A recent issue of the journal Child Maltreatment included a report of the American Professional Society on the Abuse of Children (APSAC) concerning attachment therapy (Chaffin et al., 2006). The article contained a critique of the controversial holding therapies and coercive parenting approaches advocated by some clinicians for attachment disorders.  The article pointed out that these methods have no empirical evidence of effectiveness and in fact may be harmful.  The practices described included coercive restraining procedures, aversive tickling, forced eye contact, withholding of food and water, and insistence on total parental control. These therapeutic strategies are not derived from accepted principles of attachment theory based on the work of John Bowbly and Mary Ainsworth which stress sensitive and responsive parenting in order to foster secure attachments.  The article also cautioned against the overuse of the diagnosis of attachment disorder pointing out the difficulty of distinquishing between this diagnosis and others such as oppositional defiant disorder or conduct disorder.

Unfortunately, the authors of the APSAC report on several occasions used the term "attachment parenting" to refer to coercive parenting techniques.  Attachment parenting is a term first used at least 20 years ago by William Sears to refer to the responsive style of parenting shown to lead to secure attachments based on the work of Bowlby and Ainsworth.  Attachment Parenting International, a group that facilitates the formation of parent education and support groups, promotes practices such as preparation for childbirth, emotional responsiveness, breastfeeding, baby wearing, responsive nighttime parenting, avoiding frequent and prolonged separations, positive discipline, and maintaining balance in family life (www.attachmentparenting.org).  Though some characterize attachment parenting as extreme, proponents argue that  it represents a return to the close contact pattern of child rearing that characterized our species for 90% of human history (see the work by Mel Konner) and represents the pattern to which babies are adapted.  A reply to the Chaffin article by the Attachment Parenting founders and research group was published in the November 2006 issue of Child Maltreatment.

Chaffin, M., Hanson, R. Saunders, B. E., Nichols, T., Barnett, D., Zeanah, C., et al. (2006).  Report of the APSAC Task Force on attachment therapy, reactive attachment disorder, and attachment problems.  Child Maltreatment, 11, 76-89.

A recent study by Mosier and Rogoff (2003) suggests that the “Terrible Two’s” may in fact be a product of our cultural beliefs and associated power-assertive parenting strategies. Mosier and Rogoff observed U.S. middle class mothers and Guatemalan Mayan mothers while their toddlers (14-20 months) and older siblings (3-5 years old) sought access to attractive objects.

The Mayan mothers were what we might call “indulgent” because they did not expect their toddlers to share or take turns with the older siblings. Toddlers hold a privileged status in Mayan society because they are seen as too young to be capable of misbehaving intentionally or willfully harming a person or object.  The older Mayan siblings were expected to yield the attractive objects to their toddler siblings.

By contrast, the U.S. mothers expected the toddlers to share or take turns with the older siblings and they were forced to comply. Despite the disparity in age and maturity, U.S. toddlers and preschoolers were given equal treatment by their mothers.

Mosier and Rogoff argue that the Mayan approach of respecting the freedom and choices of toddlers results in more cooperative behavior when these children grow older. Indeed, they found that 68% of the interactions of U.S. toddlers and their older siblings involved competition over the attractive objects, whereas 61% of the interactions of Mayan children were cooperative.

The authors suggest that the adversarial approach to childrearing in the U.S., in which toddlers are expected to follow rules established by adults at an early age, may stem from Puritan practices to break a child’s will to overcome an inborn evil nature. Power-assertive behavior management techniques such as the use of rewards and punishments are used to induce toddlers to comply against their will.  This adversarial approach to childrearing may result in behaviors we associate with the” Terrible Two’s.”

Support for Mosier and Rogoff’s claim can be found elsewhere in the developmental literature. For example, in two studies, Susan Crockenburg found that power-assertive techniques used by mothers in her U.S. samples were associated with anger, defiance, and non-compliance among toddlers (Crockenberg,1987; Crockenberg & Littman, 1990). Ironically, the very disciplinary strategies commonly used in the U.S. to enforce compliance, may actually result in the opposite of what is intended – angry defiance.
 

Crockenberg, S. (1987).  Predictors and correlates of anger toward and punitive control of toddlers by adolescent mothers.  Child Development, 58, 964-975.

Crockenberg, S., & Littman, C.  Autonomy as competence in 2-year-olds:  Maternal correlates of child defiance, compliance, and self-assertion.  Developmental Psychology, 26, 1990.

Mosier, C., & Rogoff, B.  (2003). Privileged treatment of toddlers:  Cultural aspects of individual choice and responsibility.  Developmental Psychology, 39, 1047-1060.

Common wisdom would dictate that immigrant Latino women, coming from Mexico, Central and South America, should try to “acculturate” as soon as possible to enjoy the benefits of the US dominant culture. This would mean that they might try to learn to speak English, perhaps speak English at home and to “adopt” new and more modern ways  of rearing children and doing things with the family. However, in view of several recent studies, this should be put in question. The evidence suggests that immigrants may “lose” in terms of mental health outcomes the more acculturated they are. This is the case clearly with women in the perinatal period. Surprisingly, the evidence, Ixchel has learned, shows that the less acculturated immigrants from Latinamerica, have lower infant mortality, perinatal complications and low birth weight compared with Latino women who are more acculturated ( i.e. who have been born here, or who have spent over 13 years in the US) . The more acculturated ones have higher prevalence of all those problems, including drug use/dependency, alcoholism and depression. This same phenomenon has been found in men and even in adolescents, the more “acculturated” the higher the rate of psychosocial difficulties, less exercise, worse diet ( higher rate of overweight and diabetes). It is speculated that the “traditional” societies offer extensive psychosocial support, for instance for women, and also that there are informal social controls. So, mere “blind” acculturation may not be the best idea for immigrants.

Aguirre-Molina M., Molina CW y Zambrana RE  Health issues in the Latino Community . Jossey Bass

Heilemann MV, Lee KA, Kury FS.  Strengths and vulnerabilities of women of Mexican descent in relation to depressive symptoms.  Nurs Res 2002 May-Jun;51(3):175-82

Martorell, R., Mendoza, F.S., Castillo, R.O., Pawson, I.G., Buldge, C.C.  Short stature and plump physique of Mexican-American children.  American Journal of Physical Anthropology.  1987.  Vol. 73.  475-487

Ortega AN; Rosenheck R; Alegría M; Desai RA. Acculturation and the lifetime risk of psychiatric and substance use disorders among Hispanics . J Nerv Ment Dis. 2000 Nov;188(11):728-735

Pastore D.R., Diaz a.D. Cultural and medical issues of Latino adolescents. Adolescent Medicine. 1998. vol. 9 . 315-322

What is the outcome of persistent or excessive crying? D. Wolke and his team explored this question in a recent pediatric article.  Several authors who have investigated excessive crying and “colic” in early infancy have reassured parents that the problem seems to be benign  and that it often resolves spontaneously. In  infant mental health clinics  this condition is not often fulfilled, as the child continues crying well after the typical remission of “colic”.  In this important follow up study several dozens of children were followed up to preschool years. The assessment of behavioral profiles showed that they had roughly double the risk of having attentional problems and hyperactivity compared with the general population of children. This corresponds with the “common wisdoms” of many clinicians who see hyperactive children, in a proportion of them there is a history during infancy of excessive crying. Many infants who cry excessively during the first year and beyond continue to have some sort of “regulatory difficulties’ later on in their life.

Dieter Wolke, Patrizia Rizzo, and Sarah Woods .Persistent Infant Crying and Hyperactivity Problems in Middle Childhood
Pediatrics, Jun 2002; 109: 1054 - 1060

This is a very difficult question to answer with any certainty. Glover and her group have in the past studied the effects of stress in terms of contraction of the uterine artery (causing distress to the fetus) and also the correspondence of high levels of cortisol in the mother and in the fetus. In the present very important report, this group attempts to investigate the behavioral outcome in children at age four, whose mothers suffered from various stressors and emotional difficulties during the pregnancy with them.

This huge study involved 7448 pregnant women and their children up to age four. Women were assessed at various periods during the pregnancy for their level of anxiety, depression, presence of stressors, including obstetric risks. Anxiety in the mother predicted statistically more behavioral difficulties in boys and girls at age four, in terms of inattention and more hyperactive behavior in particular, although it was also associated with emotional difficulties. The authors suggest a direct association between maternal anxiety and an influence on the developing brain of the fetus.

O'Connor TG, Heron J, Golding J, Beveridge M, Glover V.Maternal antenatal anxiety and children's behavioural/emotional problems at 4 years. Report from the Avon Longitudinal Study of Parents and Children.Br J Psychiatry 2002 Jun;180:502-8

The clinician is often faced with the question from concerned parents: should I breastfeed while taking this medication? Is it safe for our baby to breastfeed while the mother is taking, say an antidepressant medication? The response to these questions is not easy to find…This article is a review of the literature on this topic, reviewing articles since 1955. It is a great accomplishment in this sense, only to leave most of the clinical questions yet unanswered. What this means is that there is very little research on the safety, effects and possible long term consequences of exposure to these medications through breastfeeding. The article is valuable as it reviews the issue by class of medicines and also by psychiatric disorder ( e.g. depression, anxiety disorder, bipolar disorder, etc.). One great value of the article is that it calls the attention of the clinician to issues like the immaturity of the baby’s liver to metabolize certain medications, the different body composition of the baby ( eg. Content of fat) and the different functioning of the blood brain barrier ( much more permeable than in the adult). Also, it gives some recommendations about the timing of the medication  taking into account when the baby is going to take the feeding. For instance, they recommend to give an antidepressant like an SSRI at night, as most babies will tend to eat less during that time and therefore the exposure to the medicine will be minimized, depending on the “peak serum level” of the medicine in question.  Anyone wishing to know the state of the current knowledge about this topic in some detail should read this article. In short there is no way to offer complete reassurance to mothers, for instance dealing with antidepressants, but there is no evidence of any ill effects for the baby with the most commonly used SSRI’s.
 

Burt, V.K., Suri, R., Altshuler, L., Stowe, Z., Hendrick,V.C., Muntean, E. The use of psychotropic  medications during breastfeeding. American Journal of Psychiatry . 2001. vol. 158. No 7. pp. 1001-1009

This book is written by Sarah Hrdy who was trained as an anthropologist, primatologist, and evolutionary theorist.  She had personal reasons for delving into this topic as she experienced enormous conflicts in wanting to pursue her career while also being a mother.  This book has incredible depth in the examples she is able to call up from both the animal world and across human cultures.  One of the most fascinating discussions for me was the thorough review of the prevalence of infanticide and abandonment in humans.  The level of committment by human mothers to any particular offspring is influenced by a myriad of circumstances, including whether or not she has support from others, whether she has other offspring needing attention, the amount of resources available to her, etc.  This perspective puts into context the trade-offs that mothers have always made and suggests that the abortion rates we see today may not be an aberration but an expression of the age-old choices that mothers have had to make as to how much investment they could put into each offspring.    I also enjoyed Hrdy's discussion of the baby's role.  Because the mother's committment is not automatic, babies have evolved mechanisms to "woo" their mothers to care for them (cuteness, chubbiness, crying, etc.).  Babies have about 72 hours in which to do this as most infanticide and abandonment occurs before this period.  Although she is not a proponent of the "glue" theory of bonding, she does argue that in mothers at risk of distancing themselves from their babies, close intimate contact in the first hours and days after birth can have the effect of invoking maternal feelings in the mother.   Differing attachment patterns in older babies are viewed as adaptive solutions to caregiving that reflects differing levels of committment, i.e. a baby adopts avoidance as a strategy so as not to provoke a rejecting mother.  This book is well worth reading.

Hrdy, Sarah (1999). Mother Nature:  Maternal Instincts and How They Shape the Human Species.  New York:  Ballentine Books.

* Deals with the importance of remembering the social brain as well as the cognitive brain and how much early experience impacts that.  Attachment theory is the major scientifc base of the field of infant mental health.

* Wonderful section on drawing a circle of respect
* "It's vital that you remember that he is a separate person, deserving of your undivided attention and respect but also capable of acting on his own. I want you to try to envision youself drawing a circle around your baby, an imaginary boundary that delineates his personal space."
* Great little tips about how to be with the baby, avoiding overstimulation, making the environment interesting, pleasant, and safe, fostering independence, talking with rather than at, engaging and inspiring while letting the baby lead. I think this book is a gem for home visitors and anyone working with parents. Certain parts are also resources for teachers and  child care care
providers.

Tips for programs that have been in operation for awhile:

* Review all written materials about your program and imagine that you are a parent wishing to enroll your child.
* Think about how these materials help or hinder you in your work
* Schedule time to train/retrain your First Contacts, scheduling a group event with food so that participants can learn from each other and process their work.  Then follow up by checking now and then and thanking them. If you can't get a group together, do it individually.

The California Head Start-State Collaboration Office produces an impressive newsletter called Bridges.  A recent issue focuses on infant mental health, training and technical assistance, children with challenging behaviors, and web sites. This issue is excellent in defining infant mental health, relating the importance of relationships to brain growth, citing research that presents convincing evidence about the importance of early identification and intervention, and offering readers both interesting facts and further resources. This issue of Bridges can be found at the Child Development Division’s World Wide Web site. www.cde.ca.gov/cyfsbranch/child_development/headstart.htm

A group of pediatric gastroenterologists met in Rome to try to produce a “diagnostic consensus” on a number of  common conditions in infancy and early childhood, about which there is little agreement on how to diagnose them and what they look like clinically. The group produced the so-called Rome II criteria for these disorders.  The article is quite valuable in that it covers a number of conditions that sometimes are baffling for clinicians, it helps to think about how to diagnose them and how they should be treated. It is a “small jewel” in this respect. It describes conditions of vomiting in infancy like infant regurgitation and the “infant rumination syndrome”, as well as the more rare relative “cyclic vomiting” which is thought to be an equivalent of migraine. For the somewhat older child, conditions like dyspepsia ( discomfort in the stomach), aerophagia ( constant swallowing of air leading to abdominal discomfort and premature satiety during meals) as well as abdominal migraine. Finally, it also describes a condition in infants called “infant dyschezia”, which occurs in the very young infant, less than six months of age, who screams and cries before every bowel evacuation, which may lead to constipation if the child avoids defecating due to the fear of pain. In short, this paper is very worth reading and keeping around to review the diagnostic criteria and tests that might be useful when a puzzling diagnostic issue of this nature is seen in a very small child.

Rasquin-Weber, A., Hyman, P..E., Cucchiara, S., Fleischer, D.R., Hyams, J.S., Milla, P.J., Staiano, A. Childhood  functional gastrointestinal disorders.Gut, 1999. Vol. 45. suppl. II. 11601168

For some time now, it has been thought that women ( and men) from traditional socities, i.e. Developing countries, often do not express depressive feelings in the same way as in more “modern” societies, for example in Northern European Countries or the US. It is thought that depression manifests itself not so much by thoughts of self-deprecation, guilt and  feelings of sadness. Instead, depression is thought to be manfiested more by back pains, headaches, constant tiredness and other vague somatic sypmtoms. This is a relevant point for instance when exploring maternal or postpartum depression in a woman. The study from Zimbabwe points out that same finding. However, the authors go on to say that if one then asks the women whether they feel sad, upset, irritable or depressed they often do endorse such feeling.

This very interesting study  from Dr. Patel and a research group that has studied depression in Africa for some time, argues that in practice most patients who suffer from depressio also suffered from anxiety and question the wisdom of making depression and anxiety states two “different” conditions. Also, they highlight the great prevalence of these states in conditions of psychosocial stress, poverty, environmental deprivation and feeling trapped. These conditions are exactly what is prevalent in many inner city neighborhoods for instance in the U.S. particularly  in minority populations.  It seems that many of those conditions of deprivation are also quite prevalent in modern socieites and the same manifestations occur in affected  groups.

Patel, V., Abas, M., Broadhead J., Todd, C., Reeler, A. Depression in developing countriess: lessons from Zimbabwe. British Medical Journal 2001. Vol. 322. 482-484

For some time now, in the media and other sources, there is the idea that the incidence of autism and autistic-spectrum disorders has increased dramatically. The idea has been unchallenged in the literature until now. In a very lucid article, Dr. Eric Fombonne (Institute of Psychiatry , London University), questions the available evidence for that claim. To being with, he points out that the cases in question are usually referred cases, which suggests that one is talking about an increase in treated cases, earlier identification, and a sheer increase in population in centers where this has been reported, like in California. Dr. Fombonne carefully reviews a number of fallacies and biases in a widely quoted report from the California Department of Developmental Services, which is one of the centerpieces of the claim about the increased incidence of autism. Together with other reports reviewed in his brief article, the author demonstrates that there is no scientific basis to conclude that there is such increased incidence. He does not say that there is no increase, but simply demonstrates that the evidence used to make the claim of increased incidence is non-existent. Among other things, the article makes one reflect on the lack of sophistication of most professionals (including ego) reading scientific literature, not only regarding epidemiology, but statistical analyses, etc., so the claims are often taken “on faith”. This is a refreshing reminder that the “devil is in the details”.

Fombonne, E. Is there  an epidemic of autism? Pediatrics. Feb 2001.  Vol.107. No.2. pp. 411-412.

Steven Poole and David Magilner remind the reader to always take into account the possibility that a child with intense excessive crying might have a medical condition. Actually, the authors describe their experiences in evaluating  babies who are brought to the emergency room of a hospital with a complaint of excessive cry. This is particularly important in the child who has cried for several hours and cannot be soothed. They warn that some of these infants are misdiagnosed as “ having colic” and sent home when there may be an infection, encephalitis, urinary tract infection, or the effects of an insect bite. One of the most frequent cause they found in their review of previous cases in a large emergency room was an infection of the middle ear,  followed by a viral infection leading to dehydration. Another cause may be constipation leading to difficulties with the passing of stools.  Their advice is to perform a careful physical examination of the baby, including the skin and to obtain a careful history  searching for clues. In some cases they recommend observation in the Emergency room and further laboratory studies. This is one of the rare accounts of medical conditions leading to excessive cry. There is an long list  of conditions the reader will want to keep in mind as much as possible so as to take these factors into account when faced with a baby who cries excessively. The piece is a chapter of a great book on crying, that refers mostly to research findings, rather than clinical material, but is a great resource nonetheless.

Poole, S., Magilner D. Crying complaints in the emergency department. In: Barr, R.G., Hopkins, B., Green, J.A. Crying as a sign, a symptom and a signal. 2000. London. Mac Keith Press.

There are many studies of maternal postpartum depression, but few have looked at the status of the new father. A  study conducted in Liverpool, Australia (Matthey, Barnett, Ungerer and Waters) addresses, among others, this topic. Studying 157 couples who had their first child, the researchers found a higher risk of depression in the new father, when the new mother suffered depression. The risk was even higher the other way around, when the husband  was depressed, the spouse had a much higher likelihood of being depressed herself. Other few studies have found similar results, yet depression in the father – or spouse- is seldom addressed or thought about.  The risk factors for depression in the new father (similar to those for the new mother) are different early in the postpartum period than when the baby is around one year old. In the early postpartum period, there is correlation with the way the father was raised by his own parents (a style that is more controlling and overprotective was the most strongly correlated). Around the first birthday, the strongest predictor of depression was difficulty in the marital relationship, or low support between the spouses. The authors stress that it is difficult to get men to endorse symptoms of depression, particularly in self-administered questionnaires, and speculate there may be a number of barriers for men to acknowledge negative feelings. The study suggests that the stress of having a baby about to turn one require a particular attention to support between the spouses. The issue of paternal depression is relatively neglected and would deserve further study and exploration in the clinical setting.

Matthey, S., Barnett, B., Ungerer, J., Waters, B. Paternal and maternal depressed mood during the transition to parenthood. Journal of Affective Disorders, 2000. Vol. 60. 75-85

When an infant is very small, has low weight or does not gain in stature, the doctor often looks at the mother. If she is rather small, this is thought to be the cause of the child's own small size, i.e. a genetic reason.  Together with other information (eg.studies of Waterlow on food supplementation in preschool children ), a study by Thame and colleagues in Jamaica throws
further doubts on the assumption of "small mother-infant". This is an important point because an assumption of genetic link overlooks the more obvious explanation -  the child is small because he/she is not eating enough calories, or
proteins (in the case of small stature). Furthemroe, the mother is small because she herself did not eat enough of these when she was a child. Several previous studies have shown that when preschool children are given supplementary diets,
their final height is much more than that of their mother or father. In their study, Thame et al. also show that the more the mother is small, thin and chronically malnourished, the smaller the infant will be at birth. The authors also point to the evidence of a  high risk of hypertension and even diabetes during adulthood, when the child was born with malnutrition in utero (or
small for gestational age). This has been called a "programming" effect on the body.

Reference:  Thame,ML, Wilks, Rj, McFarlane/Anderson, N, Bennett, F.I.,Forrester T.E.  Relationship between maternal nutritional status and infant's weight and body proportions at birth. European Journal of Clinical Nutrition.1997 March. Vol. 51. 134-138

In an issue of the Child and Adolescent Psychiatric Clinics of North America, James Garbarino includes a chapter on being poor in the United States. Ixchel finds that the author offers a fresh and more "in depth" account of what being a poor child is, including some personal memories of his own childhood. The review is historical and includes data up to the late 90’s regarding poverty. Contrary to the usual accounts of numerous statistics, Garbarino goes beyond numbers to give a human face to poverty, including the experiences of shame, of "feeling outside" and not as "regular people". He correlates the numerous stressors of poverty with brain development, social and emotional development and with values. He cautions against taking "economic indicators" (that are very optimistic) at face value, as they do not take the poor into account when the economy is measured as if it were a uniform and global phenomenon only . This is a powerful review of the effects of poverty on the emotional life of children and families.

Garbarino, J. The stress of being a poor child in America. Child and Adolescent Psychiatric Clinics of North America. 1998. Vol. 7. No. 1. p. 105-118

Pediatric advice to parents changes from time to time, on issues like feeding, the position of the child while asleep, holding, etc. In this comprehensive review, Dr. Susan Orenstein, who is one of the world’s experts on gastroesophageal reflux has some new advice for clinicians and parents. The reader will be surprised to learn that what for decades has been the standard recommendation, i.e. to put the child in a sitting position, is now thought to be counterproductive. The new recommendation is to have the child lie on his/ her belly, as this tends to diminish the amount of reflux into the esophagus. The prevalence of the condition is thought to be around 8% of unselected infants, although many clinicians have the impression that this is diagnosed with increasing frequency. Gastroesophageal reflux is associated with asthma, and “apparently life threatening episodes” as they are called now, i.e. episodes of near asphyxia. Dr. Orenstein does recommend thickening the feedings in the younger infant, for instance with rice cereal, making each meal more consistent and richer in calories ( going from the usual 20 Kcal/ounce to 30Kcal/ounce), including breastmilk ( put in a bottle and thickened). There is a review of medical and surgical treatment and their relative success rate.

Reference. Orenstein, S.R., Izadnia, F, Khan, S., Gastroesophageal reflux disease in children. Gastroenterology Clinics of North America. 1999. Vol. 28. No.4. 947-970

Everything you always wanted to know about obstructive sleep apnea. This article is a very thorough, even though not very extensive review of the features of this, often neglected or ignored, problem. The piece provides an excellent review of the multiple causes of sleep apnea in the infant and young child, from malformations of the mandible, palate and soft palate, to tonsillitis and adenoiditis. We learn about the association of sleep apnea with difficult behavior during the day, irritability, hyperactivity and even with failure to thrive. A review of treatment approaches is at the end of the review. This article will familiarize the newcomer to this disorder, which has a prevalence of about 3% of young children, and when present, can lead to multiple complications. The clinician should take it into account and routinely ask whether the young child snores, sleeps in funny positions, thrashes a lot during the night or appears tired during the day.

The reference is  Bower, C.M. and Gungor, A. Pediatric obstructive sleep apnea syndrome. Otolaryngological Clinics of North America. 2000. vol. 33. no. 1. 49-75

This is a fascinating and compelling article about the innate fragility of males (Kraemer, Sebastian.British Medical Journal. 2000. 1609. Vol. 321. 1609-1612). It reviews literature from various fields and presents a number of facts that might be surprising for many readers. For instance, male mortality is greater than female mortality throughout life ( from in utero till old age).  Based on the review of many sources, Kraemer says that there is evidence that male embryos are more vulnerable than female ones. At the time of conception, there are more male than female embryos, but they tend to survive less to the time of birth.  Apparently, perinatal brain damage, cerebral palsy and congenital deformities of genitalia and limbs are also more common in boys, as well as prematurity and stillbirth.  Also, a female newborn is physiologically equivalent to a 4 to six week male child.  It is better known that autism, hyperactivity, clumsiness, stuttering and Tourette syndrome are also more frequent in  males. It is hypothesized that these conditions might be linked to an X chromosome site. Also, it appears that boys are more difficult to take care of; they tend to be more irritable, to be less rhythmic and more challenging and more sensitive than girls. Kraemer suggests that precisely the cultural expectations that boys should be more tough and stronger than girls, runs against this fragility and vulnerability.  Later on in life, boys are less likely to be able to talk about their feelings and to have more aggressive behavior statistically. Girls have better literary skills and express their feelings more explicitly. Alexithymia, the inability to tak about one’s feelings is more frequent in males . When exposed to the distress of others, boys tend to be less sympathetic than girls, which has been suggested by a number of studies of exposing children to the cry of infants.  More data and facts are presented in this compelling review.

Is it time for clinicians and society to change their view that boys should be stronger and tough than girls, given those remarkable vulnerabilities?

Dr. Kraemer is a child psychiatrist at the Tavistock Clinic in London, UK

Finally we have “manuals on child rearing” from other cultural perspectives. A new book , put together by Judy DeLoache and Alma Gottlieb is a collection of such manuals.  The authors of the different chapters of this book ( called A World of Babies. Imagined Childcare Guides  for Seven Societies. Cambridge University Press 2000)  present a number of prescriptions on  the care of the pregnant woman, for delivery, and for care of the newborn baby. Also, they have a lot of material on the health beliefs and cultural practices, rituals and their rationale taking the perspective of members from those specific cultural groups. One surprise is that there is a section dedicated to “Puritan practices”, where the researcher wrote down what the immigrants from England to New England would have prescribed for child care, dealing also with the work ethics and the strict moral principles that still  resonate strongly in the US. There is a section that is illuminating about some Islamic practices in Turkey, one from an African group and one from Polynesia as well. In the section on a Turkish village, for instance, the reader would learn what swaddling the baby means. Beyond purely having the child not startle himself (or herself) with hand movements, the idea is that the baby is “spoken for” as he or she is carefully covered. It is a way of manifesting love for the baby, and that the baby is “covered by care”. In their culture, very valuable things or symbols are carefully wrapped or covered, as they are objects of desire. Also, a blue bed is attached to avoid the effects of the evil eye.

Every chapter is written “from inside” that culture and giving prescriptions and advice as it were self-evident that this is the way to do things.  People will surely enjoy reading the different perspectives, as the book is very well written and fun.

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