.
(It’s interesting, by the way, that Gordina refers to the possibility that adopted children will have “Developmental Trauma Disorder”, a diagnostic category that remains poorly defined and “unofficial” in spite of recent attempts to bring it into use. )
- Breastfeeding and bonding. The term “bonding” is best used to describe the powerful positive feelings and intense interest of a parent with respect to a young infant. Writing decades ago, Klauss and Kennell originally used the term “maternal-infant bonding” to refrer to this, but for the second edition of their book chose the term “parent-infant bonding”. In that second edition, they also attempted to correct the misunderstanding that bonding occurred instantaneously for all parents or even for mothers alone, or that all aspects of the parent-child relationship were somehow determined by some bonding event soon after birth.
Nevertheless, quite a few people continue to assume that some event pushes a button, which causes bonding, which in turn causes good parenting. The events that push the button are usually expected to be related to “primitive” or “traditional” folkways. They include an emphasis on skin-to-skin contact and of course on breastfeeding immediately after birth (although in fact a number of “traditional societies” do not let the baby nurse at once and regard colostrum as dirty, and many others have traditionally swaddled the newborn, making skin-to-skin contact minimal). The actual association of such experiences with parental attitudes and with effective parenting has never been demonstrated. It seems most unlikely that there are such associations, as human beings care for and feed infants in a wide variety of ways, usually with good outcomes-- just as they feed both children and adults on a wide variety of diets.
It’s thus improbable that breastfeeding causes bonding. However, if mothers are told that they cannot do a good job caring for their infants unless they breastfeed, wear purple for the first year of the child’s life, or play pinochle regularly throughout the third trimester, they are likely to believe these things because of their strong wish to do well. If they are told that breastfeeding will make them bond, and that without it their feelings for the child will be fragile, they will be distressed by any “failure” they experience.
Gordina’s presentation notes the needs of adoptive mothers who have been distressed by infertility, miscarriage, or infant death, and suggests that successful adoptive nursing can help them recover from these traumatic experiences. She does not support this statement with evidence, nor does she examine in this PowerPoint the possible effects of lack of success either in lactation or in nursing. Given a mother who has never breastfed or even been pregnant, and a baby who has learned to suck an artificial nipple (a different suck-swallow pattern than is used at the breast), the chances of experienced failure can be pretty large.
- Breastfeeding and older children. Gordina’s PowerPoint references Karleen Gribble, an Australian nurse who has apparently recommended breastfeeding for adopted children as old as school age, and who says that it may take as much as a year for breastfeeding to be accomplished (https://www.breastfeeding.asn.au/bf-info/adoption). Curiously, Gribble also notes that a child may need to attach before being abIe to nurse, but that at the same time nursing supports attachment.
I am far from opposing toddler nursing or even culturally-appropriate nursing of older children who have been at the breast since birth, but there are some obvious difficulties for children who were bottle-fed from an early age. One is, as I mentioned in the last paragraph, that these children have learned to suck and swallow differently when using a bottle than they would have if breastfed exclusively. (If the latter, of course, they would not have learned how to nipple-feed and could have a difficult time adapting if suddenly weaned from the breast before they drank from a cup.) A second problem is that most children learn by preschool age that breasts are “private parts” and are not to be touched—most adoptive parents, in fact, would be very concerned and speak of sexualized behavior and even a history of sexual abuse, if a child touched the adoptive mother’s breasts.
Incidentally, Gribble and Gordina both allude to adopted children showing their wish for breastfeeding, but they give no details that I can find, nor does there seem to have been any systematic investigation of this issue.
So, am I saying that there is never any good reason for adoptive nursing? No, indeed. Breastfeeding has some real physical benefits in terms of development of the jaw and resistance to infectious diseases. The breastfeeding mother’s mature immune system serves as an auxiliary support to the immature infant’s reaction to infection, and this can be very important for babies who are poorly nourished, exposed to many infections, or in a dirty environment. When breastfeeding can be established for the young adopted baby, there will be real physical health benefits. It’s also beneficial that a mother enjoys nursing and that families may regard the nursing relationship as a more “real” connection than any other.
But what about attachment, security, and other emotional benefits? No, these are not reasons to do adoptive nursing, because they are not based on breastfeeding in any case.
Tomorrow, I want to go on to talk about some of Gordina’s views on the need for child dependency, and on her connections with other authors like Gribble who propose that older children need to be treated as if they were infants.