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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the big picture: do mothers cause social problems?

I’ve suggested Allen and Duncan Smith’s understanding of brain development and of data from large-scale studies isn’t as good as it might be. So what?

The role of evidence

It’s not clear why Allen and Duncan Smith feel compelled to use evidence from brain development to shore up their case for early intervention. We already know that maltreatment, neglect and poor attachment cause problems, often lasting ones; that’s why they’re called ‘maltreatment’, ‘neglect’ and ‘poor’ attachment. We’ve known for millennia that early intervention in children’s lives is more effective than late intervention. We can also demonstrate the effectiveness of an intervention without knowing how it works. The use of brain development as evidence is especially puzzling since Allen and Duncan Smith clearly don’t understand it well, and because people who understand it better suggest that the evidence linking maltreatment, neglect and attachment to abnormal brain development is still rather tenuous e.g. De Bellis (2005); Glaser (2000). Basing one’s case on unreliable evidence runs the risk of defeating one’s own aims.

Correlation and causality

Allen and Duncan Smith rely heavily on correlations to support their model. If I’ve understood it properly their model looks something like this:

Allen and Duncan Smith early intervention model

But all the causal connections implied in the model rely on correlations. Assuming that correlated variables must be causally linked – ie that one causes another – is a basic error in data analysis. It’s not the first time the Centre for Social Justice has made this mistake. Their paper on marriage published in December 2009, assumes that correlations between marriage and length of relationship, mental and physical health, violence and abuse and outcomes for children, mean that marriage itself results in more stable relationships, improved mental and physical health and a reduction in violence and abuse. Not that non-violent couples in stable relationships, with adequate parenting skills, who enjoy good mental and physical health might be more likely to get married and to stay together. As with the brain development data it’s clear that the error has been made by the authors of the reports, rather than in the research on which the reports are based. In order to change behaviour it’s essential to identify its causes accurately.

The causes of social problems

A name that keeps cropping up in the child development literature is that of Urie Bronfenbrenner, a psychologist renowned for his Ecological Systems Theory of child development, often depicted as a set of concentric circles representing nested systems as shown below.

external ecological systems affecting child development (after Bronfenbrenner)

The point made by Bronfenbrenner’s ecological systems model is that many external factors at different levels of complexity interact to influence a child’s development. The same point is made by Mareschal et al’s neuroconstructivist model, except that they include factors internal to the child (genetic, epigenetic and behavioural). In the diagram below I’ve integrated the neuroconstructivist framework with Bronfenbrenner’s and Allen’s and Duncan Smith’s models, taken a cross-section, and highlighted Allen and Duncan Smith’s causal pathway in red. Even though the diagram is sketchy (I’ve omitted many factors and their possible links to outcomes), it’s clear that Allen and Duncan Smith’s model of the links between poor attachment and social problems is a narrow one. Although there is little doubt that low levels of maternal ‘attunement’ and ‘empathy’ could result in the social problems referred to, there are clearly many other factors that could also cause them, not taken into account by Allen and Duncan Smith.

integrated outline of factors affecting child development

Of course there’s no reason why government shouldn’t focus on one particular cause of social problems. After all, water purification, sewage treatment, education, free healthcare and democracy have each resulted in major improvements to quality of life. The difference is that the evidence demonstrating the adverse effects from drinking polluted water, lack of access to sanitation, education, healthcare and living under an authoritarian regime, is robust. The evidence demonstrating a causal pathway between poor attachment, brain abnormalities and an array of ‘social problems’, isn’t.

Blaming the parents

Decades of research have demonstrated that the causes of Allen and Duncan Smith’s ‘social problems’ are many, varied and often interact in complex ways. Identifying what interventions might be most successful in reducing social problems is a challenging task. And some potentially effective interventions, such as de-criminalising drug use or adopting alternatives to custodial sentences, are deeply unpopular politically. It’s much easier, and more intuitive, to allocate the blame for social problems to factors at Bronfenbrenner’s microsystems level than to tackle the complex, expensive and potentially embarrassing task of identifying possible causes at the economic, legislative or historical level. In locating the primary cause of social problems with parents – notably mothers – Allen and Duncan Smith are conveniently overlooking other possible causes at the level of the child (genetics, epigenetics, disease, diet, environmental toxins); the microsystems level (churches, schools, communities, quality of education, health and social care); the exosystems level (employment, economics, legislation, government policy); the macrosystems level (cultural assumptions, global trends) and the chronosystems level (constraints and affordances that have arisen historically). Again there is no doubt that bad mothering could cause abnormal brain development and could lead to social problems, but there is considerable doubt over whether it’s the main cause of either. In short, what Allen and Duncan Smith don’t say is as important as what they do say.

The real world is an uncompromising place

Concerned about the poor quality of evidence in the chapters on the brain in these two papers, I contacted Graham Allen. A member of his research team called me back. He assured me that the material on the brain in the Allen report had been approved prior to publication by a neuroscientist, Professor A. I contacted Professor A – who incidentally isn’t a neuroscientist. He said his role was to check the evidence on parenting programmes; the scientific advisor was Dr B. I contacted Dr B – also not a neuroscientist. No, he worked on the chapters on standards, what works and cost-benefit. Both Professor A and Dr B said they had questioned the use of the report’s cover image and had pointed out that it might be counterproductive.

This brings us back to the issues of expertise and use of evidence I highlighted in relation to Kanner and Bettelheim. The chapter on brain development in Allen’s Next Steps report doesn’t appear to have been written or checked by someone with expertise in the field – despite there being a number of high profile neuroscientists with excellent international reputations working in universities in the UK. It also raises questions about the role of ‘think tanks’. Despite inevitable shortcomings, universities have acquired a reputation for producing reasonably reliable, valid research findings; that is, research findings that reflect consistently and accurately the situation in the real world. Government policies based on a rigorous analysis of reliable, valid data are likely to be effective. Unfortunately politics tends to be not so much about the real world as about beliefs about the real world. Successful political campaigning involves persuading people that you are right and that those with opposing beliefs are wrong. It doesn’t matter, politically, if you haven’t understood the evidence or if you’ve misinterpreted the data, as long as you make a persuasive case for your policies. Of course for the people who benefit (or otherwise) from those policies, it’s quite important what evidence you are using, because if the evidence doesn’t reflect the situation in the real world, your policies won’t work. The adult social world might be open to manipulation and compromise, but as anyone who works with children, animals or materials will tell you, the real world is a pretty uncompromising place. The increasing reliance by politicians on material from think tanks founded by, or with strong links to politicians (as is the case with both the Centre for Social Justice and the Smith Institute who jointly published Early Intervention: Good Parents, Great Kids, Better Citizens) suggests we might see increasing amounts of policy-based evidence as distinct from evidence-based policy. It remains to be seen how the real world will respond.

References

De Bellis, M.D. (2005). The psychobiology of neglect, Child Maltreatment, 10, 150-172.
Glaser, D. (2000). Child abuse and neglect and the brain – a review, Journal of Child Psychology and Psychiatry, 41, 97-116.
Mareschal, D., Johnson, M., Sirois, S., Spratling, M.W., Thomas, M.S.C. & Westermann, G. (2007). Neuroconstructivism: How the brain constructs cognition, Oxford University Press.

policy makers on the brain

Findings from neurobiology research are presented as ‘medical evidence’ by politicians Graham Allen and Iain Duncan Smith to support their proposals for early intervention programmes for children from deprived backgrounds. Before looking in detail at what they have to say about brain development, it might be helpful if I summarise my understanding of the process. It squares with the account cited by Munro here [1]; so I’m assuming I’m on the right track.

Brain development

Brain development is an outcome of the interaction between four factors [2];

• genetic
• epigenetic (the impact of the environment on gene expression)
• environmental (from nutrition to the behaviour of others)
• behavioural (the impact of the child’s own behaviour)

The relative impact of the different factors varies between individuals and at different stages of development.

The number, formation and location of brain cells (neurons) is almost entirely genetically determined, although it can be affected by environmental factors. A baby has a full complement of neurons at birth, although some neurogenesis occurs in some areas of the brain in adults.

Interconnections between neurons are formed by synapses.

diagram of synapse

The evidence suggests that the role of synapses in learning is essentially a three-stage process.

Novel patterns of sensory input result in new synapses being formed (synaptogenesis). The number of synapses in the brain increases dramatically in the first three years after birth, running into trillions – far more than are found in adult brains.

If the same patterns of sensory input are repeated, some neuronal connections are reinforced and others weakened by synapses dying off (synaptic pruning), resulting in the formation of efficient information-processing pathways.

A third stage, myelination, takes place when neuronal pathways that are used repeatedly develop a fatty myelin sheath that greatly increases the speed of transmission of electrical impulses along the neurons. This makes some processes very fast and they are experienced as ‘automatic’.

Learning also appears to be kick-started by genetically-controlled factors such as the underlying structure of the brain and reflex responses. Reflexes are automatic, unconscious motor responses to stimuli [3], ranging from tongue protrusion to the step-reflex that forms the basis for later walking [4].

When DNA divides during the formation of gametes (eggs and sperm), and then recombines at conception, it is susceptible to the deletion, duplication and transposition of genetic material. Because of these genetic variations, and the impact of epigenetic factors during development, each human being is genetically unique. This means that due to genes alone, one would expect to find a wide range in abilities, behaviours and personalities across a large population. This variation would increase through interaction with environmental factors.

The second chapters of the papers by Allen and Duncan Smith are about brain development and particularly about how maltreatment and neglect can affect it. Although I can see what these chapters are getting at, my impression is that they include a number of misunderstandings, over-simplifications, assumptions and statements that are simply incorrect. This is a long post – I’ve detailed several examples.

Early Intervention: Good Parents, Great Kids, Better Citizens

Graham Allen MP

Rt Hon Iain Duncan Smith MP

1. “Human infants arrive ready to be programmed by adults. From our first moments of life we are tuned into the facial expressions of those around us, as can be seen from the infant reflex to mimic.” (p.56)

Although there’s no doubt that children are influenced by adults, I think many parents and teachers would question whether they can be ‘programmed’; if that were the case, children with good parents would consistently display exemplary behaviour.

It’s not clear what is meant by a ‘reflex to mimic’. A reflex is an automatic response to a stimulus. Mimicry (in humans) involves copying an action made by someone else. Newborns do appear to mimic some facial movements such as mouth opening and tongue protrusion, although it’s not clear whether this is a reflex response (e.g. tongue protrusion occurring in response to objects moving toward the baby’s face [5]) or active mimicry. In addition, there is the question of which adult behaviours children mimic, since they clearly don’t mimic all of them, which suggests that mimicry isn’t a reflex. Newborns are indeed tuned in to facial expressions, but whether that’s because the infant visual system is good at pattern-matching and adult faces are a frequently encountered visual pattern, or whether infants have an inbuilt preference for faces is still unclear.

2. “The problem is that this wonderful advantage turns into a disadvantage when it is met by the longterm lack of positive expression on the nearest face, that of the primary caregiver. When this most basic need for a positive response is not met, and when a tiny child does not feel secure, attached and loved, the effect can be lifelong. Neuroscience can now explain why early conditions are so crucial: effectively, our brains are largely formed by what we experience in early life.” pp.(56-57)

This statement assumes that from the ‘first moments of life’ a baby recognizes a positive facial expression, is capable of feeling security, attachment and love, and that the absence of these feelings can have a lifelong effect. There’s no doubt that what a newborn experiences affects brain development, but no evidence is cited for a basic ‘need’ in newborns for any particular facial expression or affect state.

Neuroscience does not claim that ‘our brains are largely formed by what we experience in early life’. Quite the contrary; what it claims is that our brains are formed by the interaction between genetic expression and experience. In the first moments of life genetic factors are disproportionately predominant because the child has had very little experience.

3. “As synapses are also strengthened and reinforced by experience, early life defines which of them live and which die. Synapses become ‘hard-wired’, or protected, by repeated use, enabling very rapid learning via early life experience. Conversely, just as a memory will fade if it is hardly ever accessed, unused synapses wither away in what is called ‘pruning’. In computer terms what takes place is the software (programming by the caregiver) becomes the hardware (the child’s fully-grown brain). The whole process has the effect of making early learned behaviour resistant to change.” (p.57)

If this model were correct, adults would be unable to learn anything. They wouldn’t be able to correct early misconceptions because the relevant synapses would be ‘protected’, nor would they be able to develop new skills because the relevant synapses would have ‘withered away’ through early lack of use. The term ‘hard-wired’ is usually used to refer to biologically determined connections in the brain (those that don’t rely on information from the environment), not to neural pathways developed via experience. Training in the armed forces and emergency services demonstrates that well-established patterns of what’s normally considered instinctive behaviour (panic, aggression etc.) can be over-ridden, provided enough rehearsal of new behaviours takes place. And the Cambridge delinquency study shows that violent and aggressive behaviour in young males falls off rapidly as they get older indicating that behaviour patterns are not set in stone.

In addition, the passage allocates all experience to ‘programming by the caregiver’ as if children receive no other environmental input. This might be the case for a child kept in a sound-proofed, darkened room, but for most children, however deprived, the caregiver’s ‘programming’ forms only a part of the input from the environment.

4. “To summarise: scientific discoveries suggest it is nurture rather than nature that plays the lead role in creating the human personality.” (p.57)

What scientific discoveries actually suggest is that nature and nurture play an approximately equal role in influencing human behaviour and that their relative contributions vary throughout the lifespan. Much of the environmental variation is due to chance events in later life rather than early experience [6].

5. “The more positive stimuli a baby is given, the more brain cells and synapses it will be able to develop”. (p.57)

The number of brain cells is almost completely genetically determined; neurons are not formed in response to positive stimuli and the baby has a full complement at birth. What the research suggests is that connections between brain cells (synapses) are formed in response to novel sensory information (‘positive’ or otherwise) and are then pruned when those stimuli are repeated, to create robust pathways for processing information that is handled repeatedly. And that synaptic pruning is what is critical for making information processing efficient. People whose synapses are not pruned at the typical rate often have significant learning difficulties [7].

6. “Trauma also confuses the neurotransmitter signals that play key roles in directing the paths of growing neurons and therefore hinders brain development.” (p.60)

Some neurotransmitters are involved in neuronal migration but no evidence is presented as to how trauma confuses their signals or what deficits occur as a result. The primary role of neurotransmitters is to activate or inhibit neighbouring neurons across synapses.

7. “ To the best of current knowledge, the sensitive window for emotional sensitivity and empathy lies within the first 18 months of life, and these ‘skills’ are shaped by the prime caregiver”. (p.60)

This assertion appears to be based on work by Schore [8] although there is no attribution in this section. There’s a debate over sensitive or critical periods; they certainly exist for basic visual and auditory processing skills, but windows for other more complex skills are less clear-cut. If there is a sensitive window for emotional development within the first 18 months of life, how is the success of emotional literacy programmes explained and how could early interventions up to the age of 3 years be effective?

8. “Because the infant’s cortical and hippocampal emotional circuits require significant time and experience to mature, the child must regulate its inner world primarily through attachment relationships with primary caregivers. It accomplishes this through aligning its state of mind with that of the caregiver, by establishing a conduit of empathic attunement, functioning as an emotional umbilical chord.

Babies who are healthily attached to their carer can regulate their emotions as they mature because the cortex, which exercises rational thought and control, has developed properly. However, when early conditions result in underdevelopment of the cortex, the child lacks an ‘emotional guardian’.”(pp.61-62)

I think what this passage is trying to say is that prior to the maturation of frontal cortex which plays a significant role in controlling behaviour, infants regulate their behaviour in response to what primary caregivers do. What the passage does say is open to question. It’s unclear what is meant by ‘emotional circuits’; there’s no mention of the significant role of the amygdala in emotional processing; no evidence is cited to support the idea that a child needs to ‘regulate its inner world’ as if through some form of emotional homeostasis, nor to support the idea that a child can do so only via an attachment relationship with a primary caregiver. What exactly is meant by a child ‘aligning its state of mind’ or ‘a conduit of empathetic attunement’ isn’t clear.

9. “Following a 10-year immersion in thousands of scientific papers on neurobiology, psychology and infant development, Alan Schore concluded:

The child’s first relationship, the one with the mother, acts as a template that permanently moulds the individual’s capacity to enter into all later emotional relationships’

We glimpse this in the way small children look to a parent’s facial expressions and other non-verbal signals to determine how to respond (and feel) in a strange or ambiguous situation.” (p.62)

Dr Schore has done some impressive work on brain development and emotion, but this statement doesn’t reflect the wide range of factors known to impact on emotional relationships. In fact, all the neurobiological findings cited in Early Intervention: Good Parents, Great Kids, Better Citizens appear to have been filtered through a psychodynamic model of child development, notably attachment theory. The paper also relies heavily on a small number of sources; Bruce Perry, for example, gets 17 mentions (and 11 in Early Intervention: The Next Steps). It’s difficult to avoid the impression that the paper started out with a thesis and then selected evidence to support it.

Now for;

Early Intervention: The Next Steps

10. The cover image

Cover image from “Early intervention: The next steps”

The caption for this image says the right hand scan is from a series of three children, but the original source (a paper by Bruce Perry) [9] says it’s from one child in a group of 40 identified as having suffered global neglect (defined as ‘relative sensory deprivation in more than one domain…e.g. minimal exposure to language, touch and social interactions’). MRI or CT scans were available for 17 of those children, of which 11 were deemed abnormal. It isn’t clear what variation there was within the group, or whether possible genetic causes or environmental causes other than sensory deprivation were investigated. Perry’s team found ‘dramatic differences’ from the average in head circumference. There was ‘some recovery of function and relative brain-size’ after a year in foster care. There were no marked differences between neglected and control groups in the much more common ‘chaotic neglect’ (physical, emotional, social or cognitive).

I don’t doubt that children with minimal exposure to language, touch and social interactions have brains that differ from the norm, nor that they improve in foster care. However, Perry’s analysis raises a number of questions. Healthy, non-neglected children don’t have identical brains (the healthy brain was on the 50th percentile), so why not compare the neglected brain with one at the lower end of the normal range? What type of neglect had the child suffered? Were genetic disorders taken into account? Or diet? Or disease? Does the rate of increase of head circumference change with age? Does it vary between individuals? Although striking, all this particular image actually tells us is that one child who suffered global neglect also had abnormal brain development.

11. “Our responses to situations are not pre-set at birth. The nature/nurture debate has moved on, as was demonstrated in ‘Early Intervention: Good Parents, Great Kids, Better Citizens’.” (p.13)

The nature/nurture debate has indeed moved on, but not quite in the way Good Parents, Great Kids, Better Citizens thinks. See point 3 above.

12. “ Children are born with an instinct to engage socially and emotionally, especially with their mothers. They communicate with the voice, face and hands. They express a curiosity about both the world and their need for comfort and security.” (p. 14)

See points 1 & 2 above.

13. “Recent research also shows insecure attachment is linked to a higher risk for a number of health conditions, including strokes, heart attacks and high blood pressure, and suffering pain, for example from headaches and arthritis. Secure attachment was not linked to any health problems that have been studied.” (p.15)

The validity of attachment theory appears to have been accepted without question. Like many constructs used in psychiatry, ‘attachment’ is loosely defined and difficult to operationalise. Not all children develop patterns of attachment that fit neatly into Ainsworth’s categories, nor are patterns of attachment solely determined by parental behaviour [10].

I’m also concerned about the conflation of correlation with causation. A correlation between insecure attachment and heart disease, smoking etc. does not mean that they are necessarily linked, or even if they are, it doesn’t follow that insecure attachment is the cause of heart disease, smoking or reckless driving. It could equally well be the case that inherited characteristics that predispose people to heart disease, addictions or risk-taking, via low dopamine levels for example [11], could also contribute to inadequate parenting.

14. “Although poor parenting practices can cause damage to children of all ages, the worst and deepest damage is done to children when their brains are being formed during their earliest months and years. The most serious damage takes place before birth and during the first 18 months of life when formation of the part of the brain governing emotional development has been identified to be taking place.” (p.15)

The second sentence appears on p.71 of the Munro Review of Child Protection: Final Report, and is attributed to a Royal Society publication Brain Waves Module 2: Neuroscience implications for education and lifelong learning (Munro reference 95) which contains no such statement. Munro’s reference 94 is to Early Intervention: The Next Steps, so the attribution is obviously a typo, but nonetheless the assertion that poor parenting causes ‘brain damage’ is presented here as a matter of fact without any supporting evidence.

15. “Different parts of the brain (governing, for example, sight, hearing, etc) develop in different sensitive windows of time. The estimated prime window for emotional development is up to 18 months, by which time the foundation of this has been shaped by the way in which the prime carer interacts with the child.” (p.16)

See point 7 above. Presumably this claim is based on the same source, but no sources are cited here.

16. “Infants of severely depressed mothers show reduced left lobe activity (associated with being happy, joyful and interested) and increased right lobe activity (associated with negative feelings)19” (p.16)

The Dawson et al. paper (reference 19) is behind a paywall so I couldn’t clarify what is meant by left and right ‘lobes’ and their supposed functions. Presumably this refers to work that suggests the left and right frontal lobes respectively have specialized functions, but this isn’t made clear. Nor is it clear whether the levels of activity in the ‘lobes’ is due to the mothers’ depression or whether mothers and babies share biologically inherited activity patterns.

17. “One result is significantly fewer synapses (or connections). Specialists viewing CAT scans of the key emotional areas in the brains of abused or neglected children have likened the experience to looking at a black hole. In extreme cases the brains of abused children are significantly smaller than the norm, and the limbic system (which governs the emotions) may be 20–30 per cent smaller and contain fewer synapses.” (p.16)

According to Sue Gerhardt in Why Love Matters: How Affection Shapes A Baby’s Brain (her presentation to the Quality of Childhood Group in the European Parliament in December 2009) the ‘black hole’ quote comes from Harry Chugani [12], and refers to the development of medial prefrontal cortex (MPC) in the brains of Romanian orphans. Here, Gerhardt is talking about the development of the ‘social brain’ (MPC):

The less attention a baby receives, the less this part of the brain connects up. In the worst cases, like some of the most damaged Romanian orphans, this area of the brain was virtually a black hole according to one researcher, Harry Chugani.” (Gerhardt, p.89)

and illustrates the point using Perry’s image – the one that’s on the cover of the Allen report (Gerhardt, p.88). Although MPC is involved in emotional regulation, it is also involved in risk assessment and decision-making using information from many parts of the brain. It’s not clear whether MPC in the orphans was permanently or temporarily abnormal, or what had caused the abnormality. Genetic, nutritional or infective factors don’t appear to have been controlled for. And a small brain isn’t a bad thing per se; autistic children tend to have larger brains than average, for example. Chugani et al were investigating glucose metabolism in the brain, but Gerhardt doesn’t mention this, so it would be all too easy for people unfamiliar with the technical problems associated with interpreting brain scans to go away with the impression that neglect causes children to develop holes in their brains.

18. “Schore has spoken of ‘the child’s first relationship, the one with the mother, acts as a template … [that] permanently moulds the individual’s capacity to enter into all later emotional relationships’25. ”

To attune to a child means responding to their emotional needs, resulting in the child’s sense of being understood, cared for and valued. Empathy begins with the sense of oneness with the other created in this process of attunement. The quality of empathy – the ability to feel for and with another – is not only key to building sound emotional stability, it is also a key inhibitor of the development of a propensity to violence. Conversely, empathy fails to develop when prime carers fail to attune to infants in the first 18 months of life. Absence of such parental attunement, combined with harsh discipline, is a recipe for violent, antisocial offspring. Empathy is influenced very early in life by observed parental reactions to another’s suffering. Even in their first year, children already show signs of whether their reaction to the suffering of another is empathy, indifference or downright hostility.” (p.17)

The quotation from Schore also appears on page 62 of Early Intervention: Good Parents, Great Kids, Better Citizens and is widely cited on the internet, but I couldn’t locate the source; I couldn’t find it in note 25, Schore’s account of the right hemisphere’s role in emotion regulation. There is no question that a child’s early relationships are significant; but no evidence is provided that the relationship with the mother forms a template for all other relationships.

Conclusion

Both Allen and Allen & Duncan Smith papers are about Early Intervention Programmes – the brain development chapters are simply there to add weight to their arguments in favour of the programmes. I haven’t discussed the interventions themselves because I was primarily concerned about the material on brain development. There’s little question that many of the interventions will do some children some good; whether they will address the social problems they are meant to address is another matter. One of the difficulties with social problems is that they are often caused by complex interactions between many factors – so interventions aimed at one or two factors are likely to have only a small effect overall. For example, an evaluation of the Carolina Abecedarian project [13] shows that mean mental test scores for children improved by less than 10 percentage points and that early gains reduced markedly over time – there was little difference at age 21. Age at the birth of a first child was 19 in the treatment group compared to 17.5 yrs in controls. Differences in academic achievement were larger and were maintained – possibly due to the early language support in the programme leading to improved reading. In short, the programme had a beneficial effect, but whether it made significant inroads into ‘social problems’ is debatable.

What concerned me most about Early Intervention: Good Parents, Great Kids, Better Citizens and Early Intervention: The Next Steps is that neither is based on a systematic evaluation of neurobiological data, with the data themselves providing information about what could be done to reduce social problems. Instead, both papers start from a Freudian framework for child development, without questioning its fundamental assumptions; Allan Schore [8] is explicit about the direct descent of this framework from Freud via Bowlby’s attachment theory, and I’ve already drawn attention to the shortcomings of attachment theory.

Instead of drawing on our wide range of knowledge about child development as a whole, both papers focus on just one facet of it; emotional development. Furthermore, they focus on one facet of emotional development – attachment; and on one facet of attachment – the child’s relationship with the primary caregiver. The primary caregiver is often implicitly assumed to be the parent, and more specifically the child’s mother – even though fathers, grandparents and siblings are often primary carers and many children have more than one primary carer. This narrow model of child development is supported with often over-simplified and misunderstood neurobiological findings, selected, it appears, because they support the assumptions that the model makes. Findings that do not support these assumptions are simply omitted.

It could be argued, with good reason, that an in-depth analysis of the neurobiological evidence would be beyond the scope of policy papers like these. However, the omission of aspects of child development other than attachment to the primary caregiver is a serious one. It implies that interventions are being proposed on the basis of a belief that they will be effective, rather than on the basis of an evaluation of research evidence across all areas of child development. This introduces a significant risk of interventions failing to eliminate social problems and being abandoned despite some beneficial outcomes for the children involved. A better approach might have been to enlist the help of a developmental neurobiologist for the evaluation of neurobiological evidence, to identify all the reasons why young people fail to reach their potential and to look at interventions which address each reason, including taking a critical look at the efficacy of current healthcare, education and social support systems.

References

1. National Research Council (2000), From Neurons to Neighborhoods: The Science of Early Childhood Development (Chapter 8), Washington D.C. (available online at http://www.nap.edu/openbook.php?isbn=0309069882)
2. Mareschal, D., Johnson, M., Sirois, S., Spratling, M., Thomas, M. & Westermann, G. (2007). Neuroconstructivism: How the Brain Constructs Cognition, vol. 1. Oxford: Oxford University Press.
3. See e.g. http://en.wikipedia.org/wiki/List_of_reflexes_%28alphabetical%29
4. Thelen, E. & Fisher, D. M. (1982). Newborn stepping: An explanation for a “disappearing” reflex. Developmental Psychology, 18, (5), 760-775.
5. Chen, X., Striano, T. & Rakoczy, H. (2004). Auditory–oral matching behavior in newborns, Developmental Science, 7, (1) 42–47.
6. Pinker, Steven (2002). The blank slate: The modern denial of human nature, Penguin.
7. Cohen, I.L. (2007). A neural network model of autism: implications for theory and treatment. In D. Mareschal, S. Sirois, G. Westermann & M. Johnson (2007). Neuroconstructivism: Perspectives and Prospects, vol. 2. Oxford: Oxford University Press.
8. Schore, A. (2000). Attachment and the regulation of the right brain, Attachment & Human Development, 2 (1), 23–47.
9. Perry, B. (2002). Childhood Experience and the Expression of Genetic Potential: What Childhood Neglect Tells Us About Nature and Nurture, Brain and Mind 3, 79–100.
10. Oppenheim, D., Koren-Karie, N., Dolev, S. and Yirmiya, N. (2009). Maternal insightfulness and resolution of the diagnosis are associated with secure attachment in preschoolers with autism spectrum disorders, Child Development, 80, 519–527.
11. Iversen, L. (2008). Speed, Ecstasy, Ritalin: The Science of Amphetamines, Oxford University Press.
12. Chugani, H.T., Behen, M.E., Muzik,O., Juhasz, C., Nagy, F. & Chugani, D.C. (2001). Local Brain Functional Activity Following Early Deprivation: A Study of Postinstitutionalized Romanian Orphans, NeuroImage 14, 1290–1301.
13. Early Learning, Later Success: The Abecedarian Study (1999). Highlights of the Age 21 Follow-up Study, Chapel Hill: University of North Carolina, FPG Child Development Center. Available at http://fpg.unc.edu/sites/fpg.unc.edu/files/resources/reports-and-policy-briefs/EarlyLearningLaterSuccess_1999.pdf

Image of synapses from Wikipedia.

brain development and social problems

Reading the final report of the Munro Review of child protection, my attention was caught by what turned out to be a minor typographical error. The last sentence of paragraph 5.8 appears to refer to reference 95, the Royal Society paper Brain Waves Module 2: Neuroscience: implications for education and lifelong learning, but in fact cites reference 94. Reference 94 is an independent report commissioned by the current UK coalition government, published in January 2011, written by Graham Allen, Labour MP for Nottingham North and entitled Early Intervention: The Next Steps.

Graham Allen MP

Early intervention is summed up as follows by the ‘Early Intervention Review Team’;

Early Intervention is an approach which offers our country a real opportunity to make lasting improvements in the lives of our children, to forestall many persistent social problems and end their transmission from one generation to the next, and to make long-term savings in public spending….” (p.vi)

In 2008, Graham Allen had written another paper on early intervention, this one co-authored with Iain Duncan Smith and entitled Early Intervention: Good Parents, Great Kids, Better Citizens published jointly by the Centre for Social Justice (CSJ) and the Smith Institute. Iain Duncan Smith is a former leader of the Conservative Party and currently Secretary of State for Work and Pensions. In 2004, he founded the Centre for Social Justice, a centre-right think tank, just after his period of party leadership ended. The Smith Institute is a left-leaning think tank set up in 1996 in memory of the former Labour Party leader, John Smith. Ed Balls, later to become the Labour government’s Secretary of State for Children, Schools and Families, worked for the Institute between 2004 and 2005.

Rt Hon Iain Duncan Smith, Secretary of State for Work and Pensions

In previous posts I’ve complained (at some length) that the model of child development being used by children’s services pays little attention to recent biological research. It would be unfair to suggest that biology is entirely absent however. There are many references to physical development in this literature, Aldgate et al’s book contains a chapter on genetic and biological influences and the Munro report cites the National Research Council’s From Neurons to Neighbourhoods: The Science of Early Childhood Development – chapter 8 contains a comprehensive summary of brain development. The second chapter of each of the two documents written by Graham Allen is also dedicated to brain development. It’s these two chapters I want to concentrate on in this post.

I’m not entirely clear why it was deemed necessary to refer to brain development in papers about early interventions intended to forestall social problems. After all, few people would want to see evidence from brain scans before they could be persuaded that sanitation, a balanced diet or education have good outcomes for individuals and for the population as a whole. And given the technical problems with brain scanning and the interpretation of the resulting images, there are other more reliable ways of measuring the effectiveness of interventions. Allen and Duncan Smith’s Early Intervention: Good Parents, Great Kids, Better Citizens justifies the inclusion of material on brain development as follows;

We make no apology for presenting, as laymen, a considerable body of medical evidence in this chapter. When economic resources are under intense pressure, and facing strong claims from well-established programmes and special interests, we believe that this medical evidence points overwhelmingly in favour of a shift to Early Intervention.” (Good Parents p.45)

What’s the evidence?

The first few pages of chapter 2 of Good Parents focus on results from three large-group, longitudinal studies purported to show that early adverse childhood experiences result in later health risks such as smoking, alcoholism, illicit drug use, obesity and high level promiscuity (Good Parents p.54). At first glance, the conclusions presented are persuasive, but when you look a little more carefully, the picture isn’t quite so clear-cut.

I’ve mentioned several other documents that in some cases refer to each other. To clarify how they are linked, I’ve mapped out the connections here:


Two of the studies, Farrington and West’s Cambridge Study in Delinquent Development, a Prospective Study of South London Males From Ages 8–32 and the Dunedin Multidisciplinary Health and Development Study are prospective – that is, they started with children and have periodically sampled their health, development and behaviour over many years.

According to Allen and Duncan Smith the Cambridge study showed that adult offending could be predicted in childhood (Good Parents p. 51). That’s not quite what the study records. The 2006 report, which tracked the participants up to the age of 48, found that there were predictive factors in childhood for adult offending. In other words, some factors were predictive of behaviour for a particular group, not for particular individuals. The highest correlation between childhood factors and persistent offending was for children having a convicted parent or sibling. What this means is that children with previous offenders in their families are more likely to offend, not that offending can reliably be predicted in individual children. A significant number of children from families with an offender didn’t commit crimes, whereas some children from non-offending families did.

The Dunedin study looked at the health and development of 1037 babies born in Dunedin, New Zealand, between 1972-73. Data from the Dunedin study has been used in over 1000 publications but I couldn’t find which one Allen and Duncan Smith were referring to. They claim that nurses’ assessments of which of a group of 3 year-olds were at risk, predicted criminal convictions, violent behaviour and domestic abuse at age 21. They conclude;

the fact is that children who are likely to have poor outcomes, including adult criminality, can be identified at age three when they are still riding their tricycles.” (Good Parents p.52)

Not exactly. As Allen and Duncan Smith themselves point out, not all of the at-risk children offended, and some of the not-at-risk children did – 18% exhibiting violent behaviour and almost 10 % abusing their partners (Good Parents p.51).

The third study, the Adverse Childhood Experiences (ACE) Study, by contrast, is retrospective; it relies on self-reports about childhood maltreatment, family dysfunction and health status, and therefore on that notoriously unreliable data source, human memory. You can read the questions that were posed to participants in Preventing child maltreatment: a guide to taking action and generating evidence. It’s published jointly by the World Health Organization and ISPCAN, The International Society for the Prevention of Childhood Abuse and Neglect. My curiousity about Preventing child maltreatment: a guide to taking action and generating evidence was initially piqued by the title. I have no problem with taking action against child maltreatment, but do have concerns about ‘generating evidence’. Evidence is usually ‘gathered’ or ‘found’ – implying that it’s already out there, researchers just have to go and look for it. ‘Generating evidence’ suggests that, like Bettelheim, your case might not actually have strong evidence behind it so you need to create some.

I was also concerned by a reference in the Foreword to the idea that

the traditional “privacy barrier” between the domestic and public spheres has inhibited the evolution of policies and legal instruments to prevent violence within the family and provide services for those affected by it.” (p.vi)

I’d predict that the prohibition of violence is as likely to be effective as the prohibition of alcohol consumption, but that violence might be lessened if its causes were to be addressed. Furthermore, the ‘traditional “privacy barrier”’ isn’t about “privacy” – a relatively recent development in human history – but about protecting the individual from the abuse of power by the state. I’m sure the author, who’s had extensive experience with the UN, is aware of that. But I digress.

I also had concerns about Box 1.1 (p.8). It’s entitled Child maltreatment and damage to the developing brain and is adapted from a pamphlet published in 2001 by the National Clearinghouse on Child Abuse and Neglect Information and the National Adoption Information Clearinghouse called In Focus: Understanding the Effects of Maltreatment on Early Brain Development. The pamphlet lists 31 references, 11 by Bruce Perry and one by Allen Schore. In 13 pages, Schore’s work is cited 17 times and Perry’s 40 times. These names crop up again in the papers by Allen and Duncan Smith.

My concerns about Box 1.1 and the In Focus pamphlet weren’t so much about what they said, as about their emphasis. Firstly, maltreatment and neglect of children is, by definition, harmful – that’s why they are called maltreatment and neglect. We already know that certain practices cause harm to children, at the time they happen, immediately afterwards, and, in some cases, throughout life. We don’t need evidence from brain scans to tell us that. But maltreatment and neglect are being presented as if pre-existing evidence of harm isn’t sufficient to persuade legislators that more stringent legislative measures are required to prevent maltreatment and neglect, so neurobiological findings are being recruited for this purpose. Secondly, although there is certainly evidence to suggest that maltreatment and neglect have a negative impact on brain development, they are only two of the factors that do so. In other words, you could predict with some confidence that maltreatment and neglect would result in ‘abnormal’ brain development, but you can’t assume that because someone’s brain has developed abnormally, that they were maltreated or neglected as a child. Thirdly, there’s an implicit assumption in the way the evidence is presented that maltreatment and neglect are the primary cause of ‘social problems’, when social scientists have been aware, for decades, that those causes are many, varied and have complex interactions.

In short, the evidence doesn’t appear to support the idea that the predominant cause of social problems is child maltreatment or neglect. Allen and Duncan Smith call for a study along the lines of the Dunedin study to be carried out in the UK “in order to provide definitive evidence on the benefits of Early Intervention” (Good Parents p.52). I can’t see why another study is necessary – the Cambridge study makes clear that the causes of antisocial behaviour are complex and that patterns of behaviour change significantly over the lifespan.

Update 13/12/16:  Thanks to @PaulWhiteleyPhD on Twitter for drawing attention to this article in Nature analysing the Dunedin study findings.

In the next post, I want to look at what Graham Allen and Iain Duncan Smith have to say about brain development.

Photographs of Graham Allen and Iain Duncan Smith from Early Intervention Early Intervention: Good Parents, Great Kids, Better Citizens.