Tuesday, December 24, 2013

Stress

It seems like everyone's talking about stress lately. As a society, we have encouraged people to fill every bit of free time with something productive, to skip out on sleep in exchange for coffee so we can work more hours in a day, to just keep going and going with no chance to stop and 'smell the flowers'. (What's so great about flowers, anyway? They just smell like plants to me.) And more and more, we're paying the price. Obesity, heart disease, diabetes, depression, anxiety disorders, autoimmune conditions - there is a long list of conditions that are caused or exacerbated by stress. We ignore stress at our peril.

Stress has also been a big part of my life. When I was 10 months old, my parents became foster parents to two very disturbed, abusive children. For the next four years, I experienced stress far above what most people will ever experience, to the point where the stress literally rewired my brain, causing Post-Traumatic Stress Disorder.

When my foster siblings were out of my home, my stress continued. Now, it was a school that expected a normal, compliant child, and got a quirky, imaginative and traumatized child instead. Instead of showing sympathy and understanding, they put more pressure on me, assuming I'd bend before I broke. I didn't - I couldn't - and my PTSD got worse.

My peers joined in on it, too. For whatever reason, schools seem to breed a desire to single out one child for torment, and that child was usually me. Every school day was just something to survive as best as I could, desperately shoring up my wall as they tore it down.

By the time my parents decided to homeschool me, I knew all about stress. I knew that enough stress could tear me apart, and any coping measure could eventually be worn down. I knew that stress could eventually kill a person. But now, I finally had the chance to avoid stress altogether.

And I did. For the next three years, I stuck to my safety zone - my family, my interests, my reading. I learnt a lot of facts, but faced few challenges. I played it safe, and that gave me space to heal.

But I have big dreams, and I believe I can make a difference. So I cautiously stepped back into the world of stress. I've tried things I was afraid to try. Some have turned out badly, others much better than I expected. I've grown a lot in the past few years.

But I know better than to ignore stress. I'm still too wounded to cope with very much of it, and even if I could, it would cause damage that is harder to see, like it does for many 'normal' people. So I move carefully, looking ahead at my goal, but also watching my stress level. If it gets too high, I take a break.

I'm forced to pay attention to stress. When I ignore it, I end up crying and screaming, lost in the depths of terror and despair. But maybe, my inability to cope with stress has a bright side as well. I know better than to push past my limits - something most 'normal' people seem oblivious to.

Tuesday, October 15, 2013

Autism or Measles?

Let's say, for the sake of argument, that the anti-vaccination people are right - vaccines do contribute to the development of autism in susceptible children. Let's say, for example, that 90% of autistic children would not have been autistic if they had not been vaccinated. And let's say we have no way of knowing ahead of time which children are going to get autism from the vaccine.

A rational person would still vaccinate their children. Here's why:

The Risk is Low

Firstly, the risk is still pretty low. Some estimates put the rate of autism at 1 out of 88 children. This is a little over 1%. In other words, even if vaccines cause most or all cases of autism, around 99% of vaccinated children will not get autism. And this is not just the risk from one vaccine. This is the risk among children who get all the recommended vaccines. Either there's only one or a few vaccines that cause autism and the others are safe, or the risk from any one vaccine is pretty miniscule indeed.

Admittedly, if you live in a high-vaccination country, your child's risk of being exposed to many of these illnesses is also low. It will also vary, depending on how many people in your social group visit countries with low vaccination rates, and the actual percentage of immune people in your social circle. It's especially high if your child decides to travel themselves, or if you take them travelling with you.

It's Not Just Your Risk

If your child suffers an adverse reaction to vaccines, they're the only one who'll get sick. But if you leave them unvaccinated and they get a vaccine-preventable viral illness, they could potentially spread it to anyone in contact with them.

Even in a high-vaccination country, not everyone will be immune. Some children are too young to have been vaccinated yet (for example, less than 18 months for the MMR). Some people have medical problems that mean they can't handle and/or won't benefit from vaccination, such as immune disorders. And some were vaccinated, but failed to develop immunity or lost their immunity later on (no vaccine is 100% effective).

With many illnesses, you could even spread it before you know you're infected. For example, a person infected with measles is contagious for four days before the rash appears. Even if you get prompt diagnosis, you might already have transmitted measles to someone in your social circle. If you get a delayed diagnosis, you could be contagious for up to four days after the rash appears, as well. Measles is transmitted as easily as any cold, if not more easily. When you talk, sneeze or cough, you'll leave virus in the air that can linger for up to two hours afterwards. (So you could even transmit it to someone without meeting them!)

If it were only parents of autistic kids who were afraid of vaccinating their children, this wouldn't be that big an issue. Younger siblings of autistic kids are a pretty small proportion of the population. But anti-vaccine parents are often quite open in expressing the belief that their child's autism was caused by vaccines, and many of them also over-emphasize the negatives of autism as well. Many people in their social circle may choose not to vaccinate on their recommendation. Worse yet, there are people talking publicly about vaccines causing autism, in some cases leading to people who've never even met an autistic person avoiding vaccination. We know that even if vaccines do cause autism, close to 99% of children can be vaccinated without getting autism. It's completely unnecessary for these people to avoid vaccination, and the lower the percentage of immunity in a population, the greater the risk of an epidemic.

Some of These Diseases Cause Autism Too

If vaccines can cause autism, you may reduce your risk of autism by not vaccinating. But you won't eliminate it, because vaccine-preventable illnesses have also been linked to autism.

For example, the MMR vaccine protects from three diseases - measles, mumps and rubella. All three of those diseases can cause autism.

The strongest link is with rubella. A child or adult who gets rubella will generally suffer only mild symptoms - flu-like symptoms as well as a rash - and many people don't even notice that they've been infected. However, if a woman gets rubella during the first 20 weeks of pregnancy (possibly even before she knows she's pregnant), her child can develop congenital rubella syndrome.

Unlike rubella, congenital rubella syndrome is quite prominent. The classic triad consist of deafness, eye abnormalities and heart defects. In addition, children can develop a wide range of other symptoms, including mental retardation and autism. So if you don't vaccinate your daughter against rubella, you could have a grandchild who is autistic due to congenital rubella syndrome.

Both measles and mumps can develop into viral meningitis or encephalitis. Meningitis refers to an infection of the mesh surrounding the brain, while encephalitis refers to an infection of the brain itself. Both of these complications can be fatal, and if the patient survives, they could suffer permanent brain injury. In addition to blindness, cerebral palsy, seizures, mental retardation and learning disabilities, autism is also a potential effect of this brain damage.

Autism is Not Worse Than Death

Many of these vaccine-preventable illnesses can be fatal. And this, alone, should mean that we'd take autism over those illnesses. But unfortunately, the idea that disabled people are better off dead didn't go away with the end of formal eugenics movements.

Because autism is the tail end of a bell curve, the majority of autistic people are mildly affected. Mild autism means struggling with social skills, and potentially with anxiety, executive functions, sensory processing and/or specific academic areas, but having a normal IQ and certain areas of strength. Many people in this range are highly successful, by many of the conventional standards of success. There are professors with mild autism, for example.

And secondly, even severe autism does not mean a pointless life. If given the right accommodations, a nonverbal child in diapers has as much potential for a happy life as anyone else. They can love and be loved and they can have fun. And that's what matters most. If you can do that, there is no way you'd be better off dead, no matter what you can't do.

Monday, September 30, 2013

Comparing Apples and Oranges

I came across this article, and I just had to respond. So I sent off this email to both of the authors.
I read your article regarding the criminal culpability of successful vs unsuccessful psychopaths, and I would like to point out that you showed a common misunderstanding of the nature of autism.
The term 'empathy' is used to describe three broad domains of social ability -- social perception, social cognition and emotional empathy. Autistics and psychopaths have distinctly different profiles across these three domains.
Social perception, the ability to recognize and interpret facial expressions, is impaired in both autism and psychopathy, although the impairment is more severe/generalized in autism.
Social cognition, the ability to infer what others think or believe, is impaired in autism, but not in psychopathy. Indeed, in order to be competent at lying and manipulation, an individual must have intact social cognition (many autistic individuals can't lie, and those who can are often quite poor liars).
Lastly, emotional empathy refers to experiencing emotions that are more appropriate to your perception of another's situation, rather than your own situation. It is important to note that accurate perception of another person's situation can be affected by social perceptual and social cognitive abilities. However, when studies ensure that the autistic individual is aware of another's person's emotional state, they show emotional empathy at a typical level. In contrast, psychopathy causes a severe deficit in emotional empathy.
With regards to the moral/conventional distinction, research has shown that autistic individuals are not using a simple rule of 'actions that cause distress are wrong'. Specifically, when the person's distress is unjustified (such as a child crying over not getting an extra share of a fairly-distributed resource), autistic children, like typical children, do not have much sympathy for the 'crybaby'. There are also many anecdotal examples of high-functioning autistic adults presenting moral arguments that use basic principles of morality while going against the rules they were taught about behavior. The debate about treatment of autism is a clear example, with many autistic people who underwent typical treatment practices arguing that these practices are wrong because they cause harm. (See this blog post as an example.)
Comparing successful psychopaths to high-functioning autistics is like comparing deaf people to blind people - they may both have sensory (or social) disabilities, but the nature of their difficulties is completely different.

[PS: Actually, comparing apples and oranges is not actually an example of what that idiom is generally used to mean. Apples and oranges have a lot in common, since they're both fruit. They are both sugary gifts from plants intended to entice animals into distributing their seeds in a little pile of fertilizer.]

Sunday, September 08, 2013

Why Would I Hate You?

Recently, I came across this wonderful documentary on FASD. When I was watching it, at first I was expecting it to be the usual thing of adoptive and foster parents talking about how awful their child's birth mother was and how she damaged their child. But in fact, every mother in this documentary is a birth mother of a child with FASD, and the focus is on accepting the fact of FASD, owning up to the effects of their drinking, and getting the right help so they children can do the best they can do.

What I found particularly striking was the accounts that mothers had of explaining to their child that he or she had FASD, and it was caused by their mother drinking during pregnancy. Firstly, as a person with a developmental disability, I would like to point out how important it is, to the disabled person, to know that there's a name for their condition, they aren't alone, and it's not their fault that they're struggling with things other people find easy. For anyone with a developmental disability, if they have enough verbal skills to understand what you're saying, it is helpful to talk openly to them about what they have and how that affects them. (And even if you think they don't understand, to be on the safe side, talk to them about it anyway. You never know if they might understand more than you realize.)

But for a biological mother to tell her child about FASD must be especially tough. From the child's perspective, it's an explanation for their struggles, but from the mother's perspective, it's an admission of guilt. It's clear, from these mothers' accounts, just how tough it was to tell their children about FASD. One mother even said: 'I told Faith that I wouldn't blame her if she was so angry with me that she never wanted to talk to me again.'

Her daughter's response was probably not what her mother expected: 'Mom, why would I hate you? Why would I be angry with you? You didn't drink because you wanted to hurt me, you drank because you didn't know any better. I'm just glad to know that I'm not stupid.'

Her reaction is typical. None of the mothers who reported telling their children about FASD seemed to have gotten a negative response. In every case, the FASD person immediately forgave their mother. They didn't hold any resentment. And although it clearly took their mothers by surprise, and probably took many other people by surprise too, it really doesn't surprise me.

Firstly, research has shown that, compared to self-reports, other people consistently underestimate how happy a disabled person can be. There is this perception that having a disability is this horrible, devastating thing to deal with, and this is simply not borne true in the actual experience of living with a disability. Although some disabilities are certainly easier to deal with than others, most are far better to live with than most people think. And this is especially true for congenital disabilities, where the person has never known any different, never lost something they've come to count on. FASD is a congenital disability, so the person with FASD has never experienced life without FASD. It's hard to miss what you never had.

FASD is also a developmental disability. And I know, as an autistic person, how developmental disabilities affect characteristics that are basic to your identity. I can't hate autism without hating myself, and I suspect this is true for most developmental disabilities - if the person truly understands the pervasiveness of the disability's impact.* So if an FASD person has a good self-esteem, chances are they don't hate having FASD. Why would they resent someone causing it?

Then, there's the easy understanding of addiction. I don't know what it's been like for those kids, growing up, but I suspect for many of them, this is not the first time they've heard their mother talk about alcoholism. Depending on when she stopped drinking, they may even have seen her drinking, and seen her in the early stages of recovery. They've learnt from the start that alcoholism is a disease and not willful behavior, just like my brother and I learnt early on what PTSD was and how people might really be reacting to a past event that vaguely resembles the current event. If alcoholism was talked about as openly in their families as PTSD was in mine, they'll understand already why their mother drank.

Even if it wasn't, I suspect some of the characteristics of FASD may make understanding addiction easier. In particular, FASD impairs executive functions. As someone with executive dysfunction, I'm continually surprised at how much people think other people can control about their behavior. I'm so used to having difficulty controlling my own actions, it makes it a lot easier for me to imagine someone else doing something they don't really want to do. Addiction, therefore, is likely to make intuitive sense to someone with executive dysfunction - it's another kind of loss of control. I may not have had an addiction, but I have missed appointments I really wanted to attend, and been late for classes I enjoy, and lost objects I really wanted to keep. I know that desire is not the only determinant of behavior. And people with FASD probably know this too.

And lastly, there's someone they love and cherish. She's admitting a wrong she did to them, and she's clearly very sorry about it. In fact, judging from the emotional reactions that merely recounting the conversation provoked, I'm guessing most of these mothers were crying as they told their children about FASD and how they caused it. There's the person they love, crying and apologizing. It would take a pretty strong resentment for them not to want to comfort her and make her feel better.**

* I've seen some autistics people who think autism is just sensory overload and stimming. Those traits are fairly peripheral to identity, and you can hate those without hating yourself. (I hate sensory overload - I don't think it's possible not to hate it.) But when it comes to things like how you think and feel, that's a different matter.

** Or psychopathy, but the available research shows no association between psychopathy and FASD. Although reactive attachment disorder can cause psychopathic-like traits, most of these kids have probably not gone through enough to cause RAD. They were lucky to have mothers who got into recovery and have taken fairly good care of their children.

Tuesday, September 03, 2013

Overweight People in Wheelchairs or Scooters

[Note: This is aimed primarily at people outside the disability community. Most of this stuff should be familiar to many disabled people and their supporters.]

Many people are unable to walk, and use wheelchairs or scooters to get around. There are also many people who can walk - at least a few steps - but with difficulty. If their walking is poor enough to seriously impede their everyday living, a wheelchair or scooter can make a big difference to their lives. Even if a person can walk, if they don't have the endurance to walk as much as most people do in an average day, or if they often suffer falls causing serious injury, they still need a wheelchair or scooter.

A manual wheelchair requires that the person grab the wheels and push them. It can be used by someone with good upper body strength (such as a person with a spinal injury low enough to leave the arms unaffected). Some people do not have the strength or coordination to use a manual wheelchair, even if they can use their hands for other tasks. Some people can use a manual chair, but don't have the endurance to use it all day. Those people can use a motorized wheelchair or a scooter if they need to do a lot of traveling.

For the most parts, motorized wheelchairs and scooters do the same sort of thing. Both are mobility aids that allow a person to get around without having to stand up and walk. A scooter is more often used by people who can walk short distances, because it's easier to get in and out of than a wheelchair. However, it can often be more a matter of personal preference than type of disability, and some people use both wheelchairs and scooters at different times. Many people tend to react differently to a wheelchair as opposed to a scooter, but in reality there is not much difference between them.

People who use wheelchairs or scooters have the same variety of features as people without disabilities. Some are short, some are tall. Some have blond hair, some have darker hair. And they can range in weight just as much as non-disabled people do, for the same reasons. In many cases, their weight has nothing to do with their disability.

Lifestyle can play a part in weight, but it is far from the only factor. Many medical conditions can cause a person to become overweight, such as hypothyroidism, diabetes, kidney failure, Cushing's disease (affecting the adrenal glands) and many more. Although a few of these conditions can be affected by lifestyle, most are predominantly genetic. In addition, normal variation in genes can also contribute to differences in body weight, with some people naturally predisposed to gain weight more easily. Just because someone is overweight does not necessarily mean they eat too much or get too little exercise. Furthermore, although severe obesity is dangerous to a person's health, many people think someone is somewhat obese when their weight is in fact healthy. Especially for women, our ideals about weight are often unrealistically low, and many people who are considered appropriately skinny are actually endangering their health by being underweight.

In some cases, a person's weight and their mobility impairment may both result from the same medical condition. For example, diabetes can cause a condition known as diabetic neuropathy, which can cause difficulty walking. There are many other examples where a metabolic disorder can cause both weight gain and mobility impairments. In the majority of these cases, the person would still have a mobility impairment if they lost weight.

Inactivity can also contribute to gaining weight. While most people don't exercise as often as they should, for people with mobility impairments, it can be considerably harder to get enough exercise. Due to their disability, they spend most of the day sitting, while other people are walking around. And many people with disabilities need specialized equipment and/or trained personnel to help them exercise, making exercise more expensive and inconvenient for them. (And if an untrained person tries to assist them, this can sometimes result in injury - for example if they try to stretch a limb that can't stretch as much as normal.)

Many people, when they see an overweight person using a scooter, they assume the person is too lazy to walk. But there are many different reasons why a person, overweight or not, may need to use a scooter, and many disabilities are not readily visible, especially if you're not a trained medical professional. You should never assume that you know why a person is using a mobility impairment unless they themselves have told you. And if you're a stranger to them, you have no right to expect them to explain their disability to you.

Wednesday, July 24, 2013

What Disabled Pets Can Teach Us

Most people assume that having a disability tends to make someone unhappy. When a disabled person appears happy, the rhetoric about them tends to describe them as either 'putting a brave face on it' and acting happier than they really are, or else as choosing to be happy despite the disability - overcoming the disability, or 'not letting it slow them down'.

Well, those are testable interpretations. In particular, both faking emotions and choosing to consciously alter your emotions are cognitive skills. Developmental psychologists have documented the emergence of both skills in the late preschool and early school years.

And both, as far as we can tell, are uniquely human. Even chimpanzees tend to feel what they feel and show it outwardly, with only clumsy and ineffective attempts at disguising their true feelings. Even this rudimentary deception is a rare skill among non-human animals. For example, apart from instinctively hiding signs of pain, dogs and cats show virtually no ability to disguise or control their emotions (apart from the most basic emotion control strategy of 'go get what you want', of course). Dogs wear their hearts on their sleeves, and while cats can be fickle, they are never two-faced.

(Incidentally, for those of you who need to be told - dogs and cats do have emotions. As best I can tell, they feel them as strongly, if not more strongly, than humans do. In particular, it is entirely possible for a cat or a dog to show depression. It's also possible for them to feel joy.)

So, if happiness among disabled people is either feigned or deliberate coping, then disabled dogs and cats - who can't hide or control their emotions - should show obvious misery. Do they?

Watch these videos:

http://www.youtube.com/watch?v=MFxQxg_As5o - Wiggles, a dog with a spinal or neurological issue impairing his motor coordination, most likely congenital. He is unsteady on his feet and has poor bowel control.

http://www.youtube.com/watch?v=qTij5uHGB7E - Julia ('Wonky'), a dog whose front tendons were shortened, causing her to walk on her front ankles instead of her front paws. Physiotherapy improved her issue considerably, but we can see both before and after videos.

http://www.youtube.com/watch?v=SIXrY68Pkl0 - Emma, a dog with a severe physical disability, greeting one of her humans after he returns from military deployment. Her hind limbs are stiff and her tail doesn't seem to move, but she can drag herself around with her front paws.

http://www.youtube.com/watch?v=DsKsEn6Xejs - A kitten, name not given, who lost the use of his hind legs after a car ran over him.

http://www.youtube.com/watch?v=TwGwzpeGSNo - Chairman Mao, a cat born with cerebellar hypoplasia. He has tremors and poor balance.

http://www.youtube.com/watch?v=lNpeTCEPrRk - Oskar, a kitten born without eyes, playing with a ball with a bell in it.

http://www.youtube.com/watch?v=0Ex3bbqrjBQ - Faith, a dog born without front legs who walks on her hind legs.

To those who can read the nonverbal cues that cats and dogs convey, the answer is clear. These dogs and cats, though clearly disabled, seem reasonably happy. They show joy readily, in situations where nondisabled cats and dogs would show joy. They are curious and explore their environment to a similar degree as other cats or dogs of the same age. And while they may get upset at times, they don't seem predominantly unhappy. In general, they show similar emotion to what a nondisabled animal would show in the same situation.

Another explanation for being disabled and happy, often applied to cognitively disabled humans, seems more likely for these cats and dogs - maybe they 'don't know they're disabled'. But what does it mean to 'know you're disabled'?

Well, if you watch their actions, these cats and dogs - like nondisabled cats and dogs - show an implicit understanding of what they can and cannot do. For example, unlike humans with anosognosia*, they don't try to support their weight on paralyzed or absent limbs. Many of them have learnt strategies to do activities in a way that circumvents their disability, such as the dog with no front legs walking bipedally. So they know what they can't do.

Although it's harder to tell from their behavior, it's reasonable to assume that, if they interact regularly with other cats or dogs, they know these cats and dogs can do things that they can't do. After all, it wouldn't be any harder than knowing that humans can open doors - and obviously most cats and dogs know that!

So, in the most basic sense of knowing they can't do things that other members of the same species can do, it certainly is possible for cats and dogs to know they're disabled. But is there another meaning to that phrase?

Well, for humans, disability means more than 'I can't do something that other humans can do'. I mean, I can't speak fluent Mandarin. I also can't pee standing up. Both of those are things that many other humans can do easily, but my inability to do them is not considered a disability.

There is a social concept of disability. The idea that certain abilities are skills you are supposed to have, skills you are somehow entitled to have, is the essence of this concept. And the lack of any of these skills puts you into a social category we call 'disabled' - a category of people who are supposed to be inferior and unhappy.

Dogs and cats, as far as we can tell, do not have a social concept of disability. Maybe that's why they're so happy, even when they're disabled.

* A condition, usually due to acquired brain injury, where a person is unaware of an obvious disability. For example, they may be paralyzed on their left side, but insist they can walk and use both hands. Furthermore, anosognosic patients often attempt activities that are impossible given their disability.

Friday, June 14, 2013

Attachment in Autism

In the psychoanalytic view, autistic kids were considered unattached. This was presumed to be due to having a cold, distant, 'refrigerator mother', who did not present the child with the possibility of forming an attachment.

It is now known that autism is not caused by parenting, but is rather a neurobiological condition with a substantial genetic component. However, some people still think autism inherently impairs attachment. See, for example, the following comment, posted over a year ago as a response to this blog post:

"I can't speak directly to CP or other congenital anomalies but I do know for certain that children with autism fail to form appropriate attachments to their caregivers because that is one of the core features of autism - not because their parents didn't accept their autism."


So, do autistic kids attach? Moreover, do they form secure attachments? Yes, in fact, they do. But they don't always show them the same way.
I recently came across an excellent illustration of an autistic child with a secure attachment style, in this paper:


"Tommy, a 36-month-old boy with ASD and very little language, was observed together with his mother in the SSP. In the first episode of the SSP, in which only he and his mother were in the room, he seemed oblivious to his mother’s presence and to the toys in the room and was running around the room in circles, humming to himself, appearing self-absorbed and content. 

Upon receiving a cue from the observer, Tommy’s mother exited the room. Tommy immediately stopped his running around. He lay on the floor, appearing somewhat distressed and called softly, “Mama. . . .” When the stranger entered the room, she tried to soothe Tommy and engage him with toys, but he remained lying on the floor and looked at the door. 

Finally, Tommy’s mother entered the room. He immediately stood up, briefly looked at her, and resumed running around the room as he had done initially, before his mother had left."


Now, many parents might assume, if their child does not greet them or show overt pleasure at their return, that the child doesn't care for them. And indeed most neurotypical children would greet the parent. Depending on their distress level, they might run up and initiate physical contact, or they might simply smile and make a greeting gesture or sound from afar. Tommy did neither of those. The only overt social signal directed at his mother upon reunion was a brief glance, which she might easily have overlooked.

However, he is still a securely attached child, despite expressing it in a much less sociable manner. To illustrate this, you need to understand the two main functions of attachment - to support exploration and to provide comfort when distressed.

In the Strange Situation, toddlers and preschoolers are more playful when their caregiver is in the room. They are especially playful before the first separation episode. The security that the caregiver provides merely by being present gives the child the confidence to explore.
In contrast, when the caregiver leaves, the child loses that security. Play typically decreases greatly or stops altogether, and the child expresses distress. Some kids are more reactive than others, for reasons relating more to temperament than attachment. A less reactive child might just get quiet and subdued, and be relatively inactive. If they're somewhat more reactive, they might whimper or whine, or call for the caregiver if they have the language skills. And if they're highly reactive, they might burst out with a full-blown cry.
However, among securely attached kids, this distress is resolved by the caregiver's return. Their response to the caregiver varies based on how distressed they got, but they are capable of seeking out and receiving just as much comfort as they need to return to play. In contrast, some insecurely attached kids cling to the caregiver but are not comforted by this contact, or may even alternate clinging with aggression. And others seem to bottle up their feelings, refusing to seek contact even though they were clearly upset by the separation. A few seem to fall apart altogether, and can't seem to decide whether to approach the caregiver or run away, or might even show signs of dissociation.
So, compare Tommy here. He didn't play with the toys, but he engaged in his own style of play by running in circles and humming. When his mother left, he stopped this behavior and showed mild but obvious distress. And then when his mother returned, her presence comforted him enough for him to resume his previous behavior.
That's secure attachment. Even though he didn't greet her or initiate interaction with her, Tommy clearly needs his mother and derives an emotional benefit from her presence.