Invisible disability: Building Great Britons

A report was published on Wednesday by the All Party Parliamentary Group (APPG) for Conception to Age 2 – the First 1001 days. It’s called Building Great Britons.
The thrust of the report is similar to Early Intervention: Good Parents, Great Kids, Better Citizens (2008) and Early Intervention: The Next Steps (2011) from MPs Graham Allen and Iain Duncan Smith. Building Great Britons sets out a policy framework aimed at preventing the social problems believed to originate in adverse experiences between conception and a child’s second birthday.

Breaking the cycle

The conceptual model underpinning the report is a familiar one. Neglect, maltreatment and insecure relationships in early childhood are assumed to be a primary cause of mental health problems and antisocial and criminal behaviour. Parents who had such experiences during childhood tend to adopt the same child-rearing strategies as their parents, setting up a damaging (and costly) self-perpetuating intergenerational cycle.

Like the Early Intervention reports, Building Great Britons argues that preventing child neglect, maltreatment and insecure attachment will save money and result in a flourishing society due to the emergence of well-rounded citizens who are “physically and mentally healthy, well educated, empathic, prosocial, hardworking and contributing to the costs of society” (p.3). As Tim Loughton, Co-Chair of the APPG says “the economic value of breaking these cycles will be enormous” (p.4).

“This” it’s claimed, “is not ‘rocket science.’ Technically it is ‘neuro-science’” (p.3).
The basis for that claim seems to reside in repeated references to brain development, although there’s no detail about how brain development is involved. The association between early adverse experiences and long-term unwanted outcomes is well established, but there are some problems with the model.

what causes what?
The first is that just because two things are correlated, it’s not safe to assume that one causes the other. They might both be caused by something else, or be totally unrelated. So parents might neglect, maltreat or form poor attachments with their children because their parents did, or because the family has a genetic predisposition towards severe post-natal depression, or because they are grappling with challenging life circumstances.

multiple causes
The second problem is that even if we could predict with certainty that all neglected, maltreated, chaotically attached children will develop mental health problems or anti-social behaviour in later life, the causal chain doesn’t always hold in the opposite direction because mental health problems and anti-social behaviour have other causes such as poor physical health, adverse life events or peer pressure.

looking back vs looking forward
A third problem is that retrospective surveys linking adverse childhood experience with later health and social problems, such as the ACE study referred to in Building Great Britons (p.14), tend to rely on self-reports – not always the most reliable sources of information, especially about early life. Prospective assessments that track children through their life course such as the Dunedin and Cambridge studies tend to be more reliable. They have also found correlations between adverse childhood experiences and problems in later life but that the emerging patterns are quite complex.

When reading through the research findings, I was struck by how often researchers expressed surprise at the frequency of adverse childhood experiences. The ACE study was prompted by the unexpectedly high incidence of sexual abuse in childhood reported by people dropping out of a weight loss programme. The Dunedin study began as a small-scale follow-up assessment of perinatal risk. Its scope was broadened after researchers found a higher incidence than they expected of accidental injury and impairments to sensory function, development and behaviour in 4/5 year olds. The implication wasn’t that the children had been neglected or maltreated (although some might have been), but that developmental impairments in the general population were more frequent than had been previously thought.

children with disabilities: noticeable by their absence

This brings me to a glaring omission in Building Great Britons. One group of children is especially susceptible to social, emotional and behavioural problems and is at increased risk of poor physical and mental health in later life. They are children with disabilities. But the only mention of disability that I could find in Building Great Britons was of children with Foetal Alcohol Syndrome, caused by a mother’s excessive alcohol intake during pregnancy.

Childhood disabilities can be caused by neglect or maltreatment but they can also be caused by factors such as;

• inherited genetic conditions
• spontaneous genetic variations at or before conception
• mother’s illness during pregnancy
• environmental damage during gestation (e.g. exposure to toxins)
• childhood infections
• accidental injury.

Whether you think disability is caused by a ‘functional impairment’ or by the way society responds to that functional impairment, for administrative and legal purposes a clear-cut distinction is usually made between someone who’s deemed disabled and someone who isn’t. But from a biological perspective the boundary is rather blurred. As the Dunedin study found, a significant proportion of children has some sort of developmental impairment; currently in the USA it’s 15%. In the UK, only 6% of children are classified as disabled, but that figure rises with age. Around 16% of the working-age population has a disability.

Not all disabilities are obvious, and some are difficult to detect. The average age at which autism is diagnosed, for example, is 5.5 years, and diagnosis is often much later than that. Autistic children have unusual attachment patterns and autism is so frequently confused with attachment disorder that Heather Moran, a consultant clinical psychologist, devised the Coventry Grid to help professionals distinguish between them.

There’s little doubt that neglect, maltreatment or poor attachment in childhood can, and does, lead to social, emotional and behavioural problems and to impaired physical and mental health. But what Building Great Britons does is to frame the causes of those problems solely in terms of neglect, maltreatment or poor attachment, and more specifically in terms of the ‘troubled families’ who are deemed to be the source of these societal ills (pp.3-4).

When I was delving into the thinking behind the Early Intervention reports, I asked a few researchers who’d been actively involved how some obviously erroneous claims about brain function had crept in. None had had a say in the final content of the reports, but one told me that it was sometimes necessary to present data in a way that was most likely to persuade government to come up with funding. I take his point; but I couldn’t see how that justified presenting the data in a way that was misleading.

What the data on social, emotional, behavioural, physical and mental health problems tell us is that children by definition are vulnerable, and parenting by definition is challenging. They also tell us that we are all, at all times, at risk from unforseen life events that could trigger social, emotional, behavioural, physical or mental health problems that result in us needing help from the community. That’s why in the developed world we have education, health and social care services.

It’s true that a minority of families cause a disproportionate number of problems, for themselves and others. There are good reasons why early intervention is appropriate for them. But because all children are vulnerable and all parenting is challenging, there are good reasons why early intervention should be available to all families. We shouldn’t have to justify it in terms of ‘good citizenship’ or the financial costs for ‘society’ – which at one time we were told didn’t exist.

Nor should reports produced by Members of Parliament about vulnerable children and challenged parents look right past one of the most vulnerable groups of children and one of the most challenged groups of parents. In the total of 351 pages that make up the two Early Intervention reports and Building Great Britons, childhood disability is mentioned, in passing, only five times – and three of those references are to Foetal Alcohol Syndrome.

When I contacted @first1001days, the Twitter account for http://www.1001criticaldays.co.uk/ to point out the omission, I got a prompt response inviting me to write some supplementary material. Within an hour, another parent and I had responded with a paragraph summarising the main issues, and notified @first1001days. I wasn’t surprised not to get an immediate reply, as the report was being launched that morning. But we’re still waiting…

Disabled people are still invisible, it seems.

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what about attachment parenting?

During my excursion into the world of child development theory, I’ve been acutely aware of one important group I’ve so far overlooked; the advocates of attachment parenting (AP). Attachment parenting is an approach derived from Bowlby’s theory, but includes practices like extended breastfeeding, ‘babywearing’ – carrying the baby close to the parent’s body, co-sleeping, and a high level of responsiveness to the baby’s needs. I must admit to being sympathetic to AP as an approach; I must also admit (like many other parents) to being something of an attachment parenting backslider. Both my children were in a buggy by the age of six weeks because I couldn’t find a sling that didn’t hurt my back, due to a series of complications I stopped breastfeeding my son at four months, and one child slept happily in bed with me whereas the other simply wouldn’t.

A significant influence in the AP movement is William (‘Dr Bill’) Sears, a paediatrician and author of a number of best-selling parenting books. Dr Sears’ wife Martha is a director of Attachment Parenting International (API), an organization founded in 1994 by Barbara Nicholson, a learning disabilities specialist and Lysa Parker, who also has a background in special education. Parker also worked with La Leche League International, as did four other of the API’s eight directors. (La Leche League was founded in Illinois in 1956 by a group of mothers who wanted to promote breastfeeding, a practice then rapidly dwindling in the USA.)

Dr Bill’s shoes have to an extent been filled by Gordon Neufeld, founder of the Neufeld Institute in Vancouver, Canada. Unsurprisingly, Neufeld’s approach is firmly grounded in attachment theory, with separation, for example, being seen as playing a key role in the ‘epidemic of anxiety’ that apparently afflicts our children. Neufeld’s ideas are very popular, but it’s instructive to read what a group of parents who have used the AP approach with their special needs children have to say here.

Why attachment parenting?

The predominant reasons given for the attachment parenting approach are that it involves ‘instinctive’ and ‘natural’ child-rearing practices that parents have used for thousands of years. In essence this is the same argument used by Bowlby and Perry in support of their models of child development. I think it’s flawed in two respects. One is that ‘instinctive’ behaviours have also led to the adoption of practices that attachment parenting advocates are unlikely to approve of, such as infanticide, cranial deformation and genital mutilation. You could argue, of course, that such practices might be instinctive but they’re not ‘natural’. Unfortunately, ‘nature’ isn’t always benign either.Throughout human history, infants in hunter-gatherer societies have been at high risk of death from predation, starvation, injury and infection. And if hunter-gatherer societies appear to be healthier than those in the developed world, it’s often because of the price paid by their ancestors and the weaker members of their community. Although AP proponents often advocate as natural a lifestyle as possible, few in the developed world would expect mothers and children to be self-sufficient, live in huts, cook over open fires or fail to take advantage of modern medical interventions if required.

Evidence or belief?

In other words, neither the ‘instinctive’ nor ‘natural’ justifications for attachment parenting provide sufficient evidence to support it. I suspect that rather than AP consisting of practices based on a careful evaluation of the evidence, AP is actually based on a set of beliefs. They’re not unreasonable beliefs; breastfeeding, carrying babies in a sling and being responsive to a child’s needs are highly likely to be of benefit because they optimize nutritional intake and reduce the risk of gastro-intestinal infection, keep the infant warm, comfortable and within the parent’s sight and increase the likelihood of the child’s needs being responded to promptly. In other words, they are beneficial to the child for good, demonstrable reasons, not because they are ‘instinctive’ or ‘natural’. Other practices are less obviously beneficial; Attachment Parenting International has issued safety guidelines in respect of children sleeping in the parent’s bed, for example, and numerous parents have described attachment parenting resulting in outcomes such as a bad back and sleep deprivation.

Personally, I have no problem with parents basing their parenting approach on a set of beliefs; as long as children aren’t harmed, parents are free to bring up their children as they see fit. They are also entitled to share their beliefs with others and to try to persuade them that those beliefs are right. I don’t even have a problem with practitioners such as Sears or Neufeld advocating a particular approach to child-rearing, because parents and practitioners committed to an approach don’t generally claim to have carried out an exhaustive evaluation of the relevant evidence. It’s usually fairly obvious that they are propagating beliefs and are using evidence selectively to back up their views. What I do find worrying is researchers adopting the same approach. Even though their credentials suggest they are able to evaluate all the relevant evidence in a reasonably objective manner, some follow the same strategy as attachment parenting advocates and base their theoretical models on beliefs backed up with supporting evidence only. What’s also worrying is that an uncritical evaluation of the evidence appears to be acceptable to some peer-reviewed journals.

In a previous post I compared Leo Kanner’s and Bruno Bettelheim’s approaches to the early evidence relating to autism. Kanner’s initial model of autism was based on his evaluation of evidence in the light of contemporary child development theory. As time went by, he repeatedly revised his model as new evidence became available. Bettelheim, by contrast, not only based his model on a belief about the cause of autism (parental behaviour), but also used evidence selectively to support it, and his background in philosophy appears to have persuaded him that this was valid way of handling evidence. I don’t know if Bettelheim’s approach is embedded somehow in the world of child development research, but it keeps cropping up amongst child development researchers. Bowlby’s essential dismissal of genetics and unquestioning acceptance of the idea that the origins of psychiatric disorders are to be found in childhood experiences contrasts starkly with his painstaking analysis of concepts such as instinctive behaviour and emotion. Schore goes into considerable technical detail about the development of the orbitofrontal cortex, but doesn’t question Bowlby’s model of attachment or the findings of researchers he uses to support his orbitofrontal model, despite Bowlby’s theory and the function of frontal areas of the brain being the subject of considerable debate. Perry’s discussion of the evolution of human socio-emotional behaviour is pretty speculative, and although on the face of it his brain scan findings are persuasive, digging a little deeper suggests that he hasn’t paid sufficient attention to defining concepts such as neglect, nor to the range of other possible causes of abnormal brain development.

Carrot or stick?

Another issue that’s concerned me is what the attachment model is used for. AP proponents tend to take a resoundingly positive approach to parenting – AP practices are recommended because they are seen as being good for babies and their families and ultimately, society at large. Parents are encouraged to use strategies flexibly and adapt them to their own lifestyles, even though some AP supporters might get a bit over-zealous and risk making parents feel needlessly guilty. When attachment theory filters through into public policy, however, a rather different picture emerges; one in which there’s a real risk of attachment theory being used as a stick with which to beat parents. Poor attachment is blamed for poor health, antisocial behaviour and psychiatric disorders, locating the source of those problems firmly within the family, particularly with parents and notably mothers.

Despite references being made in policy documents and textbooks to Bronfenbrenner’s ecological systems theory, his framework is rarely applied except in the sense of recommending interventions at the community, state or international level to prevent or compensate for the damage caused by poor parenting. So far, I’ve found little consideration given to the possibility that problems manifested by individuals could have causes at all levels, from genes through physiology, to economic, social and cultural pressures at the community, national or international level.

In my next post, I look at a book by a critic of current child development theories, John Bruer’s The Myth of the First Three Years.

Acknowledgement: with grateful thanks to Jennifer Skillen for information about the history of La Leche League.