What's wrong with dummies?

This is a summary, kind of, of part of a Science Showoff slot I did back in April.

One of the first decisions we were asked to make when our baby was born (I suspect because he was in the neonatal unit) was whether or not to give him a pacifier, otherwise known as a dummy. I've never had a particular prejudice one way or the other, but I've since met a lot of UK parents who either are very proud their baby doesn't use one, or who say they don't like how they look, or who are happy their child sucks their thumb. And the very term for it tells you how they are seen in the UK - dialect words are more neutral (soother, dodie) as is the US word pacifier.

There's some very emotive language out there - both from lay people ("can't you take that thing out of his mouth" - My mother, 2012) and from researchers ("Harmful oral suction habits" - just as a for example, Moimaz et al., 2010)

The two main objections that people seem to have are that pacifiers harm babies' teeth, causing malocclusions (misalignment, aka overbite or underbite) and that they slow babies down in learning to talk.

So, what's the evidence for these?

Thumb/finger sucking and sucking a pacifier tend to be know, together, as "non-nutritive sucking". Both types of these have definitely been associated with malocclusions - for example, here they are compared to bottle and breast feeding, and the type of feeding didn't make as much of a difference to children's dental alignment as did sucking a comforter (of whatever type).

From that point of view, yes, sucking a pacifier does seem to cause some dental problems. But is there an alternative? Should parents just not let their child have a pacifier? Should we have said no?

Well, if parents don't allow children to have a pacifier - the likelihood is that  they will suck their thumb or finger.  If both of these can cause dental problems, maybe that's OK. And if your mum is complaining about the pacifier, maybe she wouldn't complain as much about the thumb. That article is pretty old, but this issue seems to bother people less currently, so there isn't much later research looking at the same thing.

One of the largest studies of infants and children in the UK, ALSPAC, has some great data showing why it might not be such a good idea to prefer thumb/finger sucking over pacifier sucking.  Firstly, pacifier use was more common among less well off and less educated families (see, I knew everyone thought I was a slummy mummy for using one!). But although at 15 months almost twice as many children used a pacifier as a thumb/finger, by 36 months about the same number used each one. So, pacifier users were twice as likely to drop the sucking habit by the age of 3. If you don't want your child to turn out like Pike in Dad's Army, still sucking his thumb at the age of 17, better stick to pacifiers.

What about speech and language? Well, there's very little evidence here at all - but basically it doesn't make any difference (pdf).Children who've used a pacifier for a long time have no more speech problems than those who haven't.

There are some good things about pacifiers - they do seem to reduce the risk of SIDS, and obviously sucking in general (not just pacifiers) soothes babies, as well as older toddlers.  There does though seem to be some evidence for an increase in middle ear infections in babies who use pacifiers. The evidence for reduction in SIDS seems to be about as strong as the evidence for increased middle ear infections. As one is a lot more serious than the other, on balance for health reasons using a pacifier is probably better than not.

But you know, that isn't going to stop your mother from telling you it "looks bad" for your baby to use a pacifier. So, here's my husband's suggestion for what to do with your mother:

I promise, I really do...

Back in April I did a Science Showoff standup slot on the science of being a new parent. I talked about odd remedies that you might have recommended to you by the health visitor or GP (homeopathic teething granules, gripe water) and about the science behind dummies/pacifiers.

I have a draft of a post on pacifiers and I REALLY REALLY promise I will put it up! Soon! Honest!

Evidence for treatments for abused/neglected children - part 2

This is part 2 of a series of posts looking at the treatments that parents of abused and/or neglected children might be offered. Part 1 which explains a bit of the background, and a bit more about why evidence matters, is here.

So, moving on from the names mentioned in the previous post, we come to Bessel Van der Kolk.  Here, I'm starting to feel a little more confident.  The research (and there is actually research, with actual data) is grounded in well-established theories - I'm not a specialist in PTSD, but I do know that it's a well-established disorder, that we know it happens in children as well as in adults, and that a lot of research groups work on the disorder. This all gives us confidence both that the disorder exists, and that no one group of psychologists is going to be the only ones saying something, which could just be their personal theory.

A couple of interesting background articles include this one which talks about multiple instances of trauma in childhood (e.g. through repeated abuse, or different types of abuse) and whether this might increase the complexity of PTSD. As I say I'm not a specialist but they include neglect and abandonment as two categories of childhood abuse (but importantly they are ONLY two categories and they weren't the most common either).

They found that more instances of abuse did increase the complexity of PTSD, and interestingly the more trauma there was in childhood the worse were symptoms - but more trauma in adulthood didn't mean more symptoms.

I know many parents whose children were neglected but there's no evidence of abuse are interested in how this can affect them - it's hard to say specifically from this paper but because there were several possible traumas in childhood, it doesn't look like "only" being neglected is likely to lead to complex PTSD.  I'd have to do more reading to say what the link was between neglect and any PTSD at all, though.

The diagnosis of complex PTSD does seem to be applied to a proportion of children who have been abused and/or neglected and Van der Kolk also has some ideas on treatment, such as this chapter. The suggestion is for what he calls Phase Oriented Treatment, which briefly seems to start with symptom management and move on via other steps to therapies including Exposure Therapy and EMDR.

However, I started to get a little sceptical when I looked up this treatment programme (it's not so much a treatment as a programme of different treatments, that must be applied in a particular order). I can't find a group that has evaluated the programme in a valid way - no controlled trials. Van der Kolk in this same chapter says that his programme of treatment for adults (note not children, and we have to be very wary of recommending treatments for children on the grounds that they work for adults) works better with PTSD patients, citing a controlled trial. I can't find the precise trial he talks about, but another paper  (pdf) by the same group says that the two treatments were just as effective as each other, and the part of that study that Van der Kolk calls "prolonged exposure and cognitive restructuring" - his recommended treatment - seems to be CBT, about which a lot is known, and seems to be effective.

I find it a bit odd that Van der Kolk uses this study to suggest that CBT (or PE/CR as he calls it) is no use for PTSD while the original researchers suggest it is good for PTSD.  And it's all very well to say (even if it's true) that "lots of patients drop out in conventional PTSD treatment" (the figure was 30%) but to go on to say, which he does, they are "harmed" by it seems a bit strong.  The study he's citing here does not actually include the programme of treatment he recommends, anyway. So I'm not sure what to conclude about his treatments.

Although Van der Kolk doesn't seem to be saying that his treatment recommendations in general are all about EMDR (which is an eye-movement based treatment, but which does have something in common with CBT. It has a bit of a bad press among a few quack-watch types but there does seem to be some evidence for it), he himself has published a controlled trial (pdf) of EMDR in adults (versus a drug treatment or a drug placebo - there wasn't a therapy control group), and there's another study of EMDR versus a waiting list group in children. As I said in my previous post, waiting list (or no therapy control groups) are not great to evaluate psychological therapies - just talking generally to a helpful therapist is likely to make people feel better.

Both of these studies though seem to show that EMDR helps PTSD symptoms - and continued to help after 2 months in the child study and 6 months in the adult study.

Phew! After posting this the very nice Keith Laws sent me a metanalysis (a research study that analyses other research studies) here (pdf) specifically looking at EMDR and PTSD in children, which does look at some studies that compare EMDR to other therapies. The conclusion is it's a lot better than waiting list or other types of treatment that aren't particularly tailored to PTSD, and it's actually a little better than CBT (about which more anon). But there were, really, very few studies that did a full, direct comparison.

Recommend to a friend test: I think a cautious yes on the EMDR, but most of the evidence is only versus no therapy.  Though Van der Kolk's theories on the development of PTSD in children are backed up, there doesn't seem to be anything at all backing up his ideas on his programme of therapy - that's a definite No, especially as it seems to be so very time consuming and lengthy (and therefore expensive. Am I very wrong to hypothesise that he charges a lot? And charges a lot to train people to do it?). He himself criticises dropout rates in other therapies but doesn't tell us how many people drop out from his multi-phase treatment.

It's time to talk more here about treatment for PTSD in general. The NICE recommendations (pdf - the NHS best clinical evidence recommendations) say that there isn't enough evidence of complex PTSD being different from "regular" PTSD so they look at treatments for all kinds of PTSD (other researchers say this too. Let's be conservative and say more trauma in childhood probably = worse PTSD). Because it's difficult to diagnose in children (Van der Kolk's first study is of outcomes in adults whose trauma was in childhood), and there aren't that many studies, most of the studies are on those who have experienced sexual abuse - though behaviour and mental health difficulties are, as Van der Kolk says himself, similar.

There are some controlled trials here - phew!

For older children, there seems to be some help from CBT (compared to "supportive therapy", in other words talking to a therapist without a specific type or plan for treatment) on some aspects of children's behaviour and mental health, but not others. For children under 7, it's hard to measure mental health directly but CBT also seems to help children's behaviour. None of the studies went on for long enough to tell if the CBT affected children's behaviour or mental health in the long term. As families often drop out of therapy when they don't find it's helpful, they also looked at whether the dropout rates differed.  Again, it wasn't possible to tell.  These all seem to have been studies of trauma-focussed CBT, in particular.

Interestingly some practitioners  and some of the trials, compared what happened when the mother had CBT with giving it to the child.  I wasn't too surprised to read that it didn't help to give this instead or as well!

RtaF: As far as we can tell this particular type of CBT does help PTSD in children, at least in the short term, and it helps quite young children too. I would recommend this, but would love to see more data.

Before I finish what was supposed to be a concluding post but is going to be one of at least a couple more, I can tell, I can see (!) I wanted to comment on another theory that Van der Kolk has, which is that as well as the category of PTSD there should be a category of Developmental Trauma, for children who have suffered prolonged abuse and neglect and have consequent behavioural and mental health problems.  This may or may not be a separate category of disorders according to the "official" manual used to classify psychiatric problems (the DSM). A new version is about to come out and I can't find out if it is going to include this.

Van der Kolk, among others, has suggested this would be a good idea and that it should form a separate diagnosis.  He thinks it would be a better diagnosis than PTSD, and he's probably right in saying that there are more symptoms in a lot of children than would be covered under this.  But as he also says (pdf), many children who have suffered abuse meet  another diagnostic criterion.

And there hasn't been any particular treatment proposed for this group as a whole - who's to say that lumping all these children together isn't a mistake too, and that you need to look more closely at their symptoms and/or other diagnoses they might have, to treat them effectively? The consensus among some researchers is that if the diagnosis exists with an emphasis on cause, there might be too much temptation to diagnose all children with this background with the same thing, regardless of what problems they have. Children not only may have differing problems but vary in their resilience in the face of trauma - so will have differing degrees of the same problems.

Therapies for children who have been abused or neglected part 1

Children who are adopted often need a new family because their first family abused or neglected them. This maltreatment can have lifelong consequences for behaviour and development. Parents often experience huge difficulties with their children, and don't know where to turn. They feel disempowered, that they don't know anything, and that no-one will help.  Like parents of children with disabilities, they may feel very grateful if anyone offers a solution. The problem may come with those solutions.

I'm reposting this, slightly edited, from my personal diary blog - I wasn't sure where to post it originally but have been persuaded to put it in both places. I originally started this blog to look at simple, everyday parenting issues like reading and writing, friendship, babies' development but the issues brought up by reading about parents of children with difficulties have meant I want to have a look at therapies.

To give this some background, I've also been having some Twitter conversations with psychologists who don't have anything to do with adoption, but who are getting increasingly irritated with scientists and clinicians publishing papers saying "this therapy is brilliant!" when it isn't. And I also follow a lot of quack-watch type people (Ben Goldacre etc.), and frankly, the state of "therapeutic" offerings for children who have had dreadful early life experiences is way, way below the standard offered by the slightly self-promoting scientists and clinicians. It seems in some cases to be nearer the homeopathy, cranial osteopathy, and pseudo-qualified nutritionists of this world that are the subject of quack watch types.

Let me say at this point that I know I am going to get comments by people saying "but but but we've tried A B or C and it was FABULOUS and our lives have been TURNED AROUND and this person is a God!".

Fine. You can believe that. But if something, on average, has no effect - then that means half the group gets better, half gets worse.  What if you ended up in the group that got worse? Would you be happy you spent your money on it?

And if on average children on a treatment get better (but only compared to themselves at the beginning, or only compared to children who weren't getting any treatment) then it could easily be because they are growing older (children learn things and become better behaved, mainly, as they get older) or because they've had some special attention.  This is usually cheaper than therapy.

If you need to be persuaded further why we need evidence on parenting have a look at my introductory post.

So... I thought I'd see what evidence there was for a couple of the really popular training and therapy centres that are talked about a lot by adoptive parents: the Child Mental Health Centre (Margot Sunderland's place) and Family Futures (which is a voluntary adoption agency,and I believe in that capacity has great inspection reports, I'm not sure that its training side gets inspected).

The Child Mental Health Centre says one of its aims is:

Dissemination of Research

To promote positive social change through disseminating the latest research in child, parent and family mental health

To make available to parents, teachers, child-care professionals, providers and custodians of services, politicians and the lay-public at large, a comprehensive up-to-date knowledge base in child and family well-being

To fund an effective dissemination of psychologically and neurobiologically based research. Organisational isolation can be costly: ...wasting time slowly re-discovering what is already known (Baron Peter Slade, 2000)

Family Futures says:

Our therapeutic interventions draw upon and are informed by the work of Dan Hughes, Theraplay, Bruce Perry, Bessel Van der kolk, Babette Rothchild and Dr A. Jean Ayres and many others.

I'm still looking for a list of research that the Child Mental Health Centre is disseminating. So I'll start with Family Futures. Let's take those in turn and see what evidence there is that these theories and therapies work.

Dan Hughes: I found this paper by him about his therapy and its basis. It doesn't present any evidence for its evaluation, and I am not completely sure (because it's not my area of specialisation) that his therapy described there is the same as Dynamic Developmental Psychotherapy, but DDP is compared in a few studies to treatment-as-usual, and it seems to come out well. The studies aren't large, but then fully diagnosed Reactive Attachment Disorder isn't common.  The studies don't tell us anything about DDP in children who haven't got RAD. This review suggests however that the statistics in Hughes' study are pretty rubbish, and worries about some of the ethics of it.

Family Futures now offer a training course that includes DDP, which they call "Neuro-Physiological Psychotherapy". I'm not sure what makes it neurophysiological, as neurophysiologists are generally medical doctors who have a speciality in a branch of neurology, or lab scientists who work with lab animals. I'm also not quite sure whether the hyphen makes a difference.

The "Recommend to a Friend test": I might recommend this to a friend whose child had a diagnosis of RAD. But probably not. I'm not sure if enough is known about it to know if it would be harmful or helpful, or neither, to a child who didn't have such a diagnosis.

Theraplay: Chapter 5 in this book by Wettig talks about the evaluation of Theraplay. The studies randomised children to either treatment or waiting list controls (which aren't necessarily the best control - partly because just giving children attention rather than no treatment can improve outcomes). A lot of the children in this study had some developmental disability, which is typical of children who also have the kind of behaviour problems Theraplay is often recommended for. 
The chapter says that the children who had therapy improved more than the children who were on the waiting list, though I can't seem to find (perhaps I'm not looking hard enough) any graphs or figures that directly compare these two groups, only graphs showing children's behavioural problems before and after Theraplay. A review I found here says there aren't any other studies showing Theraplay is effective, and makes a good point about its theoretical basis in attachment theory but the fact that it kind of ignores attachment theory in how it is supposed to work.

The RtaF test: I'm not convinced I would.  The Wettig book chapter is rather grandiose in how many different disorders it claims Theraplay can treat or influence, too, which puts me off considerably.

Bruce Perry: I can find a lot of articles by Bruce Perry on the theory behind what happens to children if they are neglected or abused.  Certainly (if you are getting accurate information) it can be helpful to understand what's going on when you have a child that's difficult to parent. He does talk a little about therapy, but doesn't recommend or describe any particular type, saying instead 

the Neurosequential Model of Therapeutics (NMT) allows identification of the key systems and areas in the brain which have been impacted by adverse developmental experiences and helps target the selection and sequence of therapeutic, enrichment, and educational activities.

It's beyond the scope of this post (read: I should be doing something else) to evaluate ALL of his ideas about what affects what when development is disrupted. He does have a tendency to say "brain" when he means "behaviour" or "cognitive development". For example he talks about "

NMT Functional Status and Brain ‘‘Mapping’ [...] An interdisciplinary staffing is typically the method for this functional review. This process helps in the development of a working functional brain map for the individual [see Figure 2, which is a rather odd pyramid showing the names of brain areas shaded in dark or light]. This visual representation gives a quick impression of developmental status in various domains of functioning: A 10-year-old child, for example, may have the speech and language capability of an 8-year-old, the social skills of a 5-year-old, and the self-regulation skills of a 2-year old. 

(In other words, they will do some behavioural and cognitive testing, make assumptions about which brain area is responsible in children, and tell parents they are making a brain map. My quack detectors are twitching. We know very little about how normal brain-behaviour links are mapped,and even less about how they develop in children who have difficulties. Many very clever and famous people have said this, lots of times). He is careful not to recommend any specific types of therapy but he also says:

the sequence in which these are addressed is important. The more the therapeutic process can replicate the normal sequential process of development, the more effective the are (see Perry, 2006). Simply stated, the idea is to start with the lowest (in the brain) undeveloped=abnormally functioning set of problems and move sequentially up the brain as improvements are seen.

Erm... well, I'm a developmental neuropsychologist, and I've never, ever heard of this principle. As he's quoting himself, do you think possibly he might be the only person who thinks this? 

OK, it's possible that he's right, and everyone else is wrong - 64 other articles have cited this article. The fact that I can't find any neuropsychologists who have cited it might tell you something. I also looked up his affiliations and tried to find papers he'd published which had experimental data in them, or anything really that evaluates this method. I didn't have any luck.  

I could be missing something, but most of the articles I can find seem to be theory, and not to have any data. He's listed as head of his own Child Trauma Academy, and as an Adjunct Professor in his alma mater - but at that institution all I found was a simple listing, again with no research papers.

The RtaF test: Go and do a university developmental psychology course, preferably also a university neuropsychology course, if you want to know how the brain develops.  The Open University is very good. Also, if you want to know the state of knowledge (which isn't very much) about how brain and behaviour links develop, especially in atypically developing brains, I'd highly recommend Annette Karmiloff-Smith's articles - this one (pdf) is one of my favourites.  

She talks a lot about how we cannot be sure that, especially if brain development is disrupted, all the same processes are going on that would be happening without disruption (which we know little enough about anyway), or in adult brains (which is what we know most about).  Bruce Perry's theory seems quite wedded to the idea that specific areas of the brain do specific things, we know exactly what they do and therefore we can be sure which areas aren't working properly if certain functions are disrupted, and you can (or indeed must) work on their functions separately - more or less the opposite of what many developmental neuropsychologists would say.

Incidentally, and I'll come back to this if I find more, if you have a child who's suffered trauma, there is an evaluated treatment for this - which is again mentioned by the Allen review article - Trauma-Directed CBT. I can't see either of the centres I'm looking at recommending this or training people on it. I'll keep looking. It's recommended by NICE for children who have PTSD. I've seen very few mentions of children or young people being offered it, or parents looking for it.

So, sensing that my readers' patience might be wearing thin, I'm going to leave my trawl through this branch of therapy for the moment, and hopefully come back to it in the future.

Parents getting control of money? Shock Horror!

The Department for Education recently announced that they will be piloting "personal budgets" for adoptive parents, to fund therapy and services. Sounds fabulous! Why am I sceptical of this idea?

We have no horse in this race (our son was adopted, but not from care) but as someone passionate about evidence-based parenting I am very wary of the wide range of training, therapies, and interventions that are out there for children with difficulties. I knew about this before I became an adoptive parent, through my work with children with disabilities.  And I'm becoming increasingly aware, mainly through social media, of the types of interventions adoptive parents seek and would love to have funded.

The trouble is - and this is the subject of many very long blog posts, at least one of which is pending - we know nothing or next to nothing about the treatments and interventions that work for children who have suffered abuse and neglect.  There is a multiplicity of organisations that talk lovely stuff and promote themselves, and have expensive training days. There are some therapies that purport to work.  Parents find it very difficult to get these therapies funded, currently. But many of the websites and books seem to throw around "brain", "science" and names of brain areas in ways that sound suspiciously like neurobollocks. My preliminary trawl of one or two has yet to come up with a therapy with a good evidence base. I'll keep you posted on that.

In fact, some of the organisations, therapies and trainings that neurobollocks specifically talks about are the very ones that adoptive parents seem to be told about, and that they would like for their children (in the category of home remedies, brain training on handheld computer games comes up a lot for example, and is taken at face value, ditto fish oils for ADHD).

I have tweeted the DfE (twice) to ask whether there will be safeguards to ensure treatments and interventions are evidence-based and vulnerable parents will not be exploited. I'll let you know if I get a response to that too.

Edit: I got a reply!  DfE sent me a web page that has a link to another site that talks about the piloting of personal budgets. I'm not clear if they are already piloting them (it doesn't look like it) but as far as I can see, the budgets are to be used on service provided by local NHS Trusts (for those outside the UK, hospitals or primary care/mental health care) and education authorities OR (and I'm not completely clear on this) partners who are charities working in children's developmental needs or mental health needs.

I asked them if they had any adoption-specific charities to add to this because that would be very interesting - are they adding any and if so, which ones. I wasn't surprised not to get an immediate answer to that as the Twitter monkey typist will be off asking the ringmaster for information.

I am not completely reassured by the use of the budgets only in NHS or education authority circles though. We all know about various neurorubbish like Brain Gym and learning styles that's used in schools, and several of the therapies I'm researching at the moment (see my new post) are provided by NHS mental health services.

Edit 2: I got another reply! "The Government is currently exploring options on how to pilot personal budgets for adoption". So they don't know yet, but they haven't got any providers of dodgy therapies that charge loads on board, just yet. At least there's that.

Attachment in traditional, "AP" type societies

Do traditional societies promote strong attachment in the way that "Attachment Parenting" enthusiasts would like to suggest? I've posted some personal opinion on this issue a while ago, but I thought some evidence was in order.

I have been reading work on attachment in African societies - there are a few studies over the years, some quite old, some fairly recent - and first I should explain a couple of things:

Firstly, and I know a lot of people will realise this, babies are not "attached" or "unattached". Researchers in this field talk about babies having a "style" which does seem to lead to some differences in older childhood or later life.  But some styles - mainly a "secure" style - have been suggested may lead to children being more confident and able to cope with life when they are older. And others - in particular a "disorganised" style seem to be associated with risk factors. If you want to read more about the overall theory of attachment,

Secondly, although mainstream attachment researchers believe that a mother's sensitivity to her child's behaviour is what leads to differences in attachment, there's now a lot of evidence that other differences between mothers (especially mind-mindedness - parents' ability to work out what a baby might be thinking) are more important.

So although the mainstream attachment researchers might not completely agree with other researchers who look at babies' development on what is driving babies' attachment styles, it's still interesting to look at what's happening in traditional societies - especially since some of the core components of "Attachment Parenting" are found in these societies - especially bedsharing, breastfeeding on demand, and carrying babies close in a sling or arms most of the time.

Some of the factors in the African societies I've been reading about, though, are far less than what child development researchers - and a lot of parents - would consider optimal for babies. Other factors are just a little different to what we in the North or West might be used to.

It's pretty common in a lot of developing countries for older children to spend a lot of time caring for young infants. This is something most of us might consider a neutral influence - in the extreme it might not be ideal for the older children, and it's different to the standard Western setting where a parent or two are the main carers, but it's unlikely to be harmful, would be most people's thought at the outset.

Among the Gusii people in Kenya this is the standard caring practice but older children spend most of the day playing with the baby, while the mother still feeds and washes the baby. Some schools of thought would say that it's the main carer - the one who does all the practical stuff for the baby - that would be the person a baby is most attached to. But in this group, babies are attached both to their mother and to their older child playmates. And interestingly, it was the attachment to the playmate that predicted babies' cognitive development - not, as we'd expect from Western families, their attachment to their mother.

Gusii woman and toddler

A couple of other situations that are common in developing countries, that we might think were less than ideal (to put it mildly), are polygamy* and high infant mortality.  Two of the African attachment studies were in societies that practice polygamy and with particular dangers to infants, and/or high infant mortality.

In the Hausa society in Nigeria, many adults - including co-wives - live in a compound with children of all of the adults.  Babies are cared for by one caregiver in particular, usually an adult, but not always the mother - in some cases, the mother feeds the baby and then the baby is immediately passed back to the caregiver.  Infants aren't allowed to move around or to explore physically, but they are happy to explore objects they are given or to look around their environment - but only if they feel secure, if their main caregiver is present.  They seem to be attached, mainly securely, to their main caregiver - and as in the Gusii society it's not necessarily the person who feeds them.

Hausa woman and toddler

In the Dogon group in Mali, life seems to be quite similar to among the Hausa. Babies suffer very high infant mortality, and live with their mother and her co-wives. Babies are fed on demand - as the "AP" enthusiasts would like - and kept physically close. However in this group a lot more babies seemed to be "disorganised" in their attachment. This seemed to be related not to any failure in the main "AP" practices but to some rather frightened or frightening behaviour on the part of the mother.  Interestingly this doesn't fit into the main "attachment is due to sensitivity" theory as well as it does to the "attachment follows from mind-mindedness" - appearing frightened or negative when a baby wants to play positively is a good example of not being mind-minded.  It may be that mothers feel the need for toddlers to be obedient and stay close, due to the dangerous nature of their life, and that they think frightening the babies is the best way to achieve this.

Dogon woman carrying baby

If you're interested in finding out more:

Tomlinson, M., Murray, L., & Cooper, P. (2010). Attachment theory, culture, and Africa: Past, present, and future. Attachment: Expanding the cultural connections, 181-194.

*which is a bad thing, if you are interested, because it only works on a society wide basis with very young marriage of women, similarly very young first pregnancies, and very large age gaps between husbands and wives.