Fear and Phobia in Children

pumpkin

It’s Halloween, so what better time to think about children’s fears? Clearly, for most kids, the idea of dressing up as a zombie, blood sucking vampire or evil witch is fun and funny, so what do children find frightening and why?

There is no easy answer to this, as you get some children with very strange fears (for instance I have met children who completely freak out at hairs in the bath or the texture of flour), but I will try and describe in general the progression of fears common to most children. Fears typically vary depending on age and intellectual capacity, moving from almost “instinctive fear” in babies to sophisticated fears of abstract concepts in adulthood, that require more elaborate thought processes.

For babies and toddlers, whose cognitive capacity is still basic, fear is more of an “instinct” than involving much active thought and cognition. Evolution has honed humans to have brains that are hardwired to fear certain things that have served our ancestors well in the past: for instance loud noises (which could have denoted a falling tree, an earthquake, a sabre toothed tiger or any manner of danger) and heights, which if not avoided could lead to untimely death. If you make a loud unexpected noise next to a baby, they will most certainly startle and most will start crying. So aversive are loud noises to babies that it is possible to induce a phobia in babies by using a loud noise.

A phobia is an extreme fear associated with an object or situation. Clinically speaking, it requires that the fear leads to avoidance of the object or situation causing disruption to a person’s day-to-day function. “Little Albert” is a classic case in the psychology literature of a phobia being induced in a baby using loud noise. Little Albert was a 9 month old boy who was not afraid of rats and was given a rat to play with. A dastardly psychologist John B. Watson wanted to see if it was possible to cause a phobia of rats. Every time little Albert touched the rat, a man stood behind him and banged a piece of metal with a hammer making a loud noise scaring little Albert. Needless to say, after a while of this, Albert became afraid of rats and stopped going near them, proving it is possible to induce a phobia. Thankfully ethics boards no longer allow this type of research.

Interestingly, there appears to be an evolutionarily hard-wired biological predisposition to phobia development to things which are traditionally harmful. Thus even in adults, it is easy to induce a phobia for things like rodents, snakes and spiders but very difficult to induce a phobia to cars, guns and knives which are more likely to be a real threat in the modern age.

Although it is hard to prove whether a fear of heights is innate in babies, supporting evidence comes from Eleanor Gibson’s visual cliff experiments of the 60s which tested 6-14 month old babies. Here babies were encouraged by their mothers to cross a floor that had a section partway made of transparent Perspex over a ditch. Most babies would not crawl over the Perspex even though they could feel the floor was solid with their hands. Some babies cried as they “could not” get to their mothers for fear of falling into a ditch. Some fearful babies that did not dare cross rolled onto the Perspex part by accident, good evidence that fear, does not necessarily prevent accidents and proving that babies should not be left near real cliff edges! A few other babies, whether due to fearlessness or ignorance crawled over the Perspex. The dumb and fearless – either bound for greatness or an early exit.

At this young age, babies (at least baby monkeys) are also primed to fear what others fear. This evolutionary trick allows babies to quickly pick up the dominant threats in its environment, as if others feared something; it would probably do them good to quickly learn to fear it too. Mineka showed this clearly in Rhesus monkeys who were laboratory raised and did not fear snakes. After showing the monkeys videos of wild monkeys showing extreme fear to snakes, the baby monkeys became afraid of toy snakes in the laboratory, despite never personally having had an unfortunate encounter with a snake. Babies and young children are also primed to attend to their parents’ fear. I acutely remember breast feeding Big Sis while watching a horror movie late one night. At one point, I held my breath in anticipation of something horrible happening on screen. It would have been imperceptible to most people as I did not move or make a sound, and yet, Big Sis stopped suckling, tensed and looked at me. She could not yet sit up, walk or speak, and yet, she could sense my “fear”.

As toddlers grow into infants, they begin to develop cognitively. With this comes the beginning of understanding about the world and of imagination. They can start thinking about things that could happen beyond their own direct experience. At this age “The dark” and “monsters” are quite common fears. Often the children’s fears are completely unrealistic and may come from the strangest of places. When I was a young child, I couldn’t sleep one night and walked downstairs to find my parents. They were watching “Jaws” and I walked in at the inopportune moment when someone got munched. For several nights after this, I had nightmares that “Jaws” would come through my bedroom window and munch me. My parents found this hilarious and at the time, I didn’t quite understand why. Recently, my own children’s fears have been a source of interest and amusement to me, although I try to take it seriously and not be amused in their presence. Big Sis, while having no problems with the Maidmashing and Bonecrunching giants when we read Roald Dahl’s “The BFG”, refused to continue with “Maltida”, for fear of Mrs Trunchbull. Several nights of sleep for Big Sis and disturbed evenings for us lay at the hand of Mrs Trunchbull. Lil Bro on the other hand, took grievance with Violet Beuregarde. For some reason, being turned into a blueberry was the stuff of nightmares. Her return to normality by means of juicing fuelled rather than quelled the fear.

At this age, what parents fear are real fears are often not well understood. The ever-present fear of parents: “How will my children cope if I die?” is not at all a concern for children at this young age. They neither comprehend death nor a realistic meaning of time. Once when I uttered out loud my fear of “What will happen to you children if I die?” to my chagrin, Big Sis with typical “matter-of-fact” style replied “Oh, it will be fine, we will still have Dad”. By the age of 5-8, however, children come to understand the meaning of death and fear of death becomes a common fear in this age group.

The middle childhood years (6-12 years), are also the peak age for acquiring fear of animals. Dogs and spiders are pretty common fears for children. Sometimes, a child will develop a fear because of a specific experience with an animal, but other times, they may have a fear even without a direct upsetting experience as evolution has predisposed our brains to accepting that animals are potentially dangerous. In reality, cars kill more people than animals, and yet, practically no one develops a phobia of getting into a car without a direct traumatic experience. As children reach adolescence, fears become more similar to the fears of adults: fear of failure, fear of humiliation, fear of rejection, fear of war, illness and crime come to the fore. Whilst on the one hand, these fears are more “realistic” than the “boogie man” fears of infancy, one can also make the argument that many adult fears are also unrealistic. Fears about an ebola outbreak in the UK are probably over and above the realistic risk.

It should be remembered that fear is a natural response and it helps to serve a vital function. Without fear, our species would likely not have survived, by putting ourselves in the direct line of danger without regard. The fear response allows not only the bodily preparedness to fight or flight, but also the brain response to pre-empt adversity, plan and avoid. People who show low levels of fear often show high levels of “risk-taking behaviour”, and often end up in trouble one way or another whether it is in a high-speed car accident, audacious robbery or in bringing down the banking sector. However, fears should be based in reality and the work of psychological treatment for anxieties and phobias includes anchoring fears in reality.

As a parent we cannot shield our children from all adversity and helping children to understand and deal with anxiety and fear is part of our role as parents. Teaching children to accept and have the confidence to know that they can handle fearful situations when they arise is more important than preventing fearful situations arising or promoting gung ho “bravery”. Security and reassurance is the key; but sometimes it is easier said than done.

When Big Sis was in Year 1, she studied Edward Jenner and small pox at school. The idea of small pox put the fright into Big Sis like nothing before. Not only was her sleep disturbed, but even in the day she would get tearful thinking about the family being killed by small pox. This went on for a week, and despite my reassurance that small pox no longer existed in England anymore, she was still tearful and upset. I eventually went to school to see her teacher to tell her of the situation. When I picked up Big Sis from school that day, she declared to me that she was no longer afraid of small pox.

“How come?” I asked having given reassurance all week to no avail

“Because the teacher told me about the small pox vaccine.”

“Er –haven’t I been telling you about that for the past week?”

“Yes, but you’re just mum, she is a TEACHER.”

Guess that medical degree doesn’t count when you are just a mother…

 

References:

Gibson, E. J., & Walk, R. D. (1960). The visual cliff. Scientific American, 202(4), 64−71.

Mineka, S., Davidson, M., Cook, M., & Keir, R. (1984). Observational conditioning of snake fear in rhesus monkeys. Journal of Abnormal Psychology, 93, 355−372.

Children’s furniture – how would a child psychiatrist design it?

Furniture01

 

Children’s bedrooms are their environment. This is the one space which should be their own, where they should feel comfortable to play, relax, socialize, study and be themselves. It should be their fun, stimulating place of learning, as well as a retreat and sanctuary. Yet, I am not sure how much time an adult thinks about a child’s bedroom when they are designing them. For many children, a bed is put in, some toys and a bookcase with books, et voila. Kid’s bedroom, done, dusted. Tick. Now let’s get on to the really important room, the Master bedroom. This seems topsy-turvy to me as most children will spend more time in their rooms than the adults. This is why in our house, the best room in the house, the biggest one with the most natural light is for the children. Yes, they have to share a bedroom, but it is large, and at this age it is my preference for children to learn about sharing and that goes for rooms too. I shared a room with my two sisters throughout primary school and we had a blast. Come secondary school, when adolescence makes everyone annoying, it became tedious and I hated sharing a room, but  I have fond memories of chatting to my sisters at night as a younger child.

My pet hate are the catalogue magazine children’s bedrooms which are predominantly white and where every toy is a designer toy designed to be looked at and not touched. GET IN THE REAL WORLD! These pristine white rooms are children’s rooms designed by adults for adults. Adults with cleaners I am presuming, because I cannot fathom who else would want to be constantly cleaning this gleaming white paradise. Hopefully the children who possess these rooms have another room, a colourful, practical and messy “playroom” and a “study” where they can do all their finger painting, gluing and sticking and general romping about, but I can’t imagine any of that going on in the all-white rooms.

Equally sad, I read somewhere that the majority of children do their homework on the dining room table and have no dedicated work space. Whilst often a necessity these days at work, as an adult, who would prefer hot-desking to having their own desk? Even though I did not have the most advantaged of childhoods, my sisters and I always had a table for writing, drawing, painting and working on. A little square table that we all sat around taking up three sides. I think it is important for children’s education to have somewhere dedicated to learning. Not only as it is good to have a sanctuary away from distraction and with the proper equipment conducive to study, but also as a symbol that work and study is valued. Having emptied out the children’s bedroom of toddler and baby toys (see last week’s post), I was in the grand position of having a bit of space to work with.

I have been lusting after these designer desks and chairs which adjust in height to see children from infancy to adulthood. Indeed the promotional literature suggests that your children won’t be going to University unless you purchase this table and chair combo due to the benefits it will bring to your child’s posture, concentration and learning experience. I don’t quite buy it, but I love them anyway and they are definitely on my wish list. Unfortunately, as we are planning to do some major renovation on our house (to be able to provide the children with their own rooms come adolescence), I am not keen to purchase any furniture that will require expensive storage in the near future, and so, I was tasked with providing a work space for children without buying anything large and expensive. Further, having got rid of all the toddler toys, including a very lovely toy wooden kitchen for imaginary play, I had felt very sad that the children’s room seemed to have been stripped of fun and childhood, and I wanted to put a little of this back (without taking up so much room), especially for Lil Bro, who is after all still only 5 years old. Here’s how I got on:

Design Brief:

Provide area for study and homework

Provide area for painting, drawing and creativity

Provide area for constructive play: e.g. Lego

Provide area for imaginative play

Provide storage

Provide fun

In my view the best children’s furniture should allow everything to be easily accessible for children to take out to play by themselves. This allows children to be independent and to select and decide for themselves what they want to do, rather than be reliant on being led by an adult.

Equally, as a parent loathe of tidying up, the best children’s furniture should allow everything to be easily PUT AWAY by children themselves, so you can have some semblance of a tidy room.

Not take up too much space

Oh, and for a budget of say, 25 pounds?

 

How I got on:

How delighted was I to find that the same little square table that my sisters and I sat around as girls was still in my parent’s shed? There is something lovely about the thought of my children sitting and starting their educational journey from the same starting point that I did some 30 years ago. The table was stained a revolting mahogony, but with some elbow grease Banker striped it back to a bearable shade, and I spray painted the top of it off-white, and coated it with spray-on sealant. Secondly, given that the kids can now sit on normal dining room chairs at the kitchen table, their Stokke highchairs were recomissioned as desk chairs for studying. They are height adjustable which is great for getting the right seat to desk position. Did you know that a well known Swedish furniture store will sell you a table for £5? For storage, what better than a couple of wine boxes? Sturdy and ready made, even better if your next door neighbours are avid fine wine consumers and regularly throw out boxes, which can be snapped up free of charge (but you can also get them cheap from any wine shop). A few accessories and my favourites: “No more nails” glue, tape and castors and we’re done.

furniture02

furniture04

 

 

The end result:

Here it is all tidied up.

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A work station for 2, with easy access to pens, paper, pencil sharpener and all the stationary goods that a budding young creative might wish for. A blackboard for messages and doodles and seating with built-in storage to house all bits and bobs. School essentials are kept tidied away but in bags slung over the chairs for easy access. At the side, a handy mini-shelf to store toy cars, and when the mood takes, flip it open and supported by a storage box from beneath the table, you have a mega-ramp with which to race cars down. When homework is over, pull out the Lego and craft table from underneath. The storage box below the table slides out on castors too and hold all the Lego and beads that you need. Flip over the boxes and move the cushions from the Stokke chairs to the boxes and you have two sturdy little stools at just the right height for crafting and constructing. When it’s bed time, but you haven’t finished playing, just slide it as-is back under the table and it will be out of the way, but safely stowed to be completed whenever the mood takes you.

Very practical. But wait, what about the imaginary play? Well, when Lil Bro left nursery, the nursery asked all the children to draw what they would like to be when they were older. In among the pictures of doctors, dentists, astronauts and human rights lawyers was Lil Bro’s picture of an ice-cream man. How could I resist?

 

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And finally, empty the storage drawers, turn the blackboard over and lay out your ice creams…

furniture08

 

Charity begins at home

sale poster 1

When I was a trainee at the IOP (Institute of Psychiatry, now Institute of Psychiatry, Psychology and Neuroscience), we had a great set of lectures on altruism. This being the IOP it started with discussions in rats and monkeys before proceeding to humans, but the main conclusion of it all in my memory was that true altruism is exceedingly rare and the majority of altruism is self-serving. I understood this immediately as I had done a lot of volunteer charity work in my youth with disadvantaged children, children with disabilities, the elderly and the homeless and knew in my heart that although I was doing it partly because I enjoyed it, a significant part was related to being able to put it on my CV for medical school applications where demonstrating that you had “concern, compassion and ability to connect with people from all walks of life” was an asset. It also made me feel good and virtuous to help others, as well as to be smug and tell others about it. How many secret millionaires would there be if they actually remained secret and were not being filmed by a TV crew and allowed to reveal their true identity on national TV at the end of the programme?

Still, although I remain a sceptic of altruism, giving to others, whether truly altruistic or completely self-serving is still a good thing, and at worst is a win-win situation for both parties. Much is made in the media of the children of this generation being “consumed by materialism”, an iwant generation as opposed to ican generation. Sitting with the kids watching TV at breakfast time (yes, I let my children do this – so sloppy aren’t I?) it’s easy to relate to this as every time an advert is shown (shiny bow and diamante bedecked shoes that cost as much as mine, voice activated diaries, crass game where poop comes out of a dog, crass game where snot comes out of a plastic kid’s head and so on) my kids jump up and down shouting “I want that, I want that!”. “I’m not getting it for you” I say. “You don’t have to” they shout, knowing I am as tight-fisted as they come, “We’ll ask Father Christmas!” Poor, innocent kids; Father Christmas is as tight as their mother!

It was my dislike of this “I-want-something-for-nothing” attitude as well as the swelling pile of toys building up in the kids’ room spilling over into the entire house that led me to think about exposing the children to giving to charity and what a good thing this would be. As Lil Bro was to be joining Big Sis at Big School, I decided that it was time to clear out the “baby” stuff and bring in the “desks” for homework. We would have a sale and give the proceeds to charity. As it was the kids’ stuff, and I wanted them to be involved, they chose the charity. As much as I tried to steer them towards a lovely mental health charity, or the Teenage Cancer Trust, they chose the Battersea Dogs and Cats Home. Not my first preference, but still a great charity, and the best part was that it was their choice.

Clearing stuff out is never as easy as it sounds. Out went the mini trampoline, slide, tables and chairs, toy kitchens, easels, ride-along-animals, books, games, puzzles, soft toys, bedding, clothes and so on into the “sale room” (the study). Back came the books, games, puzzles, soft toys, kitchen utensils into the kids’ room with proclamations of “I love that. I still play with that!” – despite never having touched it or shown any inclination of reading it in the past year. And it wasn’t just the children. I would come across a baby rattle – of no good use to us now, but with memories of my having bought it especially for my new baby girl and of shaking it at her and making her giggle for the first time. Or a board book I had bought especially for Lil Bro as the dinosaur shared his name and that we had read together over and over. It wasn’t just the children that kept some of the items that really should have been passed on; I secretly built up a stash of sentimental keep-sakes that will probably hound our limited storage space forever.

Sale poster 2

 

The kids enthusiastically started to make some posters for our sale, and not-so-enthusiastically finished them. I invited a host of friends with young children to come and buy stuff with the added incentive of beers and a barbecue to help the process along. The kids helped clean their old toys. They helped to display their wares in the study as well as to show and demonstrate to the stream of toddlers coming in how to play with the different toys, and take the money for their goods. This proved a great strategy, stick a toy in a two year olds’ hand and while the kid is crying as the adult tries to prise it off them send two doe-eyed children to shake a money tin in front of them, saying “it’s only 50p and it will go to charity”. At times, I had to step in on the price-setting which was rather erratic: £37 pounds for a book and 50p for a slide, but all in all, they did a fantastic job. We didn’t quite clear the lot, but 80% of our stock was gone and we had raised £150.75 for the cats and dogs, which was not bad going. One friend who had come for a table and chairs, left with a table and chairs as well as a slide, a trampoline, books, toys and puzzles to the extent that they needed rope to tie down their boot door.

The whole experience was tiring, but thoroughly satisfying. The children were happier to part with their belongings because they knew where the money was going: to a charity that they had picked themselves. They were involved in promoting and selling their goods which will hopefully embed in their minds sales and entrepreneurial skills. We got sent lovely photos of the younger generation (toddlers) playing with their new toys so there was a sense of passing on happiness as well as the satisfaction of recycling and sparing from land-fill. Then the children got to experience altruism, giving to charity.

Recycled

The best part was that Battersea Dogs and Cats Home invited us down to Battersea for a private tour of their Kennels and Cattery, with head volunteer Mike. The children got to see first-hand directly where their money would be spent. Battersea do a great job at taking in cats and dogs from all-over London, feeding and catering to their health needs, re-training them if necessary and finding them new homes. It is a testament to their work that although their dog home was full of dogs, of often “aggressive” breeds – rotweilers and staffies, there was hardly a bark to be heard – as the dogs were content. Many even popped their heads over the top of the gates to say “Hello” to us. In the beautiful newly completed Cattery which looked like a 5 star Cat Hotel, three beautiful kittens Doris, Dorothy and Dilton, siblings that reminded the children of the offspring of Tabby McTat and the Black and White Cat were being taken to a health check and in our minds I think this became synonymous with where our money was going.

I am sure that seeing and experiencing this process of giving-up your own possessions, working for money and then seeing first-hand the good that comes from it, is a healthy process in instilling altruism in children, even if the main motivation is to clear out a bedroom. And if it inspires the next generation of entrepreneurs and philanthropists, all the better!

Battersea collage

Why the stay-at-home mother is more vital than the female CEO to achieving gender equality

Babymonitor v Blackberry

The female CEO and the stay-at-home-mother have often been pitted against each other in the media as arch enemies. Popular press likes to publicise the idea of the stay-at-home mother lambasting the female CEOs (or other high-flying career women) for “selfishly pursuing their careers while neglecting their children”, whilst stay-at-home mothers are looked down upon for perpetuating female stereotypes and being “bad role models” for their daughters, basically “letting the side down”. Yet, in my opinion, feminism is about choice in an environment of equal opportunity. The choice to be a CEO or a stay-at-home mother is a personal one, and I feel that either choice is respectable. The trouble is that the “equal opportunity” part is not quite there yet in our society, and to this end, although much has been made about the need for more female CEOs, I actually think that the stay-at-home mother (or a working mother that is heavily involved in parenting) has more to contribute to advancing feminism than the female CEOs (if they are childless or largely delegating parenting).

I watched Emma Watson’s speech for the HeforShe campaign in solidarity, having been a life-long feminist. What interested me was that at one point Emma describes her realisation of gender inequality when she was called “bossy” for “wanting to direct a play she and her siblings put on for her parents, whilst the boys were not”. I am presuming that it was her parents that called her “bossy” (as if it were her siblings, then why didn’t she just tell them where to go), which made me think about our responsibilities as parents in the pursuit of gender equality. Had Emma Watson’s parents; and every other parent in the world fostered and promoted the self-belief, confidence and ability in their daughters, and cared as much about their future academic and employment prospects as they did their sons, then we would not have gender inequality. Of course, Emma got the last laugh, perhaps because she was “bossy”. Good for her.

I attribute any academic successes that I have had 100% to the fact that I did not have a brother. Taiwanese parents of my parents’ generation had a strong preference for sons. My parents had told me that they had hoped especially that I would be a boy, having had 2 daughters already, and were disappointed when they found that I was yet another girl. They had no choice but to put their hopes and aspirations into us girls and foster and promote our abilities as if we were boys, capable of anything. My father spent time teaching my sisters and me computer programming and electronics when we were in primary school. I was never interested, but my sisters went on to study engineering and maths at top universities. Had we had a brother I am sure that things would have been different. Our brother would have been the one encouraged and burdened in equal measure with the pedestal, and we girls would have been left to cultivate a pastime. When I went to study at Cambridge, I was one of a few British Taiwanese children to get there, and it was no surprise to me that the only other female Taiwanese students that were there were ones without brothers. I read somewhere that China is seeing a surge of successful female business women and entrepreneurs and I wonder if this is related to the one-child policy, such that families are now invested in their only child, whatever the gender.

In the West, where the gender preference is less explicit, one can almost believe that the problem does not exist, but when you examine behaviours more closely, you begin to see that gender-based parenting is also pervasive. We can blame media and society at large as much as we want, but the reality is that we are all culpable: from the toys we buy, the behaviour we encourage, the expectations we hold, the activities we choose to do, the assets that we praise and our own day to day behaviour and language.

Even when we think we are being gender neutral, or are trying to be, we are not because gender bias is so subtle. How many parents of boys have actively gone out to a toy store and bought their son a baby doll, a push chair and a bottle? How many parents of girls have done this? From my inspection of the bedrooms of the little boys I know, I would say that very few boys have been bought dolls specifically. The parents will make the justification “Oh, he was never interested in dolls, he’s a boys-boy – so we didn’t bother”. Yet, from my experience of little boys with older sisters whom they look up to and wish to emulate, the majority enjoy playing with baby dolls in the preschool years (before peer pressure). Even more so if actively encouraged, as you would naturally encourage a girl. That’s just one example of many.

How many times have you praised your daughter for looking beautiful or commented on her clothes? How many times have you done this for your son? How many times have you praised your daughter’s social skills, whilst praising your son’s mathematical ability? How many times have you persisted with a 1:1 craft activity with your daughter even though she was bored and you ended up doing it yourself, while saying that your son does not have the patience for it and taking him out to run around in the park instead? When it’s a boy’s birthday party, how many times have you bought Lego as a present, while choosing a craft jewellery kit for a girl? In answer to that last question I can reveal that at a recent joint birthday party for my kids, the total tally on craft activity for Big Sis was 5/20 and 0/20 for Lego; for Lil Bro he scored a whopping 8/20 on the Lego, 0/20 for craft. We are all guilty to a greater or lesser extent of the above perpetuations of gender stereotypes; myself included.

This type of unconscious gender bias has been studied in relation to the lack of advancement of women in academia and the workplace and is thought to be one of the driving factors for lack of women in science. The King’s College London website has some interesting papers on this issue and says:

“Unconscious bias refers to the biases we have of which we are not in conscious control. These biases occur automatically, triggered by our brain making quick judgments and assessments of people and situations based on our background, cultural environment and our experiences. There is a growing body of research which suggests unconscious biases influence key decisions in the workplace and are responsible for some of the enduring inequalities that are evident today. One example is a study by Moss-Racusin et al (2012) which examined the assessment of applications to science faculties from students applying for the position of laboratory manager. The same application was used 127 times and randomly assigned either a female (64 times) or male (63 times) name. Selectors rated the male applicant as significantly more hireable than the female applicant. They also chose a higher starting salary and offered more career mentoring to the male applicant. The gender of the selector did not affect responses.”

My view is that it is not only in the workplace that these unconscious biases are occurring. By virtue of being unconscious they permeate every aspect of our lives, including the parenting of our children. What effect does this have?

In my line of work, “behavioural management” is a parenting technique that uses discriminant encouragement, rewards and praise to shape children’s behaviour. It can be used to get a child to do anything from concentrating longer to eating their greens. If our parenting is guided by unconscious bias that encourages, rewards and praises our children according to gender stereotypes, then we are unconsciously using behavioural management daily to shape our children into gender-based norms. It is only by making bias conscious that we can act in a child-centric rather than gender-centric way when acting and responding to our children.

How does this relate to the title of my post?

A female CEO can improve the lot of women in two ways. Firstly they can inspire and prove to the world that women are capable. However, the reality is that aspiring women will look at the few female CEOs and scrutinize their lives. Do I have the same intellect, ambition, personality? Am I willing to work as hard and sacrifice as much? For the majority of women, the answer will be “No”. Secondly, a female CEO can influence the culture at the top and enact policies that will help women reach the top. However, these policies and helping hands can only be extended to women that have already climbed to the middle and are reaching up to the top, and at the moment, there are insufficient numbers of women in that position. We are forever told that the reasons that there are so few CEOs, MPs, establishment figures, is that there are a dearth of applicants. So, in my view the impact of a female CEO is extremely limited.

OK, but surely the stay-at-home-mother is the antithesis of feminism? I say, NO, a stay-at-home mother that parents in a way that promotes gender equality can produce citizens of the next generation that expect equality. Boys that become men that respect women, value women, understand women and believe that men and women are equal partners in work and parenting. Girls that become women that respect men, value men, understand men and believe that men and women are equal partners in work and parenting. A stay-at-home mother that enacts child-centric rather than gender-centric parenting can create a new generation of citizens that can change the socio-political landscape. At present, given the billions of stay-at-home mothers worldwide compared to the handful of CEOs, I would have to conclude that the future of feminism depends on stay-at-home mothers practising child-centric parenting. Unbiased parenting by CEOS, stay-at-home mothers and their partners/ husbands has the ability to give our daughters a true choice of stay-at-home mother, CEO or both.

This is not something we need to lobby for; it’s something we can enact now.

 

Social hierarchy in 4 year olds

Social hierarchy

This is part of the infant 360 degree appraisal series on social ability. This post follows on from previous posts on basic,and higher level social ability and will give you information about social hierarchy in 4 year olds. I am not an expert in social anthropology and so the following is just a précis of my own observations using my knowledge of human behaviour and social science that are part and parcel of psychological and psychiatric training.

One of the best places I have found to observe social skill in my children is at a kid’s birthday party, particularly at age 4 years where the tendency is to invite the whole class. Unlike a classroom environment where structure is ever present, and authority stems from the teacher, a birthday party is like the school playground where it is a social free-for-all. In any school assessment we professionals conduct, we always observe the child in the playground as well as in the classroom because, here, and only here, children are left to fend for themselves without adult intervention, it is quite literally a different world.

For a child, the birthday party scenario is one of the most challenging of their social skill. Hell, even as an adult, who does not occasionally quiver in fear at the prospect of having to make small talk with numerable new people at a work do or colleague’s birthday party? Observing how your child copes with this situation is a real test of their social skill in the most difficult of social situations. I had stumbled on this quite by chance by attending numerous kids’ parties, but then my instincts were ratified when I found out that Professor Dale Hay, Professor of Psychology at Cardiff University uses the “Birthday Party Scenario” to assess social skills in children. Her team at the Cardiff Child Development Study, have been hosting mock children’s birthday parties on a weekly basis in their department for the last 7 years. A PhD student is even tasked with appearing at the end of each party in a bear costume! Fab!

Here, not only is it possible to observe your child’s social skill, but also their pecking order in the social hierarchy. Yes, just like in the jungle where our primate relations fight it out to be alpha-male and high-ranking female, so all human societies have a social hierarchy, even amongst 4 year olds. At the top end of the social ability spectrum, the highly socially skilled children battle it out for top-dog status.  I was first alerted to this by Big Sis’s nursery teacher. One day, she told me that Big Sis had a bad day at school because “there are some girls in the class with strong personalities and they are clashing for dominance”. It didn’t take me long to figure out that Big Sis was one of the said girls and I made a passing comment about monkeys fighting it out to be alpha-male. I was quite used to the concept of social hierarchy in teenagers and adults. The whole genre of teenage movies from “Pretty in Pink” to “Mean girls” and “High School Musical” are based on the well-established angsts of social hierarchy – but really – does it start in nursery and reception?

The sad answer is “Yes”. After frequenting many of these birthday parties and taking the obligatory shot of the birthday girl/ boy blowing out the candles of their cake, I noticed that in every single picture, the same few children, Big Sis included, were at the birthday child’s side. This happened even when the birthday child was not a particular friend of Big Sis. I began to observe a pattern of “top table children” at birthday parties where the same children would be seated around the birthday child, regardless of whose birthday it was. I developed a theory of social hierarchy being played out in the seating of children at birthday parties. I began to watch these top-table children, and they seem to be extremely socially aware of what is going on. For instance, they anticipate exactly when the call to be seated for food will go out, and where the birthday child is likely to sit (usually somewhere in the middle or at the top end depending on table layout). They then seek to position themselves at the prestigious seats which are those with closest proximity to the birthday child.

Big Sis and her friends were experts at this, but one incident stands out. Big Sis broke her leg and was required to use a zimmer frame to hop around. At a friend’s birthday party, at the all-important call to be seated, there was the usual rush amongst children to sit in proximity to the birthday boy. The table was laid in one long line, and the birthday boy moved to seat himself in the middle. I was observing Big Sis. She saw that all the children ran to seat themselves directly next to the birthday boy and there was a tussle amongst “high-ranking” children here to gain the prestigious seats. She was first to see that the seat opposite the birthday boy, of equal prestige was free and hobbled as quickly as she could on her zimmer frame down to get to the other side. Although she was clearly first off the mark, her able bodied “high-ranking” friends who had missed out on the prime seats next to the birthday boy, had now seen the free seats opposite as she had, and they raced passed her to claim the seats. I had to laugh at this as it proved my theory about birthday seating hierarchy correct. Much to my amazement, when Big Sis got to the seats she had wanted, which were now occupied by her popular friends, she started asking them if she could sit there. Clearly no alpha-child was going to give up their seat, but good-on-her for trying! I felt sorry for Big Sis, as she would certainly have got there first had she not had a broken leg, so in this instance I intervened and I pulled up a chair so she could sit there with her friends. They were happy to make space for her, but I am pretty sure that they may not have done this for all children; girls, even age 4 years are quite good at social exclusion.

In complete contrast, Lil Bro appears devoid of this social antenna. He will without fail ask to go to the toilet just before the call to be seated for food at birthday parties, such that we will emerge from the toilets and he will be sat at the last available seat a mile-away from the birthday child, even if the child is a good friend. Even when he is there, he will stand rooted to the spot until all the other children have sat down before finding the last available seat that nobody else wanted. He appears oblivious to social hierarchy and would even risk being isolated to the cold corner seats at his own sister’s party if I did not reserve a seat for him at his sister’s side. The good thing is that it neither concerns him nor bothers him. I have to admit that occasionally it bothers ME, only because I aspire for him to be super sociable and popular, but then I just have to slap myself in the face, recognise that his needs are different from my wants, see with my own eyes that he is happy and confident and let him BE. Imperviousness to social pressure is also a great strength in itself!

Clearly I have never told my children where to sit at birthday parties, and I doubt anyone ever has, so it is interesting for me to observe the presence and absence of these social instincts in such young children. This ability, termed social osmosis (i.e. picking up knowledge from social experience rather than actively being taught) is thought to be lacking in children with autistic spectrum disorder. Those with excellent social osmosis and social ability are able to climb to the top of the social hierarchy. Their success is not based on physical dominance (aggression), but social dominance – the ability to make friends and influence people. The funny thing is that once you are on the look-out for it, you see examples of hierarchy in 4 year olds all the time.

When I volunteered to go into Big Sis’s class to paint faces, the teacher asked me to choose the first child to have their face painted, and then they were allowed to choose the next child. Whilst painting one girl’s face, her male best friend loitered around saying “please choose me next”. Big Sis had told me that these two classmates were best friends, lived close together and did everything together, so I was not surprised when she smiled, and seemed to agree. Then, out of the blue saunters in “alpha-male”. A bigger, and brighter boy with better social skills. “Please choose me next” he said politely. I smiled, the wicked smile of a child psychiatrist about to test human nature, and asked the fateful question: “So, who do you want to go next?”

The answer is as predictable as it is gut-wrenching , but alpha-male wins every time, and “the boy-next-door” had to wait in line. Social hierarchy in children it seems plays out just as social hierarchy plays out in adults. You only have to observe the parents at children’s birthday parties to see this. But that’s a different story…

How to assess your child’s social ability – part 3

superman
This is part of the infant 360 degree appraisal series on social ability. This post follow’s on from last week’s post on basic social ability and will give you information about how to assess higher order social ability in 4 year olds.

Interaction with peers

As described in last week’s post, a child’s interaction with peers is more difficult for them to navigate than interaction with adults. A child that interacts confidently with adults may struggle to interact with peers. This is as 4 year old peers are immature in social skills and are themselves learning to acquire these skills. This is easy to understand if you think about tennis. A child beginning to learn tennis can play with an expert adult as the adult can direct balls at the child and return errant balls. Get two children who are just beginning to learn to play tennis to play with each other and it is much more difficult and frustrating for the children as neither can play properly.

Both Big Sis and Lil Bro went to nursery from a young age and so had much exposure to interacting with other children. From this I was able to get good accounts of their social ability with peers. Most nursery schools will be able to tell you if your child is able to take turns, share toys and join in with other children (for instance joining in with actions to songs such as “The wheels on the bus”, or a game of hide and seek). Most nursery schools will be able to tell you if your child is aggressive in interactions. If your child is constantly victimized (which you will know about as you are required to sign an incident form in a nursery if your child is bumped/ bruised/ bitten/ scratched or harmed in any way), as well as questioning what the nursery is doing about this, you should question what your child is and is not doing to end up in this situation so frequently.  Children who are frequently victimised or frequently aggressive are more likely to need extra attention as they may be vulnerable to difficulties.

Most nursery schools will be able to tell you if your child is polite (says “please” and “thank you” – very important social skills that do require to be taught) and caring (what they do in response to another child that has fallen over). They should also be able to give information regarding play. If they don’t, you should ask about it.

The importance of play for children  cannot be overstated. Not only as a means of relaxation and enjoyment, but it is in play that children are able to order, understand, rehearse and cement social understanding as well as be creative. Play is often heavily influenced by what the child has experienced in their social environment. It is sad, but no surprise that some children I know in South Africa, following an armed break-in started to play a game of “robbers” involving tying each other up. Back at home, I know children who are more likely to play “I’m mummy, getting ready to go out to a party”. What these children have in common is that they are all learning about their own social environments and about ways to behave in them. It’s no wonder that “play” with a dolls house and family characters is the preferred way that shrinks find out what is really happening at home when we assess children of this age group. If children play about the mummies and daddies shouting at each other, this doesn’t mean a direct call to social services, but does prompt questioning and assessment on the parental relationship and what bearing this may have for the child. Observing what my children play act left to their own devices is one of my favourite pastimes, and if it is about setting up a school and marking a register and reading stories to the assembled stuffed animals (which it is frequently), I can heave a sigh of relief. It’s no wonder that watching children play, and interacting in play with children is one of the main assessment tools in a child psychiatrist’s armoury.

As well as to gain insight into the child’s real social environment, children at this age will be beginning to develop imaginative and interactive play, both precursor skills required for good social ability. Dressing up and pretending to be a princess, a superhero or both is usually a good sign of imaginative play, in particular if they take on the roles, act out stories that they have generated themselves and if they play this with other children, each understanding what the other is pretending. Many adults may see this type of play as “silly” or a “waste of time”, but imagination and role playing is a rehearsal of the ability to think about how someone else is thinking and how this may affect their behaviour, the basis of “mentalization” the new buzz therapy in psychiatry.

Interactive games, such as hide-and-seek, allow observation of practical interaction skills between children. Is your child able to take turns? Will your child cry or get aggressive if they lose? Is your child able to follow and understand the rules? How does your child react if someone else transgresses the rules? Does your child take charge of the game or stand back?

Your child’s nursery can give you this type of information; else you can observe your own child’s play with their sibling (if they are close enough in age to play together) or at a play date.

Spoilers

If you want a real test of social skill, or are just a mean child psychiatrist like me, then you need to work in a few spoilers. Most children will be able to display good social ability when everything is hunky-dory and going their way. But what about compromise and negotiation? What about staying out of trouble? Most children are taught compromise when children are invited over to play and “Guests” are given privileges. “Let your friend go first, because they are the guest”, “Let your friend have the bigger slice of cake, because they are the guest” – this type of thing that happens all the time on play dates. If your children are able to accept this, chances are, they will be able to come to terms with compromise. They understand the social rules and etiquette and are able to conform to them. If they predictably have a tantrum, even when the situation is explained, then problems at school can be anticipated. Getting along with other people, good social ability; includes understanding that getting along with others is sometimes[1] more important than the bigger slice of cake.

Other spoilers can be less easily arranged, but these situations arise all the time naturally and it is often a good idea to stand back and observe how your child deals with situations rather than to wade in and intervene at the onset of trouble. When I took Big Sis to a public sand pit one day, I noticed another child who was more boisterous and disruptive playing there. The boy approached Big Sis, clearly wanting to interact, but he had already disrupted the play of some other children. Big Sis turned subtly away and kept her head down doing what she was doing and saying nothing. The boy got tired of no response and went away to disrupt someone else. Big Sis had clearly clocked this boy was trouble but she managed to deal with the problem in a way that was not rude or confrontational and that achieved its objective with minimal fuss. She was able to see trouble coming and avoid it. It may not be the most obvious social skill, but it is a highly valuable one. We all know some children who are “always” involved in trouble even if they are not necessarily the instigators and I would argue that avoiding trouble is as much a social skill as the ability to make friends. I felt confident that Big Sis could handle herself at school after this.

What happens at the highest levels of social ability – the battle for social dominance? Next week’s post is the conclusion in this series on assessment of social ability and will answer this question. Later on, I will write about what can be done to help support children’s social skills.

 

[1] I say “sometimes” as children who always suppress their own needs for others will have other issues that need addressing, and being the class “doormat”, is also not particularly desirable.

 

How to assess your child’s social ability part 2

eyesThis is part of the infant 360 degree appraisal series on social ability. This and the next few posts will give you information about how to assess social ability (from minimal to maximal) in children around the age of 3-5 years old (for short, I will refer to 4 year olds). Later on I will post on how you can help young children to develop their social skills.

Problems with social ability are currently rarely diagnosed in the pre-school period unless problems are severe. This is not because they do not exist but because adults, particularly parents are extremely obliging in making up for their child’s weaknesses, and aren’t aware of their difficulties. Even if a child is gibbering in Alien, you can bet, the parents know exactly what is being communicated and get quite grumpy when you infer that you have not a clue what they are trying to say. Play dates at home supervised by adults will involve parental supervision and intervention to assure that children “play fair”, “don’t leave people out”, “wait their turn”, “be nice”, and critically don’t beat each other into a pulp. If another child is “not nice” to your child, they are not invited back. Not so the school playground where your child will have to communicate with other children who are impatient, do not necessarily care to hear what your child has to say, have little incentive to include your child in games and may beat your child into a pulp if they find them annoying. I don’t care what any school says in their prospectus, teachers cannot be there at all times, and it is much wiser to ensure that your child has the social skills to survive! By educating parents to be more aware of their child’s social skills, weaknesses can be identified earlier, leading to interventions, better support and prevention of more difficult problems developing later on.

When people think about social ability, they tend to first think of the confident thespian, the extrovert lead in the school play. Often these people do have good social skills, but social skills are more than confidence, acting and oration. It is about ability to make lasting friendships, seek help, read emotions, understand social situations, adapt to new social environments and avoid trouble. All the skills required to “get on” with other people, the essence of social ability. If your child was assessed for a private school “assessment” at age 4 years, without a doubt one of the key components that they would have been making a selection on was social ability. A sociable child will get on with other children in the class, be easier to teach, cause less trouble and ultimately, make the school’s life a lot easier! These skills continue to be highly valued throughout life, and there is a reason that even into adulthood, we are asked to demonstrate our “people skills”, “ability to be a team player”, and “communication skills” in any career.

Before talking about how you can improve your child’s social skill, it is a good idea to think about assessing you child’s social skill. It may be that your child is extremely socially able and you have no need to do anything. Lucky you. But how do you judge this? Over the next few posts, I will detail here observations that can be made of social skills from the most basic to the fairly sophisticated levels of social skill.

Basic Social Skills

The most basic social skills are required in an interaction with a familiar adult. Most children aged 4 years should be able to interact easily and readily with a familiar adult. Many children with mild autism (de facto impaired social ability) can pass this level of interaction, as the familiar adult will be primed to be patient, can guess from experience what a child wants, is accepting and willing to invest in understanding the child, and letting them have their own way.

Spending time playing with your child and conversing with them can reveal if there are fundamental difficulties in social interaction. Some readily testable tasks are whether your child turns to face you if you call their name from behind them. Can your child ask you to pass something to them that they need? Can your child look you directly in the face when talking to you/ you are talking to them? Can your child smile at you? Can your child smile at you if you smile at them? Can your child spontaneously wave goodbye to you when you leave, shake their head to mean “no” and nod their head to mean “yes”? Can your child use gestures to show you how to do something (e.g. brush their teeth) without using an actual toothbrush? Can your child recognise facial expressions in picture books and tell you what they mean? Can your child point to show you something and check that you are looking at the right thing? Can your child make up a story? Can your child feed their teddy bears or make their dolls talk to each other? Can your child realise/ understand that other children may have different thoughts and preferences to them? Can your child copy what you do?

Most typically developing children can definitely do all of these things by the age of 4 years. Clinicians are looking for the presence or absence of ability in all the above (and many other things) in a typical autism assessment in 4 year olds with typical development.  They may sound like an arbitrary list of things to look out for, but they are amongst the basic building blocks necessary in developing sophisticated social ability.

If you do not have a preference for looking at people’s faces, particularly their eyes, which are usually the most expressive, you will fail to pick up all the social nuances in expression that a person is communicating (see part 1). “You idiot” said with angry eyes will mean something different to “You idiot” accompanied by a glint in the eye. If you are not looking at a person’s face/ eyes, you cannot infer intention and you are liable to misunderstanding. If your child does not naturally pick up common social conventions (smiling at people, nodding and shaking the head, waving) they will have more difficulty understanding what is going on as social conventions are so frequently used in communicating with others instead of speech. Think how awkward you feel when travelling to a foreign country where all the social conventions are different (bowing in the Far East, not using your left hand in India). Your actions may be misinterpreted by others and it will affect how you get on socially. If your child has difficulty understanding that others may have different thoughts, they may not act in consideration of other people. If they cannot understand facial expression, they cannot infer how someone else is feeling and act accordingly. If they cannot ask for something to be passed to them, they may have difficulty communicating their other needs in an appropriate way. If they do not naturally copy you and what you are doing, they are missing out on the most frequent method children naturally have to acquire social skill, by emulating their parents and other adults around them.

If your 4 year old child is struggling with all/ most of the above, it would be worth considering the 4 main possible reasons that a child psychiatrist would consider: hearing impairment, speech and language problems, learning difficulty and autistic spectrum disorder.

Intermediate social skill

Interacting with an unfamiliar adult takes more social skill than interacting with a familiar adult as an unfamiliar/ less familiar adult will not know or understand the idiosyncrasies of a child’s communication. For instance, when Big Sis was two, she loved to watch a music DVD called “Fun song factory” (which incidentally starred a pre-fame member of JLS). She was at the time unable to enunciate “Fun song factory”, but called it “Bun song Bactery”, or just “Bactery”. One time, when my mother was looking after her, she repeatedly stated that she wanted “Bactery”. My mother was at a loss at what she was talking about and it led to a lot of frustration on both sides. Indeed, my mother strangely concluded that she was talking about the “lavatory” (rather advanced vocabulary for this age group) and whisked her nappy off and plonked her on the lav. Needless to say, Big Sis was not amused. Eventually, my mother called me and I immediately knew what she wanted. Thus interaction with an unfamiliar/ less familiar adult pushes the need for better communication skills to avoid frustration.

In clinical practice, we often see parents that are so good at compensating for their children’s weaknesses that they cannot see that their children have pretty severe impairment. They get very upset when teachers report difficulties at school and blame the teachers, but the reality is that the level of ability required to interact with an unfamiliar adult is more challenging than interacting with a familiar one. If your child has consistent difficulties interacting with a kind and supportive teacher, the chances are, they will have difficulties interacting with many other people and are likely to have weaknesses in social ability.

Interaction with unfamiliar adults can be observed easily. Leave your children with a trustworthy friend whom they do not know well and see how they behave. How well your child is able to communicate what they want can be observed (child psychiatrists and psychologists would do this crammed behind the one-way mirror in our clinics, but you can do this by poking your head quietly into the room or hiding behind a door left slightly ajar) and you can extrapolate their behaviour in this situation to their likely interaction with their new teacher (an unfamiliar adult). If you want to challenge your child’s social skill a bit more, you can ask the adult to occasionally disagree with the child, or to deliberately thwart them (e.g. accidentally knock down the tower they were building), or try to contribute a different idea to the game they are playing and see how your child responds.  If this is all a bit too Cold War, just ask your new babysitter how they got on and garner as much intel from this as you can.

In addition to communicating needs and wants, in this scenario, a socially able child would understand that they will need to behave better than they do with a parent or a familiar adult, this is called “social inhibition”. Even if your children are naturally boisterous and cheeky to you or their grandparents, they should be inhibited by someone they know less well. This natural recognition of social context, the awareness that something is different about this social environment and the appropriate way to respond is part of a child’s natural social ability (whether they are able to sustain behaviour is a different matter). Most children are able to behave well and interact with an unfamiliar adult even at age 4 years for a short time at least, which is why even hyperactive children can behave well when they visit the doctor’s clinic much to the chagrin of their parents who have spent the entire time talking about the child’s inability to sit still. More worrying is the child that is over-familiar with strangers, and goes straight up to cuddle and sit on the lap of a stranger, not only as this has implications for vulnerability to abuse, but as here it is clear that they are unable to pick up the difference in social environment and expectation naturally.

The types of difficulties in social interaction which we professionals would be looking out for fall broadly into the following categories:

1) Aloof – a child with no interest in social interaction. They neither initiate social interaction nor engage in interaction when it is initiated by others.

2) Passive – a child who will engage in some social interaction, but will not initiate it.

3) Active but odd – a child who both initiates and engages in social interaction but does it in an odd or inappropriate way (such as the disinhibited, over-familiar manner described above).

A caveat to this interaction as a means of assessing social skill is the confounding factor of anxiety and security. I will discuss these issues at greater length in another post, but needless to say that if your child has difficulty separating from you or is anxious in new situations and with new people, you will not be able to get a clear picture of their social ability using this type of observation.

Brownie points if your children are well behaved, appropriate, polite and obliging with an unfamiliar adult. Extra, extra brownie points if they are also engaging, interactive and interested. They will have no problems with interacting and communicating with their teachers and in the structured environment of the classroom. However, it is easier for children to interact with adults. Many children with autism are able to interact with adults. This is as adults are generally nice to children and will make allowances for children, will have the ability to guess what a child wants, give in to what a child wants and are generally predictable and sensible. Higher levels of social ability are required in interacting with other children; the basis of next week’s post.

Organisational hell – what to pack in a travel handbag

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I heard about Cath Kidston’s #totesbig/totessmall campaign and laughed, surely for all parents it’s #totesbig? Mine’s this fetching strong and waterproof Longchamp number.

Carrying large quantities of “vital” stuff around with you all day has never been quite so important as when you have kids in tow. The ante on organisation is raised on having children, purely because logistically, there is so much more that is required to be remembered and carried with you at all times in preparation for all eventualities. We all have a “very organised friend”. Someone who is always on time, never forgets anything and prepares for everything. For me it’s my big sister. When baby Lil Bro yakked up lunch all over himself, and I had not brought a spare baby-gro, who should pull one out of her handbag? Apparently a spare, even though her child no longer wore baby-gros. When we went on a weekend break with the extended family and I forgot to pack towels, who produced a whole spare extra set which she had packed “In case”? Yup, my darling sister. Indeed, whenever I go anywhere with her, I can rest on my laurels as I know that if I have forgotten anything, she will be sure to have “spares”. Thank goodness!

Although I have moments of organisational inspiration (packing a volcano making kit in my suitcase on a holiday to Sicily so I could teach the kids about volcanoes in-situ), at other times I  am pitiful. For instance,  when Lil bro was a baby I remember joyfully pushing the buggy to my mother-and-baby yoga class in Primrose Hill thinking that I was on time for once, but actually having forgotten the entire meticulously packed Cath Kidston baby changing bag on the table at home. Thankfully, what I lack in organisation, I make up for in practical, can-do attitude. I didn’t miss my yoga class, I just popped into a newsagent. I got some funny looks from the skinny and beautiful Gwyneth types that frequent Triyoga Primrose Hill with their yummy-mummy nappy changing bags, matching cashmere blankets, Sophie giraffes and  wooden rattles when I rocked up with nothing for my baby save a 34-for the price of 30 jumbo pack of nappies and a pack of Johnsons’ wet wipes. Well, what more do you need – eh?

At the start of this summer though, I thought that given that I am now a blogger and passing on my worldly (ahem) views on all things parenting, I would write an illuminating blog about all the things “one” should carry in their totes when travelling with young children on holiday. Here is my list:

Sustenance:

Bottled water (I know it’s heavy, but always comes in handy)

Snack (usually of the pre-packaged biscuit/ chocolate variety – but on a good organisational skill day, a pair of satsumas)

Sun protection:

Bag Sun

Like all good doctors, I espouse the sin of sun worshipping, although a little dose here and there to relieve vitamin D deficiency doesn’t do any harm. Still always best to carry sun hats, sun glasses and sun screen with you at all times over the summer hols. A warm waterproof top is meticulously tied around the waist of each child should the weather take a turn (Brits will understand this!).

Activities:

Bag lo-tech

My kids (like most) are terribly impatient in restaurants, and will not stop asking “When’s the food coming?” as if I have personal telepathy with the kitchens. For distraction purposes, I have found it well worth my while to carry sticker books around with me at all times. In addition, fully equipped pencil cases as pencils and coloured pens can be transformed into any activity: drawing, colouring, noughts and crosses, the shape game (where one person draws a random shape and the other turns it into a picture of something) , pass the portrait (where one person draws a head on a picture, folds it over and passes it to the next person to draw the upper body, then passes it on etc.) and an endless possibility of other games. If we visit a landmark (like a cathedral) or an art gallery, the children will always be asked to draw what they see as  this really makes children look carefully, observe and remember what they have seen.  I carry 2 of everything because do you think it is possible that they could share? It’s not worth the grey hair.

Kid-proof Tech:

Bag tech

I know that most people just let their kids use their iphones or ipads, but I am of the old school who fuss and worry about tech getting broken. It comes from my dad’s indoctrination of us in childhood over the perils of biscuit crumbs and spilled milk on the Commodore 64 such that anyone holding food or drink was not allowed within a 3 metre radius of “the expensive computer”. I carry cheap his-and-hers cameras with me to give to the kids to take photos as part of a game or just to see what they find interesting. Looking over pictures they have taken at the end of a day trip is always fun, particularly when you find that the beautiful city of Rouen you visited had nothing more worthy of photographing than a mannequin in a shop front…

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The children got “kiddigos” (hand held TV/ games console for little ones) for Christmas last year. As exposure is strictly rationed, the effect of producing the kiddigo is dramatic. The kids are only allowed to use them for the last hour of a long (3+ hours) car journey if they “have been good” during the earlier parts of the journey, and it’s really amazing how well the constant threat of losing the screen time can keep the kids at bay.

So, with all this “well prepared vital stuff” being carted with me everywhere on holiday, you can imagine what a peaceful time we had. It was all going wonderfully smoothly, with hardly a hiccup of “Are we there yet?” or wails of boredom and running up and down in restaurants, until a day trip to the Citadel at Carcassone. We exited the Castle to go home. “I need the toilet” one of them said. “No problem, I’ll take you” I said. Only to find, it was a number 2 of diarrhea proportions. Only to find there was no loo paper in the ladies or the gents. I looked in both.

Despite having a variety of splendid craft and technological activities in my bag and enough sun protection to keep a Scotsman from burning in a dessert, there was no tissue or wet-wipe to be found.

Having unsuccessfully attempted  to use pages of the sticker book as toilet paper, it was  – OH CRAP – literally.

Well, as I said, what I lack in organisational skill, I make up for in can-do attitude.

Maternal hand it was….

Where was my big sister when I needed her?!

How anxiety in pregnancy can lead to anxious children

Fire engine

This is the last of the How to improve your child’s success before they are even born series. See Part 1, Part 2 and Part 3. OK, its pretty heavy going on the science, but if you really want to understand anxiety then its worth a read.

Most people are aware that stress and anxiety are not good for pregnant mothers. Even in 400 B.C., Hippocrates espoused the influence of emotions on pregnancy outcomes, leading to a plethora of literary dramas old and new where stress has caused the leading lady to miscarry or go into premature labour. More recently though, following Barker’s theories of foetal adaptation to the mother’s womb environment (see my post How to improve your child’s success before they are even born: Part 3), scientists have found that a mother’s anxiety in pregnancy can influence psychological and behavioural outcomes of her developing foetus over and above those caused by premature delivery.  There is now a well-established literature base linking mother’s anxiety in pregnancy to several psychological and psychiatric outcomes in children, including: anxiety, attention deficit hyperactivity disorder (ADHD), cognitive problems, changes in temperament, aggression, conduct problems and even schizophrenia (Beydoun & Saftlas, 2008; Talge et al. 2007; Van den Bergh et al., 2005).

 

Animals stressed in pregnancy give birth to anxious baby animals

The first evidence for this came from animal studies. Researchers found that rats and monkeys exposed to stress in pregnancy produced offspring that had long-term difficulties with attention, motor behaviour, aggression, memory and showed “hyper-vigilant behaviour” (Van den Bergh et al., 2005). Hyper-vigilant behaviour in animals is a proxy for human anxiety. It incorporates being alert to potential threat with corresponding changes in body systems to prepare to respond to threat. Think about how you would have felt travelling to work on the underground the day after the 7/7 London bombings of 2005, and this is probably a good picture of human “hyper-vigilant” state. Darting eyes on the look-out for suspicious bags with no owner, or people with over-sized back packs, slight tension in muscles, slightly increased heart rate and breathing rate, a little bit more perspiration than usual and if someone were to pop a balloon behind you, you’d probably have been ready to run. Hyper-vigilance is a good thing if you are in a stressful situation. It has served me well on many a walk home from the night-bus stop. If you are continually hyper-vigilant or hyper-vigilant in non-threatening situations like social situations or on aeroplanes; it can be very problematic and is called “anxiety”.

In animals it is easy to experiment and find out what is happening, you can wire animals up to measure muscle tension, heart rates and perspiration fairly unobtrusively. Even better, you can take blood samples and measure the levels of “stress hormone” cortisol. By doing these experiments, scientists have been studying the various effects of maternal stress on animal offspring and among several suspected effects, they have found pretty conclusively that in animals stress in pregnancy causes changes in the development of the foetal stress regulation system, the Hypothalamic-Pituitary-Axis (HPA) re-setting it to be on heightened alert.

 

How does the body deal with stress? What goes wrong to cause anxiety? – an analogy

What is the HPA-axis? The HPA axis is a collection of parts of the body that communicate by hormones to regulate certain bodily responses, including the stress response. In its function to regulate stress-response, it works pretty much like the emergency fire service. When you see a fire, you pick up the phone and dial 999. This puts you through to a national call centre, where you are asked which emergency service you would like. Once they realise that it is the fire service you need, they contact the regional fire control centre which contacts your local fire brigade which sends out an engine to where you are. The firemen hopefully put out the fire and call back the fire brigade centre to report that the job is done, which then feeds this information back regionally so that the case can be closed. Alternatively, if the fire has gotten out of hand, they can report regionally or nationally depending on the extent of the fire to request more engines to help.

The hypothalamus (a region in the brain) is the national call centre. When the eyes see threat, they alert the hypothalamus. This lets the brain’s pituitary gland, (regional fire control centre) know that there is a threat and a stress response is required. The pituitary communicates with the kidneys (local fire brigade), which then provides the stress response: the steroid hormone cortisol (fire engine). The fire engine goes out to sort the problem. Cortisol does this by going to the heart and making it pump harder, it goes to the lungs and makes it breathe quicker, it goes to the sweat glands and makes them produce sweat, it goes to the muscles and makes them tense and ready for action. All so that you can either fight or flee the threat.

If a city undergoes a heat wave and there is an increased propensity to fires starting and burning out of control. The fire service would probably request more resources on standby and be on heightened alert to send out more engines. More engines than needed might be sent out to small fires to ensure that they did not catch and turn into large fires. This is precautionary and helpful in the short term, but is an over-reaction if continued long term, beyond the time of realistic threat. The same thing happens to our body’s emergency response system. If there is a history of heightened stress, the body responds by increasing the base level of cortisol in the blood stream and increasing the amount of cortisol released in response to stress. This is not a problem if there is continued threat, but if the situation calms down and the body does not down regulate its stress-response system, the result is persistent anxiety.

In animals at least, it has been shown that the animals themselves do not need to have been exposed to stress for their bodies to be placed on heightened alert, they merely have to be exposed to their mother’s heightened alert system in the womb. Thus in animal experiments, giving pregnant mothers injections of cortisol equivalent substances can cause their children to have higher base levels of cortisol and heightened cortisol response when they are born and with continued effect into adult life (Van den Bergh et al., 2005). These animals went on to display a range of long-term behavioural and cognitive impairments. This can be thought of as part of Barker’s hypothesized foetal programming whereby the foetus exposed to high levels of maternal stress hormone predicts a hostile environment and prepares itself by adapting its HPA-axis to best cope with impending fight for survival. Where the resulting environment is actually not that stressful; the HPA-axis is now not working properly and leads to a range of problems.

 

Who cares about animals? What about humans?

Stressing humans to study anxiety is rather unethical. Shockingly, it used to be allowed and “Little Albert” is a classic case in psychology literature. Little Albert was a 9 month old boy who was not afraid of rats and was given a rat to play with. A dastardly psychologist John B. Watson wanted to see if it was possible to cause a phobia of rats. Every time little Albert touched the rat, a man stood behind him and banged a piece of metal with a hammer making a loud noise scaring little Albert. Needless to say, after a while of this, Albert became afraid of rats and stopped going near them, proving it is possible to induce a phobia[1]. No wonder experimental psychology has a bad name!

These days, we are thankfully not allowed to do such things, but it does mean that extrapolating work from animal studies into humans is harder. We have to rely on stress that occurs naturally in the lives of pregnant women rather than purposefully causing stress in order to study its effects on offspring. Natural and man-made disasters have been used to study the effects of anxiety in pregnancy.

Studies of children who were in the womb of mothers affected by 9/11 showed that these children were born with lower birth weights even though they were born at term, compared to children conceived following 9/11 (Berkowitz et al., 2003). Infants whose mothers were pregnant during the 1998 Canadian ice storm that led to electricity and water shortages for up to 5 weeks scored lower on mental development indices and tests of language development compared to other children, even after taking into account birth complications, birth weight, prematurity and post-natal depression (La Plante et al., 2004).

It is not just extreme stress such as a national disaster that can cause effects. Studies have also used questionnaires asking pregnant mothers about their levels of stress at varying times in their pregnancy and then studied their children at varying ages from newborn to adolescence. In general the link between maternal stress and impaired offspring outcome is borne out, sometimes even with a direct dose-response effect[2] (Beydoun & Saftlas, 2008; Talge et al. 2007; Van den Bergh et al., 2005). Results from different studies vary as each study is different in terms of the stress they are measuring (some studies ask for work stress, bereavement, marital stress, criticism from partners, or just how anxious you feel), the time in pregnancy the stress occurs (studies vary in studying stress in the first, second or third trimester), and the outcome and age of children they are studying (some studies look at language and development in the first year, others look at ADHD symptoms in childhood and yet others look for anxiety and conduct problems in adolescence). Despite this, the majority consensus of all the studies is that there is a significant negative effect of maternal pre-natal anxiety which can have lasting effect. In this way, it is not just your DNA that is biologically influencing your child’s outcome, but environment, via biological mechanisms.This is epigenetics, the new buzz in child psychiatry research.

 

Interesting finer details

The theory regarding differences in timing effects is that this relates to timing of brain development. Throughout pregnancy the developing foetal brain goes from a neural tube to a baby’s brain which is a complicated journey. Different parts of the brain are forming throughout the 40 weeks, and the effects of insult to the brain at a particular period in pregnancy will depend on the part of the brain that is forming at that time. So for instance, a brain insult (such as anxiety) occurring at the time that the language centres in the brain are forming may lead to language deficits down the line.  It is known that the links between pre-natal anxiety and schizophrenia are related only to stress that occurs in the first trimester (Khashan et al., 2008), whilst maternal anxiety experienced in the third trimester is more likely to cause offspring anxiety (O’Connor et al., 2002). Even more interestingly, there appear to be differential effects depending on the gender of the developing foetus, females more likely to develop anxiety, males more likely to be affected by attention, cognitive problems and aggressive tendencies! There is strong evidence for this in animal models and supportive evidence for this from human studies (Glover 2011; Glover & Hill, 2012)

The reason for these different gender outcomes has been thought about from an evolutionary perspective. Historically the female role in species survival in animals and humans has been to bear children and look after them, the male role has been to protect and provide resources. Different skills are required for these different roles. Thus, in a hostile environment, it pays for the mother to be fertile to ensure succession and hyper-vigilant to prey and threat. It pays for the father to go and explore new territory for food and shelter, to take risks to achieve this and to be aggressive enough to fight others for territory and food. In this context, the effect of stress in generating anxiety in females and cognitive impairment and aggression in males can be understood. Hey, in an Armageddon situation I think we would all want rough and tough Bruce Willis at our side not intellectual Stephen Fry.

In animal models it has also been found that stressed out female rats reach sexual maturity earlier, are sexually active earlier, have more offspring but invest less time in the care of each (Meaney, 2007). We have to remember we are talking about rats here, but in humans there is evidence that a harsh early environment (poverty, neglect, abuse) can lead to precocious puberty. You can draw any other rat-human parallels yourself.

The astute amongst you, might be complaining that this is all hogwash and that so many things might be confounding the picture. A confounder is something that can be related to both the purported cause and the outcome. The main ones affecting our current scenario are things like poverty, post-natal depression and maternal educational level. One could argue that a deprived, uneducated mother prone to depression is more likely to experience stress during pregnancy and more likely to have difficulty raising children, thereby causing the psychological deficits seen in their offspring in childhood and adolescence. In animal studies, this is easy to exclude, the new born pups or monkeys are cross fostered so that the mother stressed in pregnancy is replaced once the baby is born by an unstressed mother. Results remain. It is not possible to do this with humans.

In the majority of human studies, known and suspected confounders (social class, post-natal depression, maternal education to name a few) were measured and significant results remained even when these confounders were taken into account. What about the effect of genetics? It is possible to argue that a mother genetically predisposed to anxiety is likely to be anxious in pregnancy and to pass on anxiety genes thereby causing offspring to be anxious. You can see how hard it is to prove anything in science, yet clever research designs continue to come up to try and get to the answers. In a master-stroke of research design now possible due to the frequency of in-vitro fertilisation, Rice (2010) compared, in a cohort of IVF children, the association between prenatal stress and child outcome in those who were genetically related to the mother with those who were not (i.e. receiving egg donation). They found there was an association between mother’s stress in pregnancy and child’s symptoms of anxiety and conduct disorder even in the unrelated mothers.

 

How does this relate to you and me?

So, how to prevent anxiety in pregnancy? For me, I was smug reaching pregnancy having achieved a stable, loving relationship, stable financial and employment situation and having lived child-free life to the full. I felt I was ready to face pregnancy and motherhood in the best position that I could be in to avoid anxiety. There would have been nothing to stop a loved one being run over by a bus or being faced with infertility problems or illness but, at least the readily controllable variables were answered for.

Things can’t always go as planned though! Typical of most pregnant ladies, the thought of a new bald addition to the family somehow provokes the mental image of bald addition being placed into a beautiful, white cot with pressed linen sheets in a light and bright nursery attached to a south-facing home with wooden floors, modern furniture and period features. Hence in the first trimester of pregnancy Banker and I embarked on a 10 month process of flat hunting, flat offers, flat rejections, flat offer accepted, flat exchange of contracts, flat completion delay, eviction from rental and 2 weeks of homelessness, worldly goods in storage and 2 week enforced holiday in France to avoid sleeping on the street, flat completion, moving in, moving out, flat total remodelling and renovation, all of which no doubt sent the cortisol flying through my placenta!

Here biology and scientific literature come to the rescue again. Thankfully, like all natural miracles, the pregnant body seems to do all it can to protect itself and its prize. It is well known that in the third trimester of pregnancy and for a period post-natally the body dumbs itself right down (Henry & Rendell, 2007). Having for many years prized myself on my amazing memory and lauded it over my husband who seems to have been born with the happy disposition of the forgetful, I became just the same. Misplacing things left, right and centre, but instead of fretting and panicking, just sitting back and saying “Ah, sod it”. During my last week at work, I merrily typed away at a patient’s report only to re-read it to find that it was gobbledegook! Evolutionarily this dumbing down particularly affecting memory impairment is likely to protect against the harmful effects of third trimester anxiety, as well as to help block out the trauma of childbirth so that we become willing victims for another round!

Further, there was a caveat in the maternal anxiety literature! In a review of the literature, Vivette Glover (2011), a fellow North West London resident, describes studies selecting only well-off middle to upper class women in stable circumstances. They found that in this group mild stress in pregnancy had a beneficial influence on child outcome with better mental and physical development of the children and a similar trend for IQ. The suggestion is that in this group of women, a small amount of pre-natal stress may actually enhance foetal brain development. This inverted-U shaped dose-response effect is typical of anxiety and you will be familiar with the idea that a small amount of anxiety helps you sharpen your attention to perform on stage or in an exam, but too much anxiety can cripple your efforts. If Big Sis wins the Nobel Prize, I’ll be remembering to send a bottle of bubbly to my builders for the aptly timed “mild” stress!

References and Influences:

Beydoun H, Saftlas AF. Physical and mental health outcomes of prenatal maternal stress in human and animal studies: a review of recent evidence (2008). Paediatric and Perinatal Epidemiology, 22, 438–466.

Talge, N.M., Neal, C., Glover, V. and the Early Stress, Translational Research and Prevention Science Network: Fetal and Neonatal Experience on Child and Adolescent Mental Health (2007). Antenatal maternal stress and long-term effects on child neurodevelopment: how and why? Journal of Child Psychology and Psychiatry, 48, 245–261.

Van den Bergh, B.R.H., Mulder, E.J.H., Mennesa, M. & Glover, V. (2005). Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: links and possible mechanisms. A review. Neuroscience and Biobehavioral Reviews, 29, 237–258.

Berkowitz, G.S., Wolff, M.S., Janevic, T.M., Holzman,I.R., Yehuda, R., & Landrigan, P.J. (2003). The World Trade Center disaster and intrauterine growth restriction. Journal of the American Medical Association, 290, 595–596.

LaPlante, D. P., Barr, R.G., Brunet, A., Du Fort, G.G., Meaney, M.J., Saucier, J.F., Zelazo, P.R., & King, S. (2004). Stress during pregnancy affects general intellectual and language functioning in human toddlers. Pediatric Research, 56, 400–410.

Khashan, A.S., Abel, K.M., McNamee, R., Pedersen, M.G.,Webb, R.T., Baker, P.N., et al. (2008). Higher risk of offspring schizophrenia following antenatal maternal exposure to severe adverse life events. Archives of General Psychiatry, 65, 146–152.

O’Connor, T.G., Heron, J., Golding, J., Beveridge, M., & Glover, V. (2002b). Maternal antenatal anxiety and children’s behavioural/emotional problems at 4 years. Report from the Avon Longitudinal Study of Parents and Children. British Journal of Psychiatry, 180, 502–508.

Glover, V. (2011). Annual Research Review: Prenatal stress and the origins of psychopathology: an evolutionary perspective. Journal of Child Psychology and Psychiatry 52, p 356–367.

Glover, V. & Hill, J. (2012). Sex differences in the programming effects of prenatal stress on psychopathology and stress responses: An evolutionary perspective. Physiology & Behavior 106 (2012) 736–740.

Meaney, M.J. (2007). Environmental programming of phenotypic diversity in female reproductive strategies. Advances in Genetics, 59, 173–215.

Rice, F., Harold, G.T., Boivin, J., van den Bree, M., Hay, D.F., & Thapar, A. (2010). The links between prenatal stress and offspring development and psychopathology: Disentangling environmental and inherited influences. Psychological Medicine, 40, 335–345.

Henry, J.D. & Rendell, P.G. (2007). A review of the impact of pregnancy on memory function. Journal of clinical and experimental neuropsychology, 29 (8), 793–803.

[1] Interestingly, there appears to be an evolutionarily hard-wired biological predisposition to phobia development to things which are traditionally harmful. Thus, it is easy to induce a phobia for things like rodents, snakes and spiders but very difficult to induce a phobia to cars, guns and knives which are more likely to be a threat in the modern age.

[2] A dose-response effect is an effect whereby the greater dose of something purported to cause a particular effect, will cause a greater effect. For example, if sun exposure is linked to tanned skin, a dose response effect would mean that more sun exposure leads to a deeper tan. Finding a dose-response effect is good (but not necessarily definitive) evidence that a causal link exists.

Goodbye Babies

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I can’t believe that Lil Bro is starting school next week.

The sleepless nights, the wiping up of bodily solids and fluids, the sleepless nights, the heaving up and down, the sleepless nights, the pushing here and there, the sleepless nights, the feeding and bathing, the sleepless nights, the changing into clothes and out of clothes, days are over. He can do all that by himself now, which has all led to this point: his departure in to the big wide world. Ok, so its only reception, but if what happened with Big Sis repeats itself, I am sure that as he turns to wave goodbye to go into his class I will get a glimpse of his future teenage self, waving a goodbye to leave home forever. That split second transformed into a movie slow-motion. That’s why I’ll be packing the hankies.

Parents up and down the country are laying out crisp, clean uniforms and ironing or stitching on names, and wondering where did that strange, squashy, floppy, bundle get to? How did ‘it’ possibly become someone that was going to inhabit these long trousers and enormous shoes? And the cheekiness of time to cheat you into thinking at times “Oh my God, my life is over, this is never going to end”; when in fact, it’s gone in a blink of an eye. You have become that annoying “well-meaning friend” whose eyes you wanted to scratch out as they told you “They grow so quickly, you must enjoy this time”, as you jiggled, bounced and paced around in your puke-stained pyjamas –turned-acceptable-day-wear, willing your baby to sleep. You look back with rose tinted glasses at those times. You remember those tiny, fat, irresistibly kissable feet that smelt of talc (rather than the smelly, sweaty, verruca prone ballet/ football feet they have become), and the little hands that reached upwards to be enfolded in yours and the clear eyes that looked at yours with nothing but innocence and love. It wasn’t so bad, the crying wasn’t so loud, the poo wasn’t that disgusting; you are now accustomed to a messy house and sleep deprivation anyway.

This, my friend is about the time that you absolutely need to reach for your contraception….!

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