Monday, October 19, 2015

Why I Use a Pseudonym

Someone recently asked why I use a pseudonym. I can tell you, it's not because I'm ashamed to put my name to my opinions or to reveal that I'm autistic and an abuse survivor in everyday life. I talk quite openly about autism, abuse and neurodiversity issues in everyday life, and have even spoken at NDP meetings about disability rights.

When I first started going by 'Ettina' online, I was in my early teens, and my Dad forbade me from using my real name on the Internet. Why? Because of child predators. He did not want anyone I met online being able to track me down and try to exploit me. Which is a very real issue, and I completely agreed with that rule.

I started this blog when I was 17, and still under the 'no real name' rule (I was allowed to make my own choice at 18). By then, I had already seen another reason not to blog under my real name - anti-vaxxers. On the EOHarm listserv, at the age of 15, I was viciously flamed for saying that I thought calling autistic people 'walking biohazards' was disrespectful. Not only that, but they went so far as to Google my handle and drag up stuff I'd posted on other forums (badly misinterpreted, by the way), in order to call my claim of being a 15 year old kid into doubt. I was honestly quite shaken by this. I have also heard of anti-vaxxers sending death threats (although that link claims it is 'new', it was going on 10 years ago) and have no desire to have people sending me or my family threats over my beliefs. No one I know in person would do this, even if they disagree with me.

Plus, I plan on becoming a mother someday. For all that these people claim they're trying to protect children, they have shown themselves willing to bully and frighten children, and threaten children with violence. I don't want that for my child. I went into advocacy to give my future child a better life, not to put them at risk from the worst of the anti-vaccination and anti-neurodiversity movements.

Furthermore, I have gone by this name in communication with self-described psychopaths, even linking to a psychopathic blogger because I find his blog interesting. As far as I know, I have given them no reason to want to hurt me, but psychopaths do sometimes attack others unprovoked. If one of the psychopaths I've met online decided it would be amusing to hunt me down, I want to make sure it's not easy for them.

And lastly, I don't like my real name. I don't like how it sounds, and some of the letters in it are ones I have a dislike for (yes, I dislike certain letters of the alphabet). Not enough to change it, when I'm used to it, people know me by it and my parents chose it for me. But when given the chance to pick a different name to be called by, I'll do it.

Tuesday, October 13, 2015

Why I Give Money To Beggars

This is inspired by David Hingsburger's post Cider, about giving a bottle of cider to a beggar who said he wanted a drink to celebrate Thanksgiving.

I give money to beggars.

Not every time they ask for it, because I don't always carry enough spare change for that, and I don't think I'm obligated to give. But often, when someone asks, I will give them money.

I have been told this is a bad idea. The argument goes that many beggars have addictions, and while you might be wanting to help them get food or a place to stay, what they might actually spend the money on is whatever they're addicted to. I've been told I should give food or these coupon-thingies that can be redeemed at homeless shelters for a meal and a bed for the night, not money. That way, I can make sure my gift is used in the 'proper way'.

Well, long before I knew I had executive dysfunction, I knew I couldn't do that consistently. I carry change a lot more often than I carry food, especially shareable food. And I have no idea where to get those coupon-thingies, and doubt I could remember to keep up a regular supply. So, in many circumstances, my options are to give money or give nothing at all.

And so, I asked myself - what if they do spend my money on an addiction? Well, if that's what they were going to do, they'd have spent money from others for the same purpose. Or if they couldn't get any money begging, they might have hooked or stole to earn their drugs. And it's not like an addict doesn't also need food and a warm place to sleep. If enough people give them money, they could get those needs met as well as satisfying their addiction.

Plus, would an addict seriously decide to quit just because I disapproved of their lifestyle? When even family members or an inpatient stay at an addiction ward generally can't convince an addict to quit, what chance does some random stranger have? If they're going to quit, they need to decide to quit for their own reasons, and not because someone tries to force them to quit.

And what about the beggars who aren't addicts? You can't always tell who is or is not an addict. And you can't entirely anticipate what their needs are, either. Maybe they want food or a place to stay, sure. Or maybe they want to get some Advil for their aches and pains, or a bus ticket to another town, or some new clothes, or a pool pass so they can get cleaned up in the changing room showers. Or maybe they want to get something nice for themselves or someone else - something that isn't technically needed, but would brighten up their day and help them forget their troubles. How could I possibly carry enough coupons to guess all of those possibilities? And what if they don't want to explain themselves to a complete stranger?

But most of all, it was the thought of looking someone in the eye and them realizing that you assumed they'd spend any money they got on drugs, and that you felt you had the right to tell them what they should do with your gift to them. I'm not going to ask if you kept my Christmas present or regifted it, or what you spent that gift card or $20 on. So, if I give a gift out of empathy instead of as a social convention, shouldn't I offer the same respect along with my gift? Help should not come with strings attached.

So, I give money to beggars. Some of them might spend it on addictions. It's none of my business if they do.

Saturday, September 05, 2015

Better Off Without a Father? Sperm Donation, Honesty, and Family Design

The conservative right-wing often express concerns about children growing up in lesbian or single mother families - that is, children growing up without a father. They generally seem to think that heterosexual couple-headed families are the best kind, and kids in any other kind of family are at psychological risk.

Ironically, however, in one segment of the population, having a father in the home may be a disadvantage. No, I'm not talking about kids with abusive fathers - that's too obvious. I'm talking about kids conceived using donor sperm.

There are three main kinds of families who use donor insemination - there are lesbian couples, there are single mothers by choice, and there are heterosexual couples dealing with male infertility or genetic disorders.

Research into children raised apart from one or both biological parents, for whatever reason (adoption, sperm/egg donation, etc), consistently shows that those who were told early and often about their origins fare much better than those who found out later in life. It hurts to be lied to, especially by the people you trust most.

A preschooler has no preconceptions about how a family should be formed - if you tell them that you found them in an orphanage or went to a doctor to get 'special baby-making juice' from another man because Daddy's special juice didn't work, they'll just accept it as another part of this weird wide world they're discovering. As they grow, their understanding will deepen, but their basic reaction will stay the same. But if you don't tell them, as they grow older, they'll gradually figure out where babies usually come from, and if they're being raised by a heterosexual couple, they'll make a very natural assumption. They'll base their identity off of that assumption, looking for their parents' traits in themselves. And then, to find out that that assumption was wrong can be devastating.

Unfortunately, many heterosexual couples who use sperm donation haven't gotten that message. In this study, they surveyed adolescent and adult donor sperm offspring who were members of the Donor Sibling Registry, an organization for the offspring from donor sperm and their families to track down half-siblings and biological fathers. One of the questions they asked was 'how old were you when you found out you were conceived using donor sperm?'

It should come as no surprise that all children raised in single-mother or lesbian families knew their origins by the age of 15, with most (87% in single-mother families and 88% in lesbian families) having found out by the age of 7. In contrast, heterosexual couples tended to be less honest. A third of offspring only found out when they were over 18 years of age, with 41% finding out over the age of 15. Most were eventually told by their mother, but 6% found out without either parent telling them - some told by other family members, and one overhearing a conversation between parents. There were too few to analyze, but I suspect the sense of betrayal would be especially high if the child found out without parents intending to tell.

They also asked how the respondents felt when they found out (if they were old enough to remember), and how they feel now about being donor-conceived. Compared to individuals told during childhood (4-11 years), those told during adulthood (18 or older) were significantly more likely to report feeling confused (69%), shocked (75%), upset (44%), relieved (38%), numb (38%) and angry (38%) - suggesting that being told was a strongly emotional and mostly negative experience for them (those told in adolescence showed intermediate reactions). In contrast, those told in childhood reported feeling mostly curious (71%, this emotion was common in all three age groups), with the next most common emotion being confused (37%). Overall, this suggests that the reaction was far less distressing if they were told before the age of 12.

Current emotions mirror the pattern found at disclosure, with individuals who found out in adulthood being more likely to feel currently feeling angry, relieved, shocked or ashamed. In contrast, most of those who found out in childhood reported feeling simply curious about the donor, and otherwise unconcerned with the method of their conception. (Relief was mainly seen in individuals who had suspected something was up, or in those whose social father had a hereditary medical condition.)

It also affected their relationships with their parents differently. With regards to their feelings toward their mother, those who found out in childhood were much more likely to report no change at all in how they felt about her. In contrast, those who found out later showed a mix of sympathy and appreciation of her honesty combined with a sense of betrayal and anger at being lied to.

In heterosexual couple families, the relationship with their social father was similarly affected. Although smaller sample size lessened the ability to find correlations, those who found out as adults were much more likely to feel betrayed. In contrast, most who found out in childhood felt sympathetic of their father's struggles with infertility, or else reported no change in relationship.

Another study suggests that even if offspring don't find out, keeping their origins a secret can adversely affect family functioning. They studied a sample of young adults conceived by sperm donation and raised in heterosexual couple families, 71% of whom had learnt of their conception after the age of 16. Although all the subjects had eventually found out, those who reported that parents avoided the topic of sperm donation (as parents who are keeping it secret must do) also reported parents avoiding other sensitive topics as well, such as avoiding discussion of friendship, sexuality, negative events and relationship issues. In addition, the subjects felt that overall family functioning was poorer. In addition, a study focusing on heterosexual couples who had used assistive reproduction techniques found that mothers who kept their child's origins secret reported more feelings of distress around parenting.

So, why are heterosexual couples so reluctant to tell their children about being conceived by sperm donation? Certainly, part of the reason is because they are more capable of hiding the truth. Most children learn at a young age that a typical family includes a mother and a father, and children raised by single mothers or lesbian couples will almost certainly ask why they don't have a father. When faced with such a direct answer, most mothers will tell the truth.

But comparison of different kinds of assisted reproduction reveal a more complicated situation. Heterosexual couples who used IVF or surrogacy with their own gametes are far more likely to tell their children about their origins, as seen in many different studies - here, here, here, and here. In addition, couples who used surrogacy with the surrogate's or a donor's eggs were more likely to tell children about their gestational history than their genetic origins.

It's ironic really - many parents who are secretive about gamete donation insist that it's irrelevant. However, surely being conceived by IVF with parents' own gametes is far less relevant to the child than being conceived with a donor gamete, and yet heterosexual couples are more honest about IVF, not less. This suggests that this is more wishful thinking than their true motivation.

Interestingly, fathers are typically more reluctant to discuss donor conception than mothers - and not just because they're the non-genetic parent. In this study, fathers in both sperm donation and egg donation couples judged genetic parenthood to be less important than mothers did, and both types of fathers were more likely than mothers to worry that contact with the donor could be harmful to their child. In this study and this study, fathers of oocyte-conceived children were less likely than their mothers to have told other people, such as family members, friends or medical professionals.

Although fathers and mothers generally agreed on their intention to tell or not tell the child, this study found that about half of couples using donor gametes came to an agreement after discussing differing opinions. In most such cases, the mother was initially in favour of telling while the father was against it, and the final decision was based on who won the argument. This implies that if it weren't for the father's opposition, most of the mothers would have told.

So, why is it that men are so much more reluctant to discuss donor conception? And, given the evidence that telling early and often is better for the children, how do we convince them to tell?

Monday, July 06, 2015

A Tap On The Head

You see it all the time in movies and TV shows. Someone gets hit on the head and loses consciousness, then wakes up several hours later, with a headache but otherwise unharmed. It's a common and useful narrative device. Unfortunately, it's very unrealistic.

Severity of traumatic brain injury is scored on three measures - the Glasgow Coma Scale measuring depth of unconsciousness, the duration of time spent unconscious, and the duration of post-traumatic amnesia (a period of time in which the person is conscious but confused and unable to form long-term memories). The most relevant here is the duration of time spent unconscious.

For a mild traumatic brain injury, unconsciousness lasts less than 30 minutes - in fact, the person may not lose consciousness at all. Even these mild head injuries can cause cognitive problems lasting up to three months after injury. In addition, repeated mild head injuries can trigger a neurodegenerative disorder known as chronic traumatic encephalopathy (in boxers, this is often described as being 'punch drunk'). Symptoms of CTE are similar to Parkinson's disease in many ways, and include motor symptoms as well as cognitive and emotional symptoms.

And most movie depictions have the person unconscious for longer than 30 minutes - after all, how much can the villain actually do in 30 minutes? If the person is unconscious more than 30 minutes, that's a moderate to severe brain injury. When a person awakens from such an injury, they typically awaken gradually, with a lengthy period of post-traumatic amnesia. Once they recover, they often continue to show lasting deficits, such as paralysis, aphasia, or other specific impairments. Personality changes are common as well.

A more realistic option would be to use a sedative, since unlike a brain injury, many sedatives can easily cause unconsciousness for several hours without lasting injury. However, chloroform, the most commonly used sedative in fiction, is actually not very good for the job - it takes at least five minutes of inhaling chloroform for a person to lose consciousness.

Probably the most realistic option is using 'date rape' drugs, injected or slipped into someone's food or drink. However, even then, the villain has to be a good judge of the person's weight, or else they might give them too small a dose (leaving them still conscious) or too large a dose (placing their life at risk). It's also important to remember that these drugs take time to take effect. Just as you don't become instantly drunk as soon as you swallow a shot glass of liqueur, a drug slipped into food or drink won't affect you right away either.

Injection is a bit faster, but still not instant. How long it takes for an injection to take effect depends on the drug and site of injection. Midazolam, an example I just happened to find data for, starts taking effect 15 minutes after an intramuscular injection, with maximum sedation 30-60 minutes after injection. If injected into a vein (which is a lot harder than an intramuscular injection), it takes more like 3 to 5 minutes. In the midst of a struggle, it's unlikely you could pull off an intravenous injection unless you're extremely lucky or skilled, so you're more likely to end up dealing with an intramuscular injection.

Incidentally, one of the most accurate depictions of chemical sedation in a movie can be seen in The Gods Must Be Crazy (a South African comedy about culture shock between a 'Bushman' from the Kalahari desert and several characters from industrialized cultures). At one point, some rebels have kidnapped a group of school children, and the protagonist is planning to dart the rebels with a tranquilizer dart his people use for hunting. I don't know what exactly the active ingredient of those darts were, but it's stated to take 15 minutes to take effect, requiring the protagonist to disguise as one of the kidnapped children and dart the rebels stealthily. Then follows a comical scene of the rebels acting drunk before they finally lose consciousness. Essentially, this is exactly how use of a sedating dart as a weapon would play out in real life.

Thursday, June 25, 2015

But They'll Get Teased!

This is one of the most common arguments I've heard for pressuring a child to conform to normative behaviour (eg gender normative, NT, etc). 'I don't have a problem with it myself, but a lot of people do. If he acts that way at school, he'll get teased.'

And yes, kids who act unusual do often get teased, and this can be very damaging to them emotionally. But does that really justify pressuring them to conform?

It's important to note that if their unusual behaviour is important to their identity (and hint: if they're really insistent on doing it, and they enjoy doing it, it probably is) then telling them to stop is itself psychologically damaging, no matter what your intentions are. Assuming you are successful in getting them to stop, then, the question is - is that more or less damaging than them getting bullied for this behaviour?

I don't have good data on this. But with another psychologically damaging activity - sexual abuse - research has found that the closer the child's relationship to the perpetrator, the worse the psychological impact on the child. Sexual abuse by a parent has been found to be the most damaging form of sexual abuse, because this is a person the child depends on for safety and security.

It seems likely that getting the message that 'who you are is not OK, you need to change' is likely to sting a lot more if it comes from a parent than from anyone else. And in many cases, what the bullies would have done is just a slightly less diplomatic version of what the parents are planning to do to protect against bullying. In which case, by having that message given by a parent instead of a peer, you're actually compounding the hurt.

There's also an element of risk that a lot of people fail to consider. What if you can't make them stop? What if they can't or won't stop, even with their own parent pressuring them? Or what if they stop some odd behaviours, but still seem odd for other reasons? (This is especially true if their atypical behaviour is due to a disability. Contrary to what ABA proponents tell you, simply educating a child does not make their disability go away.) In that case, you've hurt them psychologically, and they're still going to get bullied. Plus, because you've communicated that you agree with the bullies, the child is less likely to see you as a supportive figure they can turn to for help dealing with bullying - leaving them to deal with it alone.

Also, a note about intentions: your intentions matter a lot less than most people think. Good intentions do not always mean a lack of harm. I've heard of well-intentioned abusers on many occasions, such as black parents who physically abuse children in order to teach them to behave so the racist police won't shoot them. (That's actually a much better justification than avoiding bullying. Too bad it doesn't actually work.) Good intentions leading to harmful behaviour is especially common when dealing with kids who don't fit the norm and are different from their own parents, because quite often, parents simply don't understand what their child really needs.

Which is, I think, the real reason people use this justification. They don't understand. This behaviour seems strange, nonsensical and pointless to them, and they don't realize that to the person doing that behaviour, it makes perfect sense to do that. Maybe they simply enjoy the activity, or maybe it has some practical purpose, like helping reduce overload or lessening the painful feeling of having been born the wrong gender (some kids who act gender-nonconforming are actually transgender, others aren't). Or maybe it just seems so natural, it didn't occur to them that others would object to it. Meanwhile, their reasons for doing this behaviour are things that most people just plain don't experience, and which are often hard to explain and understand unless you've lived it yourself.

I'm not saying you should never force a person to act against their nature. But please remember that trying to tell someone to stop doing something important to their identity is harmful, and it had better be justified by risk of even greater harm. (For example, if I lived in Uganda, I'd tell my gay teen to stay in the closet.) You'd also better be sure that your approach will work, because otherwise, you'll just compound the problem.

Wednesday, June 24, 2015

Myths and Facts About Reactive Attachment Disorder Part 3 - Treatment

(Note: this is part 3 of a three part series. You can read part 1 here, or part 2 here.)

Reactive Attachment Disorder/Disinhibited Social Engagement Disorder is a serious problem, interfering with the child's ability to get close to others and in some cases putting the child's safety at risk. (DSED especially, since these children are overly trusting and easy to take advantage of.) In addition, many RAD/DSED children also experience a range of other psychiatric issues which - although not useful for diagnosis - are still a cause for concern, such as conduct problems, emotional distress, social skill impairments, and learning or self-care delays.

So, how do we help these kids?

Quack Treatments

Sadly, instead of proven, effective treatments based on a solid understanding of how RAD/DSED and attachment works, many practitioners offer quack treatments. These treatments, although claiming to be 'attachment therapy', do not follow what attachment theory actually proposes. In some cases, they can even be harmful.

Candace Newmaker, a 10 year old girl, died during one such treatment, known as 'rebirthing'. In this treatment, in order to help the child leave their past behind, therapists attempted to re-enact a birth experience. They wrapped Candace in a flannel sheet and four adults sat on top of her, with the expectation that she would struggle free. She complained that she couldn't breathe and that she was dying, but they ignored her complaints. Finally, she went still, and when they unwrapped her, she was motionless and blue.

Any treatment that involves keeping an individual restrained for any substantial length of time carries the risk of causing asphyxiation, especially if any weight is put on top of the individual. But attachment theorists have also pointed out that even if the child is not physically harmed by such a procedure, it carries the potential to be psychologically harmful - especially to a child who has already suffered prior trauma.

In addition, these quack treatments often include psychologically abusive behaviour. The transcript of Candace Newmaker's last moments reveal that she was told 'You want to die? OK, then die. Go ahead, die right now.', and called  a 'Quitter, quitter, quitter, quitter! Quit, quit, quit, quit. She's a quitter!'. Words may not break bones, but they do break spirits.

Sadly, such verbal abuse is common in these sorts of quack treatments, because it is believed that provoking strong emotions in the child allows them to release their inner rage - despite good evidence that focusing on anger is not effective at reducing anger. Also, there is no good evidence that RAD/DSED children are generally filled with rage to begin with. The research generally suggests that for young infants, fear and despair are more typical than rage in reaction to prolonged separation from an attachment figure.

Although there is value in voicing unspoken thoughts so that they can be countered by more encouraging thoughts (a primary component of many evidence-based treatments), there's an important difference between expressing emotion and creating emotion. And merely venting emotion, without any effort to analyse, redirect or reinterpret it, does not provide much benefit. Otherwise, simply having a tantrum would make a child's psychological health improve.

Evidence-Based Treatments

Unfortunately, very little research has been done on effective treatment of RAD/DSED. While several hundred studies have analysed treatments for conditions like PTSD and borderline personality disorder, I was only able to find a small number of studies assessing treatments for RAD/DSED. Even insecure attachment styles, despite not being severe enough to be called a 'disorder', have received much more research into effective interventions.

The best-studied 'treatment' for RAD/DSED is to remove the child from the cause. Many studies have shown that children who have been removed from institutional care or an neglect home or placed with a permanent family do much better than children who continue to experience institutional care, neglect or placement changes. The improvement can in some cases be truly remarkable - in the Bucharest Early Intervention Project, a study assessing foster care versus institutional care, children transferred into foster care showed dramatic improvements in virtually all aspects of development, even head growth!

However, for kids who have already been placed in a good home environment and still need more help, there's only a small pool of studies into potential treatments. But what studies have been done suggest a few potentially beneficial approaches.

In the following section, I'll review several treatments that have been studied in children with RAD symptoms or children meeting criteria for pathogenic care (ie history of neglect, placement changes or institutional care between 6 months to 5 years), who are living with nonbiological parents; and have been found effective in reducing either RAD symptoms, attachment insecurity, or externalizing behavior. (Externalizing behavior - aggression, rule-breaking, etc - because it's the most commonly reported concern by parents and caregivers of RAD children, and has serious implications for success in adult life.)

Child-Parent Relational Therapy/Parent-Child Interaction Therapy
Child-parent relational therapy (CPRT) trains parents to perform play therapy sessions with their child in the hopes that this will build a stronger emotional bond between the parent and child, and therefore improve attachment.

Unfortunately, the three studies I found did not examine attachment directly. However, in all three studies, there was evidence of a decrease in externalizing behavior in at least some of the children treated.

The best-designed study was Carnes-Holt (2012), which randomly assigned 61 adopted children aged 2 to 10 years with behavior problems (most of whom were adopted after age 1) to either child-parent relational therapy (32 children) or a control group (29 children). (This design controls for the possibility that the child may have improved regardless of treatment.) Compared to the control group, the treatment group showed reduced externalizing behavior and overall behavior concerns (as measured by the CBCL, a commonly-used and well-validated parent rating scale for behavioral and emotional problems). In addition, parents reported feeling less stress and more empathy for their adoptive children.

Sergeant (2011)'s study had a much poorer design, but was still encouraging. This study reported on 34 children with symptoms of RAD, but did not specify how old the children were. The children were randomly assigned to treatment or control, but 10 children dropped out of treatment, resulting in 15 treatment and 17 control children (treatment drop-outs are concerning because they did not occur at random, and therefore bias the results - also, why did so many families drop out?). In addition, this study used the RADQ, which as I mentioned in one of my earlier posts, is not a valid assessment of RAD. However, it does seem to be a decent measure of generalized behavior problems, and they also used the BASC-2, which is a well-validated measure. Their results were promising - the treatment group scored lower than controls on both the RADQ and the BASC-2 externalizing scale (internalizing behavior - such as anxiety and depression - was unchanged). The decrease on the BASC-2 externalizing scale was still significant when the drop-outs were lumped in with the treatment group (which restores random assignment). So, although this study is flawed, it still supports use of CPRT in this group.

Soulounias-Arriaga (2009) reported on two case studies - two boys in the process of being adopted by foster parents, aged 5 and 6 and both diagnosed with RAD. Both kids also carried a diagnosis of ODD, and the younger boy also had OCD while the older boy had a whole laundry list of psychiatric diagnoses (which is very common in RAD children). Both boys received Parent-Child Interaction Therapy, which as far as I can gather, is the same as CPRT. Both sets of parents showed improvements in their parenting behavior, but only the younger boy showed an improvement in ECBI behavior problems. (The ECBI is also a well-validated scale for externalizing behavior.) However, this is the weakest study of the three, with no control group and only two children studied. Still, even a case study can suggest a potential treatment approach.

Overall, these studies together provide encouraging evidence in support of using CPRT/PCIT to reduce externalizing behavior in RAD children.

Attachment and Biobehavioral Catch-up
The Attachment and Biobehavioral Catch-up (ABC) program is a 10-session training program designed for foster parents of infants and toddlers, which teaches these parents about attachment theory and provides direct advice on how to improve parental sensitivity and avoid being misled by the child's miscuing due to insecure attachment.

I found four articles (Benard et al, 2012; Dozier et al, 2009a; Dozier et al, 2009b; and Dozier et al, 2006) about three studies assessing the impact of the ABC intervention (the two 2009 papers refer to the same study - preliminary & full results).

All three studies involved a virtually identical design - foster parents of infants and toddlers were randomly assigned to either receive the ABC training or a different 10-session parent training program about enhancing cognitive development (which is unlikely to affect attachment). The measures used in the studies were different, though, providing a more complete picture of the impact of the ABC program. I will discuss these studies as a group.

First, on a diary measure of attachment style (which has some validation, but is not that well studied yet), the treatment group showed a significant decrease in avoidant attachment behavior, indicating less tendency to hide their distress in attachment situations. Unfortunately, they did not show a corresponding increase in secure behavior (indicating a healthy seeking of comfort and soothability), but this result is still encouraging.

In the Strange Situation, a laboratory measure of attachment security (which is extremely well-validated), the results were even better. The treatment group showed higher rates of secure attachment and lower rates of insecure (avoidant/resistant) and disorganized attachment (disorganized attachment refers to a child who falls apart in attachment situations, showing contradictory and/or dissociative behavior). Overall, this is a strong indicator that the ABC intervention is effective at improving attachment.

The third measure used was the Parent Daily Report, a diary measure of general child behavior problems over the course of several days. Mirroring the attachment data, the study that used this measure found a significantly lower rate of behavior problems in the treatment group.

Overall, this is strong evidence that the ABC program can help prevent & change insecure and disorganized attachment in very young foster children, as well as reduce their behavior problems. Although they did not directly study RAD, it seems likely that the ABC program might also reduce RAD symptoms in this group as well.

Incredible Years Program
The Incredible Years Program is a 12-session training program designed to teach parents skills for effective discipline, to support their children emotionally, and to encourage children's learning. There are different modules for different ages, focusing on the major tasks of that developmental period.

I found four studies of the impact of the Incredible Years Program on school-aged children in foster care. The results were decidedly mixed, but still somewhat encouraging.

Three of the studies randomly assigned children to treatment or control groups. One study, Linares et al (2006), administered treatment to both biological and foster parents of 3-10 year old children in foster care with biological parent visitation, with 40 children in the treatment group and 24 in the control group. Both sets of parents showed improvement in parenting behavior, but the children did not show a corresponding improvement in externalizing behavior, as measured by three different scales: CBCL externalizing, ECBI (a parent-rated measure of child conduct problems) or SESBI disruptive classroom behavior.

The other two studies found more positive results. Bywater et al (2010) administered the training to foster carers of 2-16 year old children (29 treatment, 17 control). Oddly enough, they did not find significant changes in parenting behavior, but did find reductions in foster parents' depression symptoms as well as improvements in behavior on the ECBI scale and the SDQ total and hyperactivity scales (the SDQ is a well-validated measure of general psychiatric problems, with several subscales reflecting specific areas of difficulty). It's possible that the reduction in foster parent depression directly reduced the child's behavior problems, or else that their parenting improved in some way that the parenting measure used was unable to capture adequately. Nilsen (2007) found less strong but still encouraging results. They studied a very small sample of 5-12 year old foster children (11 treatment, 7 control). On the BASC conduct subscale, the treatment group scored better than the control group, but differences on the other scales were not significant.

Lastly, McDaniel et al (2011) did not include a control group, but the thirteen 8-13 year old foster children in their study showed a significant decrease in child behavior problems from pre-treatment to post-treatment.

Overall, although the studies don't all agree, it seems like that the Incredible Years program may be effective at treating externalizing behavior and hyperactivity in preschool and school-aged foster children. They did not study RAD directly, but it's likely that a substantial proportion of the kids in these samples may have had RAD symptoms. Therefore, it seems likely that this program would help children with RAD as well.

Other Treatments
A few studies have assessed other treatments, which have less of an evidence base with this group.

Cognitive Behavioral Therapy, which is well-supported in treating kids and adults with a wide variety of other psychiatric conditions, has been assessed in a few studies with foster children, with the most promising study being GaviĊ£a et al (2012). This study involved 5-18 year old Romanian foster children with externalizing behavior (given the history of Romania, many of these children may be post-institutionalized as well), with children randomly assigned to treatment or control. Unfortunately, 18 children dropped out of treatment, leaving 44 in the treatment group and 35 in the control group, and they did not perform any intent-to-treat analyses (lumping drop-outs with the group they were originally assigned to). Nevertheless, the treatment group showed improved parenting behavior, reduced parenting stress and a decrease in the child's CBCL externalizing score. We can't be sure it was due to treatment, as opposed to traits that made dropping out less likely, but the results are encouraging. The rest of the CBT studies (Carew, 2007; Cone et al, 2009; and Cone, 2009) had very small sample sizes (all focused on adolescents) and no control group, but some children showed improvements. Based on this, it is worth trying CBT if the child has other symptoms commonly treated by CBT, has not responded well to the above-listed treatments, or those above treatments are not available or not appropriate (eg because of the child's age). Since CBT is widely available, it is likely to be offered as a front-line treatment in any case.

Behavioral therapies have also been tried in some children with RAD. These treatments involve identifying what motivates a child's problematic behavior and then providing systematic rewards for good behavior and sometimes punishments for bad behavior, gradually shaping more appropriate behavior. Unfortunately, the field of behavioral therapy for most psychiatric conditions is dominated by isolated case studies, and RAD is no exception. The three studies I found (Buckner et al, 2008; O'Reilly et al, 2001; and Sheridan & Deering, 2009) reported on a total of four children (3, 5, 7 and 12 years old), one diagnosed with RAD, two post-institutionalized and one in the foster care system. All four children improved, which is encouraging, but these results are very preliminary. Still, this treatment should be considered if other approaches have failed.

The Hope Connection summer camp, a 3 week day camp for older adopted and at-risk children, has been assessed in several studies (Purvis et al, 2013; Purvis & Cross, 2007; and Purvis et al, 2007), but none of these studies included any control group. Nevertheless, their results suggest improvements in attachment behavior (although they used unusual and poorly-studied attachment measures such as proximity in family drawings and a poorly-studied questionnaire), CBCL aggression, thought and attention problems and CDI scores (the CDI is a well-studied measure of child depression). These results are promising, and if this summer camp is available, parents of RAD children may consider sending their child to it.

The Role of the New Parents

It's important to note that most of the treatment approaches that seem to be helpful in children with or at risk for RAD involve the direct participation of the parents or caregivers of the child - sometimes without even involving the child directly! In general, parent-training programs, particularly ones that focus on increasing a parent's sensitive responses to their adopted or foster child's emotional needs, seem to be the most effective at helping children with RAD and children at risk of RAD.

It's important to note that this does not mean the parent is in any way to blame for the child's issues. Older adopted and foster children bring patterns of learnt behavior from their previous living situations, and often express their needs in confusing or counter-intuitive ways (such as attacking a caregiver when they need comfort from them, or seeking help from a stranger when they really need help from a caregiver). It's well-known that children can affect the parenting they receive, as parents get frustrated or confused by their child's behavior.

In addition, a child who is already at high risk may be more susceptible to adverse reactions to slightly suboptimal parenting - that is, parenting that is in the normal range, but not entirely ideal. For example, the same researchers who designed the ABC program have found that while biological parents with insecure-organized attachments tend to raise insecure-organized children, insecure-organized foster parents tend to raise foster children with disorganized attachments, as the trauma of placement changes compounds the impact of an insecure attachment in the parent.

Overall, research strongly supports an impact of normal-range variations in parental attachment style and sensitivity and their adopted or foster children's RAD symptoms and attachment behavior. Since many studies of biological families have found that parent-training interventions can increase parental sensitivity and child attachment security, it stands to reason that similar programs would help foster and adopted children as well.

Clearly, a lot more research needs to be done on evidence-based treatment for RAD and at risk children. But until such research is done, I hope this post will help guide parents to find the treatments most likely to help their children.

Saturday, May 30, 2015

Myths and Facts About Reactive Attachment Disorder Part 2 - Symptoms

(Note: This is part 2 of a 3 part series. You can read part 1 here, or part 3 here.)

The second part of RAD diagnosis, of course, is the symptoms. In DSM-IV, these were phrased as two symptoms, with a wide range of presentation:
  • persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness) 
  • diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures) 
In DSM-V, as well as splitting these two symptom categories into separate diagnoses, they also elaborated them quite a bit.
For RAD (formerly called inhibited RAD), they list the following as symptoms:
  • The child rarely or minimally seeks comfort when distressed.
  • The child rarely or minimally responds to comfort when distressed.
  • Minimal social and emotional responsiveness to others
  • Limited positive affect
  • Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.
For DSED (formerly called disinhibited RAD), they list the following:
  • Reduced or absent reticence in approaching and interacting with unfamiliar adults.
  • Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
  • Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
  • Willingness to go off with an unfamiliar adult with minimal or no hesitation.
If you know a child with a mix of both features, by the way, you're not alone. I don't really understand why the DSM decided to split the two up, since many researchers have found that a significant subgroup of children with RAD show a mixture of both symptom types. If you're wondering how that works, keep in mind that inhibited RAD symptoms are usually most evident when the child is interacting with caregivers, while disinhibited RAD symptoms all refer to the child's behavior towards strangers. While the stereotype of disinhibited RAD is a child who is equally friendly towards caregivers and strangers, some research suggests that kids with particularly severe disinhibited behavior actually preferentially engage with strangers, while acting withdrawn towards their caregivers.

The Expanded List

Although the above symptoms (and ones thematically related to them) are the only ones that are used in clinically validated RAD/DSED diagnoses, many sources online provide an expanded list. For example, take a look at the Randolph Attachment Disorder Questionnaire, a favourite of quacks.
  1. My child acts cute or charms others to get them to do what he/she wants.
  2. My child has trouble making eye contact when adults want him/her to.
  3. My child is overly friendly with strangers.
  4. My child pushes me away or becomes stiff when try to hug him/her unless he/she wants something from me.
  5. My child argues for long periods of time, often about ridiculous things.
  6. My child has tremendous need to have control over everything, becoming very upset if things don't go his/her way.
  7. My child acts amazingly innocent, or pretends that things aren't that bad when he/she is caught doing something wrong.
  8. My child does very dangerous things, ignoring how he/she may be hurt while doing them.
  9. My child deliberately breaks or ruins things.
  10. My child doesn't seem to feel age- appropriate guilt for his/her actions.
  11. My child teases, hurts or is cruel to other children.
  12. My child seems unable to stop him/herself from doing things on impulse.
  13. My child steals or shows up with things that belongs to others with unusual or suspicious reasons for how he/she got them.
  14. My child demands things instead of asking for them.
  15. My child doesn't seem to learn from his/her mistakes and misbehavior (no matter what the consequence, the child continues the behavior).
  16. My child tries to get sympathy from others by telling them that "I" abuse and/or neglect him/her.
  17. My child "shakes off" pain when he/she is hurt, refusing to let anyone comfort him/her.
  18. My child likes to sneak things without permission, even though he/she could have had them if he/she asked.
  19. My child lies, often about obvious or ridiculous things, or when it would have been easier to tell the truth.
  20. My child is very bossy with other children and adults.
  21. My child hoards or sneaks food, or has other unusual eating habits (eats paper, raw flour, package mixes, baker's chocolate, etc.)
  22. My child can't keep friends for more than week.
  23. My child throws temper tantrums (screaming fits) that last for hours.
  24. My child chatters non-stop, ask repeated questions about things that make no sense, mutters or has other oddities in his/her speech.
  25. My child is accident prone (gets hurt a lot) or complains lot about every little ache and pain (needs constant Band-Aids).
  26. My child teases, hurts or is cruel to animals.
  27. My child doesn't do as well in school as he/she could with even little more effort.
  28. My child has set fires or is preoccupied with fire.
  29. My child prefers to watch violent cartoons and/or TV shows or horror movies (regardless of whether or not you allow him/her to do this.
  30. My child was abused/neglected during the first year of his/her life or had several changes of his/her primary caretaker.
Not counting item 30, which is a background item rather than a symptoms item, only items 3, 4, and maybe 24 are conceptually similar to the DSM criteria. The rest are a mishmash of symptoms under many different domains. And while these symptoms certainly are overrepresented in RAD children, they are also common in conduct disorder, oppositional defiant disorder, ADHD, disruptive mood dysregulation disorder, depression, and even autism spectrum conditions. Most children with these other conditions have not experienced pathogenic care, and do not show inhibited or disinhibited RAD symptoms.
Diagnosing RAD based on symptoms common to many disorders is like diagnosing chicken pox on the basis of fever and fatigue. Far better to use the highly specific skin sores, instead of symptoms present in pretty much any infectious disease. Incidentally, with the above checklist, each item is scored 1 to 5, and it says a child with a score of 50 or above might have RAD, and a child with 66 or above is highly likely to have RAD. Since only 3 out of 29 items actually relate to RAD specifically, it's pretty easy for a child to meet this cut-off without showing a single diagnostic symptom of RAD.
Some people have pointed out that parents and caregivers of RAD kids rarely seek help from psychiatric services because their child is overly friendly or doesn't accept affection. Instead, they seek help for aggressive, disruptive or disturbing behaviours, like the ones in the above list. But that changes nothing. A competent clinician looks at the full symptom picture, not just the presenting issue, when making a diagnosis. And misdiagnosing children with other conditions as having RAD is not going to lead to appropriate management of them or their parents. They should be treated for what they actually have.

RAD Versus Attachment Insecurity

Other times, when looking for stuff about RAD, you'll find descriptions of insecure attachment. For example, this blog entry seems to confuse adult RAD with adult insecure attachment, listing the following:
  • Intense anger and loss
  • Hostile
  • Critical of others
  • Sensitive to blame
  • Lack of empathy
  • Views others as untrustworthy
  • Views others as undependable
  • Views self as unlovable or "too good" for others
  • Relationships feel either threatening to one's sense of control, not worth the effort, or both
  • Compulsive self-reliance
  • Passive withdrawal
  • Low levels of perceived support
  • Difficulty getting along with co-workers, often preferring to work alone
  • Work may provide a good excuse to avoid personal relations
  • Fear of closeness in relationships
  • Avoidance of intimacy
  • Unlikely to idealize the love relationship
  • Tendency toward Introjective depression (self critical)
  • Compulsive Care giving
  • Feel over involved and under appreciated
  • Rapid relationship breakups
  • Idealizing of others
  • Strong desire for partner to reciprocate in relationship
  • Desire for extensive contact and declarations of affections
  • Over invests his/her emotions in a relationship
  • Perceives relationships as imbalanced
  • Relationship is idealized
  • Preoccupation with relationship
  • Dependence on relationship
  • Heavy reliance on partner
  • Views partner as desirable but unpredictable (sometimes available, sometimes not)
  • Perceives others as difficult to understand
  • Relationship is primary method by which one can experience a sense of security
  • Unlikely to view others as altruistic
  • Sensitive to rejection
  • Discomfort with anger
  • Extreme emotions
  • Jealous
  • Possessive
  • Views self as unlovable
  • Suicide attempts
  • Mood swings
  • Tendency toward anaclitic depression (dependent depression)
In fact, those two symptom lists refer to a different but conceptually related issue known as insecure attachment. Unlike RAD, an individual with an insecure attachment style is not necessarily impaired. In fact, since 40% of the general population has an insecure attachment style, it should be clear that you can be insecurely attached and function reasonably well. In contrast, RAD is a rare condition. (Incidentally, the more extreme symptoms on the above lists, such as suicide attempts, are relatively rare in insecure attachment.) There are two main types of insecure attachment - avoidant attachment, in which the person prefers keeping others at a distance; and ambivalent attachment, in which the person is needy but doesn't trust others.
Many RAD individuals show signs of insecure attachment, but not all do. Some appear securely attached (although I would argue that they are not truly secure). Others show too little attachment behaviour to be classified either way. In either case, RAD is assessed separately from attachment styles, and generally by using different measurements.
A related concept is disorganized attachment. This attachment style is somewhere in between insecure attachment and RAD in severity. A person with a disorganized attachment style may show traits of both types of insecure attachment, or a mix of secure and insecure behaviour, or they may show signs of dissociation or disorientation in attachment situations. Often, their attachment behaviour is markedly inconsistent.
Disorganized attachment is not currently considered a disorder, but it appears to be a stronger risk factor than insecure-organized attachment styles. It's associated with parental behaviour that is frightening or confusing to children. Common environmental causes include parental disorganized attachment or unresolved grief, parental mental illness, parental addiction, or physical or sexual abuse of the child. It is thought that disorganized attachment places individuals at particularly high risk of PTSD and dissociative disorders, although risks of many other conditions are also elevated.
Again, many RAD children show signs of disorganized attachment, but not all. Some children with RAD appear to show an organized attachment pattern instead, and some don't show enough attachment behaviour to be classified either way.
An interesting historical note - disorganized attachment was identified much later than the other attachment styles. In the 70s and 80s, most children who would now be classified as disorganized were instead assigned to the best-fitting organized attachment style, including some who were classified as 'secure'. This lead to some confusing findings, such as high rates of secure attachment in children abused by their primary attachment figure. However, some children could not be force-fit into any organized attachment pattern, and when two researchers (Main and Solomon) decided to take a closer look at these kids, they realized that these kids were best described by a fourth attachment style, one that also fit some children force-fit into other attachment styles.
Similarly, although some RAD children appear securely attached according to attachment style assessments (such as the Strange Situation), new evidence is starting to suggest that these kids aren't really securely attached. Instead, like disorganized-secure children, they simply don't fit into the existing attachment classification. For example, a child who, in the Strange Situation, behaves as though they were 'securely attached' to both their parent and a complete stranger would get classified as secure, because the assessment focuses mainly on interactions with the parent. However, when attachment behaviour towards strangers is assessed, this child clearly differs from true securely attached children.

Myths and Facts About Reactive Attachment Disorder Part 1 - Cause

(Note: this is part 1 of a 3 part series. You can read part 2 here, or part 3 here.)

Recently, I was taking a look at some of the information available online about Reactive Attachment Disorder, and it deeply concerned me. Unfortunately, there is a lot of misinformation out there. Although the official research base for RAD is reasonably good, many unofficial online sources present a very different picture of the causes and symptoms of RAD than the research does.

First of all, what is RAD? In the DSM-IV, Reactive Attachment Disorder is defined by both two sets of symptoms (defining two subtypes) and a form of environmental exposure presumed to cause those symptoms. In DSM-V, the two RAD subtypes have been split into two conditions, Reactive Attachment Disorder and Disinhibited Social Engagement Disorder, which are both diagnosed according to the same 'symptoms + cause' rule. They are part of only a small number of DSM diagnoses which include presumed cause in the criteria.

Cause: Pathogenic Care

So, what is the cause? The DSM-IV diagnosis of RAD requires:

"C. Pathogenic care as evidenced by at least one of the following:
(1) persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection 
(2) persistent disregard of the child's basic physical needs 
(3) repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)
D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C)."

In the DSM-V, meanwhile, both RAD and DSED require that:

"C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
* Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults
* Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)
* Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios)
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C)."

Although the wording has changed, both criteria imply that RAD/DSED can result from either receiving inadequate care from one caregiver, or good quality care from too many caregivers. Of course, some children experience both inadequate care and too many caregivers, and they would presumably be at even higher risk.

The inadequate care criteria are pretty clearly implying serious child neglect. Note that in DSM-IV, either physical or emotional neglect could meet criteria, while in DSM-V, emotional neglect is needed. This reflects a greater understanding that a child who is malnourished or showing other signs of inadequate physical care can still be receiving good emotional care - for example, if the family is suffering from extreme poverty. Although many children do experience both kinds of neglect, emotional neglect is the really crucial one for RAD.

Note also that physical and sexual abuse are not included in either set of criteria. That's because, while those experiences certainly are damaging to children, they do not seem to cause RAD. Instead, they would be more likely to lead to a diagnosis of post-traumatic stress disorder, although the DSM V committee did consider adding a diagnosis known as Developmental Trauma Disorder, which would likely have covered the symptoms of abused children more specifically. Of course, many abused children also experience neglect, especially emotional neglect, and for those children RAD is a possibility.

Repeated changes in caregiving, as well as institutional rearing, are both thought to contribute to RAD in a different way. Whereas emotionally neglected children have a caregiver who is consistently present but not engaged enough for the child to attach to them, children in foster care and institutions have many caregivers, most of whom would make perfectly fine caregivers on their own, but they are so transient in the child's life that the child cannot form an effective bond to any one person.

Note that, although the DSM doesn't mention it, there are also kids who experience placement changes outside of the child welfare system. My cousins first entered foster care at 11 and 14, but long before that, they had been passed around between their biological mother, biological father, stepmother and grandparents. My mother, as a family law lawyer, has also recounted tales of repeated placement changes in custody disputes. For example, in one case, a boy was living with his biological mother until she was found unfit due to drug abuse, at which point he went to live with his father and stepmother. Then, his biological mother cleaned up and regained custody. Just recently, she has suffered a relapse, so he's back with his father and stepmother again. Under the right circumstances, custody disputes or willingly passing custody off could place a child at risk for RAD as well.

Timing and Other Notes

Timing also matters. As quoted above, the DSM criteria require that the symptoms be present after the pathogenic care, not before. For example, if a child was observed to be showing symptoms suggestive of RAD at age two, and then at age 3 experienced a foster placement, the age 3 foster placement would not count towards the pathogenic care requirement. (However, if that child had been removed from the home due to neglect, and there was reason to believe the neglect started before age 2, that would count.)

In addition, while DSM-V DSED makes no mention of age of onset, both DSM-V RAD and DSM-IV RAD require symptoms to be evident before age 5. Which, by definition, requires that the pathogenic care occur before age 5. This is consistent with research data showing that placement changes in older children can trigger other psychiatric symptoms, but do not appear to cause symptoms of RAD. It's unclear why they left out the age of onset requirement for DSED, because in practice, both RAD and DSED symptoms appear equally age-dependent.

So, 5 or older is too late to develop RAD. But can pathogenic care occur too early, as well? The research says yes. In general, among children removed from pathogenic care environments and placed into healthy homes, children under 6 months old show no lasting effect, while children aged 6-12 months only show an effect if the deprivation was particularly severe (such as institutional care, where a child often experiences over 100 different caregivers in their first year as well as neglect due to high child-to-caregiver ratios).

In addition, some websites claim that RAD can be caused by prenatal or birth trauma. There is absolutely no evidence to support this claim. Certainly, such events can affect the mother's behaviour, and in some mothers this could be severe enough to cause them to provide pathogenic care, but in that case, it was the pathogenic care, not the prenatal or birth trauma, that caused the RAD. In addition, prenatal/birth trauma can sometimes cause a child to suffer a brain injury, which could affect the child's behaviour, but the symptoms of neonatal/prenatal brain injuries are distinct from RAD.

A special note about prenatal drug or alcohol exposure: parental addiction severely impacts on the quality of parenting. In fact, most if not all actively-addicted parents provide some sort of problematic caregiving, often of the type that can cause RAD. Since most drug or alcohol exposed children have experienced months or years of care by an addicted parent, and those that haven't have often experienced multiple foster care placements in their early years, it makes no sense to me why so many people think prenatal alcohol or drug exposure is a cause of RAD symptoms.

It is conceivably possible that such prenatal exposure could cause symptoms that resemble RAD in some ways (such as the hypersociability seen in Williams Syndrome, which has nothing to do with quality of care), but so far I have not seen any conclusive evidence for it. Instead, I've seen people claiming that their child adopted at 18 months, or 3 years, or even older, clearly has RAD because of their prenatal exposure, as if the child's postnatal experiences made no difference whatsoever. My best guess is that FASD or prenatal drug exposure has filled up the child's difference slot, and they can't conceive of the child having multiple separate disabilities. Or maybe it's less upsetting to think your child acts like that because their brain is damaged than to think they act like that because it helped them cope during their early years of life.