Managing your child’s behaviour: Can’t behave, Won’t behave?

Incredible years

Over the last few weeks I have been asked by a few people to write something on managing behaviour of children. This is one of the biggest challenges for parents, and yet I had put off writing about this as it is not as easy to give advice on this as it sounds. The “tips” that friends were asking for basically amount to what we in the industry call “behavioural management”. Ways in which parents can magically “change” or “manage” their children’s behaviour. Sadly, there is no magic tip, only all the things that you have already heard of and tried. Behavioural management tries to spell out what is and is not desirable behaviour and strategies try to tip the balance of choice towards behaviours that are desirable. Well known strategies include “the naughty mat” or “time out”, “ignoring” your child’s mild bad behaviour and also the blessed “reward chart”. If you want to read up on behavioural management an excellent book is “The Incredible Years” by Webster-Stratton. I won’t précis what I feel is a thorough account of good behavioural management, but instead ask:

Does behavioural management work?

The answer in theory is unequivocally “yes”.

But, so often in practice is “no”.

This is because behavioural management is easiest to implement when your child is “typical” and has no other problems, and you (the parent) are brilliant, have no problems and are super consistent in everything you do both with your co-parent and school.

Which basically means “no” or only “a bit”– as when does the above situation ever happen?

Here are two reasons why your child may not be “typical”:

Neurodevelopmental problems:

Neurodevelopmental problems, in particular learning difficulty can heavily impact behaviour.  In young children, aggression and temper tantrums are typical responses to frustration, but by school age, some control should have been gained over these behaviours. If a child is developmentally delayed, then their ability to behave should be compared to their developmental age rather than chronological age. A 16 year old boy with the developmental level of a 4 year old; can be expected to behave in line with a 4 year old. For a four year old, temper tantrums and hitting out are common responses to frustration, the trouble is that being hit by a 16 year old boy in a temper tantrum has very different consequences to being hit by a 4 year old, and yet, the child “can’t” help responding in this way. These children are often clients in child mental health services as parenting children with severe learning difficulties can be extremely challenging. Other neurodevelopmental disorders also cause behavioural problems. In ADHD children with problems with attention cannot listen to or follow instructions as well as other children. They will tend to act without thinking and may do things that they regret later because they acted without thinking. Children with Autistic Spectrum Disorder may have behavioural problems as they are having difficulty in understanding what is being expected of them and poor social understanding can lead to many more frustrations on a daily basis. Standard behavioural management may not work in these groups of children and behavioural management needs to be adapted to the child’s difficulties. In general it is harder to implement and with more varied results than in children without neurodevelopmental difficulties.

Emotional problems:

Children who are having emotional problems may have difficulties in behaviour. Emotions and behaviour are inextricably linked. When we feel down or stressed out, our behaviour changes. Some of us reach for chocolate, some for alcohol, some people become withdrawn and unsociable, other people become irritable and angry. It is important to assess emotional aspects of your child’s life if their behaviour changes or deteriorates. Children may not always volunteer their states of mind to you. They may not be able to label their emotions, or to express themselves. They may be afraid to talk about these things. Their unhappiness and frustrations are displayed in their behaviour rather than in words.  It is your responsibility as a parent to notice, to ask, to label for them, to give them words, to give them permission to talk about their difficulties. To guess and to investigate from asking teachers and friends if nothing is forthcoming. It may be that they are being bullied at school, it may be that they are picking up on the stress in your marriage, it may be something trivial, but if you don’t notice/ enquire, you won’t know and their change in behaviour will just be called “bad behaviour” or “acting out”.  In these cases, behavioural management will not work well. Rewards will feel irrelevant, ignoring and punishment will feel like persecution, negative attention will be better than no attention and rejection is a welcome confirmation of their own self-loathing. Finding out what is wrong, offering security will work better here. Unattended emotional problems in children can impact personality and aid development of long-lasting traits that can lead to “bad behaviour” becoming habitual and “part of” a person’s personality that can no longer be easily mended.

In children without these additional problems, the limiting factor to good behaviour is usually the parent not the child.

Lack of sustained motivation:

In the defining clinical trial for children with ADHD where they compared medication to behavioural management (The MTA Study), behavioural management achieved equal outcomes compared to medication. But wait, here the behavioural management programme used highly trained psychologists to work with highly motivated parents and teachers to obtain this outcome. Real-life trials (what we call pragmatic trials) using existing services, which tend not to heavily involve the schools (as the Department of Education is separate from the Department of Health), and non-selected patient groups, that have looked at the efficacy of community parenting and behavioural management programmes have netted unimpressive results.  It is not that children’s behaviour cannot be managed; it is that the will of society and parents, is insufficient.

I know this all too well. Big Sis has a weekly spelling test. On the weeks where I have my act together, we sit and learn the words and I test her on the words each day to make sure that at the end of the week, she gets full marks and I reward her for this attainment. This is basically behavioural management in action: co-working towards a set goal that is achievable, achieved and rewarded. This works fantastically well, thumbs up and smiles all around. Once she has done this for a few weeks, I get complacent and I think, well now – maybe I can just give it a skip this week, she and I can both have a relax and we’ll just have a quick look at the words the night before. She gets a couple of mistakes. That’s basically my anecdote for behavioural management. It genuinely works until one day, you can’t be bothered and it all goes a bit wobbly again. The limiting factor is me, not Big Sis.

Parental problems:

Wobbles in my behavioural management can also be seen when I am stressed or distracted. One time when I was very stressed waiting for a phone call regarding a job offer; the children were extremely badly behaved – “for no reason”. I was snappy and shouted at them and they just wouldn’t do what they were told – “it was as if they knew exactly when to wind me up”. Eventually, the phone call came, and I had got the job. That afternoon, they were very well behaved. The change had been in me, and their behaviour merely reflected my state and parenting capability, not something innate in them.

Unrealistic parental expectation:

When we talk about “bad behaviour” we all mean different things and we all have different thresholds as to what is meant by “bad”. Some friends and relatives come by our house and make “tutting” sounds when they see our kids glued to the TV, leave the table at meal times on a whim to dance around the kitchen, bonk each other on the head with cushions and generally shout at each other and at us. To me, this is not bad behaviour – this is just life in our household! Equally, I raise a brow when I see children that never say “please” or “thank you” and run away from their parents on the street, while this is not something that bothers them. When parents complain that their children “Will not do as they are told”, the severity of the issue rather depends on what they are being told to do. If they will not do 60 minutes of piano practice every night, that is rather different from refusing to do their homework, or refusing to stop watching TV; and “good” and “bad” behaviour is sooo dependent on what the  parental and school expectation is. Often there are cultural and generational expectations of how children should behave. A normal child in a school with high behavioural expectations may be deemed to have “bad behaviour”, a normal child in one culture may be deemed badly behaved in another. The behaviour is relative and in order to assess behaviour properly, it is important to first evaluate that the expectations are reasonable. There is a limit to how much a child can “change” and they will not bother to attempt to change behaviour if they feel that the bar is being set too high.

Inconsistency:

One of the main saboteurs of a good behavioural management programme is “other people”. The well-intentioned/ or not so well-intentioned other half who disagrees with what you are doing. By not supporting you, they are de facto sabotaging the behavioural management plan because children are such buggers that they can spot disagreement a mile off and work it to their advantage. Much like MPs claiming expenses and benefit fraudsters, they are not averse to trying to get away with as much as they can. Playing one parent off the other must be a favourite game for children. In my opinion parents who want to succeed at behavioural management need to get on board together, or not bother. A similar conundrum exists with the school. If children are told one thing at home and another at school, the “authority” of “the rules” is undermined. It is a good idea when implementing behavioural management to discuss plans with the child’s school so that the same message is delivered to the child.

So in summary, if emotional problems are excluded, behavioural management delivered consistently and well will definitely improve your child’s behaviour, even if they have additional difficulties; but it is by no means a magic wand. It takes hard toil, stamina, guts, persistence and tears, but can reward you with likeable human beings. Isn’t that the essence of parenting?

If you want to know more about behavioural management please buy/ beg/ steal/ borrow: The Incredible Years, by Carolyn Webster-Stratton. This is the programme recommended by my colleague Professor Stephen Scott OBE of the UK’s National Parenting Academy. I have read it cover to cover and it’s good common sense.

References:

Carolyn Webster-Stratton. The Incredible Years. ISBN 978-1-892222-04-06. http://www.incredibleyears.com

The MTA Cooperative Group (1999) A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Archives of General Psychiatry. 56:1073-1086

Freaky Friday: My Mothers’ Day Post

Heels

Its mothers’ day again which always gets me thinking about my own mother and how the passing of time changes our relationship. Over the last few years I have been having “Freaky Friday”- mother-daughter role reversal experiences.

As my parents are getting older, the hospital appointments start mounting and I am required to accompany them to hospital. Visits home have sometimes involved the adjudication of “childish spats” between my parents where both parents are sulking in different rooms in their house refusing to talk to each other. Then there was the incident with the phone bill.

My mother, who is now retired, kindly helps out with school pick-ups  a few days a week when I am at work. To help me to be able to co-ordinate with her better, I purchased her an android mobile phone and a phone contract as she and my father were living in the dark ages of land-line and a Nokia that was never turned on.  She was delighted and I showed her the functions and informed her of the contract of 300 free minutes call time. I had been reassured by my sister that that was sufficient because “Mum is sensible, she has a landline. She won’t need more than that a month on the mobile”.

A few months passed and the phone was working brilliantly. If I had a change of plan – “Big Sis has  a play date – you don’t need to pick her up today” I could get hold of my mother straight away. Her phone contract was tied to my mobile phone contract and was paid monthly by my direct debit arrangement. As I rarely exceed my phone contract limitations, I rarely check my monthly phone bills.

Then one day, I decided to sort out my finances and go through my accounts. To my shock and horror, my mobile phone bills had gone from £24.00 a month to between £150 and £500 pounds a month! I went back to look through my on-line statements that I had not checked. There in full-colour, including helpful pie-charts were the breakdowns of the calls made from my account and my account for my mother. Let’s just say that someone was eating the lion’s share of that pie, and it wasn’t me. 300 free minutes were just the tip of the iceberg in my mother’s social life.

Helpful that mobile phone companies are these days, they also give you a full listing of every single number that had been called: several phone calls to Taiwan and several hour long conversations with various friends and family were all listed.

You can only imagine the conversations that followed, the net result of which was me frogmarching my shame-faced mother (“You said it was unlimited minutes”) down to the Vodafone shop to have her phone account transferred to her own name and most importantly billing account. Although I was not exactly pleased with the out-of-pocket expenses, the humour of the situation was not lost on me and it was my own fault to assume that my mother would be “well-behaved”, and comforting to know that far from being lonely and isolated as many retired people are, she has a very active social life!

I was a strange mixture of smug and shaken at the realisation that roles had been reversed. I was the “grown-up”, “responsible” adult now. I could “take care” of other people now, in fact, it was now my “responsibility”. Visions fast forward to a time when I will have to sponge bathe my parents and mush up their food as they can no longer chew, and other things that only doctors and elderly care-workers can really imagine (like the time when helping an elderly patient out of a chair she pee-ed on my feet in open-toe sandals).

Then, last week I was sick in bed with the flu. As all parents understand being “sick in bed with the flu” is meaningless to young children. It does not mean you can’t still be woken up at 6am by bouncing on your bed. It does not mean you can lie in bed and avoid the school run. It does not mean that you avoid helping them with their homework and stopping their squabbling and beating each other to a pulp. As a parent “being sick in bed” means that that’s where you should be, but you are in fact still doing everything that you are required to do at home only in a bad tempered manner and periodically shouting “Can’t you behave, I’m sick!”

On the third day of this, my mother calls.

I tell her that I am sick.

She tells me that she will pick up the children from school, take them to her house, give them dinner and bring them back in the evening. She asks me what I want to eat for dinner. She will cook it and bring it around when she drops the kids back.

 

That’s when I realise that there is no role reversal.

She is still my mother.

No one looks after you quite like your mother.

Thanks Mum.

Happy Mothers’ Day!

My International Women’s Day post: A gender for parenting

Dick can't help

It’s International Women’s Day again! Last year I griped about the career prospect inequalities for women and I am pleased to say that although it’s not exactly “all change at the top”, I think that the world is waking up to women in the workplace and the agenda for change here has started rolling into place. So this year, I am moving the gender agenda on…

A few months ago I attended a fascinating talk on the impact of post-natal depression in mothers on their children. As you can probably already guess, the impact is not just for the duration of the mother’s depression, but due to the massive development of the baby’s brain in the first year of life in response to its environment, problems in its “environment” (which is largely provided by the baby’s primary carer) can be life-long. For mothers to get depression (or worse still, psychosis) at this time is crippling as not only does it affect them for the duration of their illness, but can impact the child LIFE-LONG. I don’t think any other mental illness can have such a profound effect.

The talk went into much detail about the observed negative outcomes in children and the mechanisms that led to these outcomes. In brief, lack of love, warmth, responsive parenting, talking and interacting with babies in “motherese” lead to abnormal or insufficient normal brain connections in the baby (motherese is the repetitive and sing-song baby-like voice that mothers adopt when talking to babies that is infinitely nauseating to non-parents – isn’t it darling? Yeees-it is! Yeees –it is!). Many clinical trials have been undertaken to treat post-natal depression to prevent these negative outcomes in children, such as cognitive behavioural therapy (CBT) and anti-depressant medication, but all with marginal effects. Really interesting stuff that I am sure I will blog about in more detail another time.

A PhD student had done some interesting work around the ability of depressed mothers to differentiate between a distressed cry and a non-distressed cry from various recordings of a baby crying. Depressed mothers can typically not differentiate the cries and find all cries aversive. Interestingly though, depressed mothers that had been musically-trained (played grade 4 or above piano) continued to be able to distinguish a distress cry from a non-distressed cry from her baby presumably because of their superior ear in differentiating musicality in sounds. This led to the suggestion that training in music may be protective in some way for the negative impact of maternal depression as these mothers preserved the ability to identify distress in their babies. Someone suggested teaching mothers the piano in pregnancy.

When questions went to the floor, other people suggested a blast of oxytocin nasal spray. Oxytocin is the “mothering” hormone released in pregnancy and during breast feeding and given to apes has been found to increase “maternal behaviour”.

Tentatively, I put up my hand. From the back of the hall (I have not yet escaped my student-style sitting at the back of packed lecture theatre habits) I wait my turn to be picked. “Umm – wouldn’t it just be easier to ask the dads to step up and do the parenting bit?”

It struck me as obvious that if the best anti-depressants were contra-indicated in breast feeding, and available anti-depressants were not achieving good enough effects and CBT was taking too long to treat mothers, that one should look not to new and under-developed drugs like oxytocin or expensive and frankly bizarre suggestions of NHS funded piano lessons for mothers to “cure” the mother; but to additional support that could take over the “warmth, love, responsive parenting, engagement and social interaction” with the baby. The clue was in the term “parenting”. Dads are parents too.

What amazed me was the response.

Maybe I had asked a silly question. Maybe there were already piles of research, unread by me; that excluded fathers from nurturing a baby. There was an awkward silence as if I had breached some sort of sacred unspoken code of conduct. There followed mutterings from the row of my esteemed male colleagues sitting in the front row. I imagined that they were saying “Trust ­her (rampant feminist implied) to bring this up!”

The speaker responded to my question thus (as verbatim as I can remember but cannot be vouched to be word for word): “Yes, but people don’t respond well to being told to do things, and of course there is already a large role for fathers to support their wives. Often fathers are at work and are not available to do this.”

Yowzers!

I wondered if I had time travelled to the 1960s.

Can it be that in the 21st century, my esteemed, brilliant, talented, caring profession is still stuck in a time-warp? Decades after my predecessors saddled mothers with terms such as “Refrigerator mother”, “Schizophrenogenic mother”, “Good-enough mother”, “Tell me about your mother” and volumes on the paramount importance of maternal bonding and maternal attachment – can it be that we have not moved on from the primeval importance of mothers to babies? I am not disputing Bowlby here; I agree that attachment is vital. My dispute is with the gender requirement. Why can’t fathers bond and attach to their children – particularly if the mother is down or out?

My view on the issue is this:

Parental bonding and responsive parenting to babies is vital.

Biology provides some mothers with an advantage over fathers for bonding through pregnancy, birth and breast-feeding hormones. This hormonally driven advantage is lost once mothers stop breast feeding. In the UK, less than 1% of mothers last to 6 months of breast feeding. The hormones do not make mothers “better” at bonding, but makes them “desire” to bond and care for their young – kick starting the supposed “maternal instinct”. If there is a strong “desire” to parent, maternity hormones are completely unnecessary, which is why mothers who adopt babies are still perfectly wonderful mothers without having exposure to any maternity hormones. Believe me when I say that it was not oxytocin that told me that if my baby is crying I should pick her up, and if my baby is crying and her nappy stinks that I should change the nappy. That’s just common sense and I don’t need hormones for that.

Some mothers lack this advantage over fathers (having low levels of hormones or being unresponsive to hormones) and have no “maternal instinct” and are uninterested in babies (in the same way that many men lack the “aggressive instinct” that they are supposedly stereotyped to possess). Many men possess a “nurturing instinct”, in the same way that many women possess an “aggressive instinct”.

Some mothers get post-natal depression and are completely incapable or are severely handicapped in bonding and responsive parenting.

The conclusion should therefore be that fathers who have a strong desire to bond and care for their babies are no worse parents than mothers. Once mothers have stopped breast-feeding, they and their husbands are equally placed biologically to provide the love, care and nurture that is required to support a baby’s development. If a mother has post-natal depression or is uninterested or incapable of parenting for whatever reason, than the father is better placed to provide the love, care and support (provided he is not also disinterested or depressed), and particularly if he is warm and loving.

And yet, no one is shouting this from the rooftops, because there is no evidence to support this.

Just piles and piles of research on the bad outcomes for babies raised by mothers with problems.

Why is that?

Because in the past, it was the mother’s role to nurture babies and look after children. The body of evidence regarding mothers has built up over time. People writing research proposals and funding bodies granting money for research want to see an evidence base for the work that researchers they fund are building on. There is very little that has been done on fathers as the main carers for babies because up until the last few decades, this just happened so rarely. Even today, the vast majority of funded research in the parenting area relates to looking at mothers and their children. There is no evidence that fathers can care for babies, but equally, there is no evidence that they can’t. There remain large personal and societal incentives for many people and organisations NOT to produce research and data that may support equality in parenting capability. Yet, anecdotally, the gay dads that I have met (both personally and professionally) have largely been fantastically capable of love, warmth and responsive parenting and I am just sad for the many children whose lives are inordinately altered by mothers with post-natal depression where fathers have not stepped in.

The next stage in gender equality is surely to evaluate if the skewed evidence that we have been fed by parenting researchers who lived through a different society is scientifically relevant going forward, and to generate new evidence on parenting; where parenting is not just a proxy for “mothering”. My profession should be at the fore front of this, advocating for this research to take place and stamping out the gender bias in parenting. For if going forwards we are moving towards equality within the workplace (which we are), are we as child psychiatrists going to hinder this progression by continuing the rhetoric of hanging the responsibility of childcare on to aspirant mothers, or are we going to apathetically hang back and allow governments to enact it’s solution: to hand childcare over to the state? I believe we should speak with one loud voice for parental responsibility for parenting. Both parents in concert where possible and gender being irrelevant.

I am reminded of Harlow’s controversial primate experiments. The baby monkey chose to lay with the wire frame dummy covered in faux fur that gave it warmth and comfort, rather than the wire frame monkey that gave it milk. It is love that matters not mammary glands, and I am confident in my assertion that mothers and fathers are equally capable of that.

How family ski holiday hell can protect your child from perfectionism

Skiing

Last week I was on the obligatory family ski holiday. Around this time of year, there is no getting away from it for those of us privileged enough to be in the demographic that “does ski holidays”. For most people, the dilemma is about “to dump” or “not dump” the children. Whizzing down black runs is not something one can achieve with a baby or toddler in tow.  If your children are old enough to learn to ski, then “dumping” the children in ski school becomes legitimatised as “teaching your child a life skill”, a “healthy sporting activity” or for the tigers “brownie points for extra-curricular activity on the child’s CV”. There will be those who opt for all day children’s ski school and others who opt for ski resorts with all manner of childcare facilities so that they can get a good days skiing in. Reserve a place at the resort crèche where the children will participate in all manner of “arty-crafty activity” and they will mix with European children and might even learn a little French or German. Wunderbar! Hire a chalet nanny, or hell, bring your own nanny (or grandparents) with you. Why not? It’s your holiday as well right?

I have no problem with “dumping children”, but what I dislike is the pretence surrounding it. Why not just be honest and say “I love skiing and this is the one chance a year I get to do it”? If you are going to do it, indulge and do it guilt free. We all need a break sometimes. However, I would refrain from framing it in your mind as a “family holiday” and make sure you have a “proper” family holiday where you actually engage with your children as well. Even better, take turns with your spouse to go during term time without the children – they will feel less “dumped” that way. Given that most people that can afford extravagant ski holidays are also the ones working long hours and not spending quality time with their children, holiday contact is really important, and if the only holidays you have involve a crèche and a nanny then you have to begin to think about the impact of this on relationships with children.  I opt for morning session ski school and family time in the afternoon. Banker is quite good at taking Lil Bro skiing between his legs and Big Sis can now ski independently. Banker says he gets great satisfaction watching the children’s skiing coming along. Haven’t I trained him well?

I have a different reason for finding family ski holidays a chore.

I don’t ski.

Not having grown-up wealthy, skiing every winter was not part of my childhood. By the time that I was earning enough money for ski holidays, I was spending my money on holidays to South Africa to visit Banker as we spent 3 years living in different continents and holidays were our only time together. By the time that we eventually managed to live in the same place, I was the lone “non-skiier” of my friends and I didn’t fancy being the hole in the donut of other people’s ski holidays.

I had happily been avoiding ski holidays to no great regret. “Oh no, I can’t come skiing, we are off to explore the temples at Angkor Watt”; “Oh, sorry, maybe next time, I’m off to climb the Himalayas”; until kids. Given that my kids are de facto wealthy by UK-not-London standards (Big Sis has proclaimed herself “Rich” – when I questioned this, she replied “I will be when you two die.” Typical Big Sis!) – was I going to stand in the way of their wealth-based leisure pursuits?

I have in mind independent secondary school and Russell Group University ski tours and ruddy faced chaps called Tristan and Hugo that might wish to invite Big Sis to a family ski holiday; or blond, horsey gals called Cressida that might require Lil Bro to deliver chocolates to her. Did I want to deprive them these opportunities?

So I have been forced onto the slopes against my will by my diligent parenting ethos. My ski instruction to date has so far consisted of 3 hours with a private ski instructor. Ski instructors are usually of the buff 20 year old variety so it is no great torture, particularly as I spent many parts of the 3 hours being hoisted and supported by them (“Oh dear, I’ve fallen down again!”). This time however, the private instructors were all fully booked so I was left to my own skill (or lack thereof) and my darling husband.

Think of the second Bridget Jones movie and you get the idea of how I spent the last week, only worse as frankly, Renee Zellwegger would look great in a paper bag. Think: short, Chinese person dressed head-to-toe in Decathalon with sporadic catalepsy. No button lift was able to keep me upright and even flat terrain was insufficient to guarantee that I could stand. There was the time that a failed turn left me skiing backwards for a time screeching like a banshee till I fell forwards and tried aimlessly to use my fingers to stop my downward trajectory so that I left a trail of scratch marks in the snow like a demented cat failing to cling on for dear life in a cartoon. There was the time my ample bottom fell off the miniscule button of the button lift, but fearing that I would be left alone half way up a mountain slope, I carried on holding on to the lift with my arms so that I was dragged on my backside for several metres before I decided I had better let go. Or the time that I fell over for no apparent reason whilst attempting to embark a button lift and couldn’t get back up and in a truly British way, not wanting to hold up the queue of teenagers waiting to get on the lift, I heroically gestured that they ought to “Don’t mind me” and encouraged them to just step over me in the interests of the queue. Speak nothing of the slope-side verbal exchanges with Banker, incredulous at my ineptitude when I tried to put my skis back on with my skis pointing downhill.  Let’s just say that I measure the success of my skiing by the ability to descend a slope alive. If no bones have been broken, it has been a successful day.

Then there was the time that I hurtled down the piste, poles akimbo at constant risk of entanglement with my skis, ineffective snow plough engaged, heart and lungs in my throat, in perfect uncontrolled freefall, shouting “sorry” every 5 seconds as I cut across paths of furious proficient skiers and forcing snowboarders on their knees as they are forced to divert their course unexpectedly, as my life flashed before me. Only then to glance sideways to see Big Sis and an orderly row of bibbed midgets skiing calmly, gracefully and naturally down the slope past me.

Ah, it’s all worth it. Hope Cressida and Hugo will be thankful.

In hindsight though, I think there is a further benefit of my ineptitude. In this age of heightened perfectionism sending eating disorders and depression in children soaring, what better role model can there be for the nonsensicalness of it all than a parent who is prepared to put participation in front of looking good and doing well. For all the talk of promoting “non-competitive” competitive sports at school and inviting motivational speakers into schools to discuss successes that have come from failures, surely the most impact to children on this matter can come from parents who are not afraid to demonstrate failure and can wear it with a smile?

And I sure do epic fails and falls well!

Assess your child’s mental health and other great resources for parents

Little Effra Pictures

This week I have been working on a resources page for the site as there are some great, free resources out there that I think are unknown to parents and under-utilised. The resources page will permanently feature on this site now, so please let other people know about it. I hope to continue to populate this resource page with new and wonderful things so do check back occasionally to the resource page.

Information

FREE Child Psychiatry Textbook

Youth in Mind is a great resource from Professor Robert Goodman a fantastic researcher in epidemiology in children’s mental health who has taught and helped me with research in the past. The website is a bit basic, but don’t let this fool you into thinking it is not legitimate; it’s just that high-flying academics have more time for research than prettying-up a website. On the bottom of the home page, you can access a download of Goodman and Scott’s textbook on Child & Adolescent Psychiatry. All psychiatrists read this book for the Membership exams for the Royal College of Psychiatrists so if you digest this book, it is probably as much as most generic psychiatrists know. Unless you are a budding psychiatrist, I am not recommending you read this cover to cover, but if you want an authoritative and comprehensive view of a particular issue, it’s a really useful reference. And FREE. Robert is a truly generous academic and I know that he negotiated with the publishers for this content to be made free particularly for colleagues practicing in the developing countries, but it does mean that this resource is now available for everyone.

For Parents

Assess you child’s strengths and difficulties

Also from Youth in Mind, you can navigate in your own language to an on-line questionnaire, the Strengths and Difficulties Questionnaire (SDQ) which you can complete on-line for your child. The SDQ is one of the most frequently used screens for mental health problems worldwide and will help highlight your child’s strengths and difficulties in key domains. The web-site will give you specific instructions and will also give you a feedback report about your child’s strengths and difficulties. A teacher version is also available, and the combination of both parent and teacher reports will give a more accurate summary. For teenagers there is also a child self-report version. Of course, no on-line questionnaire can replace a medical assessment if you are worried about your child, but it can prompt you to think about your child broadly and to consider if there are any concerns that warrant further exploration.

For Teachers

Learn how to help a child you work with

For teachers, social workers, youth group leaders and anyone working with children MindED is a great e-learning resource that will undoubtedly help you help the children you are working with. It was set up as a collaboration between the Department of Health and the Royal College of Psychiatrists as well as Paediatrics, so is a good resource.

For Young People

Headmeds

This is a website targeted at young people so that they can get informed about the medications that they may be being prescribed. It is funded by the charity Young Minds and is also very good.

Autism

The National Autistic Society Website

Still the go-to site for autism information for parents. There are regional branches of the NAS and they will give you information about resources, services and support groups locally.

Education

The Book People

What would I do without the brilliant Book People? The majority of presents that we give to other children for their birthdays come from here (Sssshh – they are so cheap – don’t tell). Books make great presents, and the Book People even do cheap but beautiful birthday cards. I hate cheap plastic tat, and so we always give a book as the party-bag present at parties too. At a pound-or-so a book (including greats such as Roald Dahl and Diary of a Wimpy Kid), it beats plastic tat and a glow-stick any day. The full Roald Dahl collection (15 books, potentially a year’s worth of reading) can be purchased for the price of two cinema tickets, and the full set of David Walliams audio-books kept the kids quiet on many a long drive. Great adult and cookery books too!

Does parenting help chess and poetry?

chess

A few weeks ago I had a conversation with a professor. She asked me how my children were. Being conscious that my part-time status should not account for nothing, I bragged:

“Oh, my daughter is in the final of the Borough Poetry competition and my 5 year old son is playing chess”.

What surprised me was her response.

“Oh – you see, that proves it’s all “G””

(G is the behavioural geneticists’ abbreviation for genetic effect – yes, we behavioural geneticists actually do talk in terms of “G” and “E” (environmental effect) in common parlance rather than actual coherent words).

“Oh” I said, “I was about to say that it proves it’s all “E””.

Of course, we all know that both “G” and “E” play an effect in outcome, but it is funny to see how (even in two people that study it) our interpretation of science is coloured by our own personal view; or perhaps rather, we skew the science to suit our own needs and to support our chosen behaviours.

My personal view is that parenting matters. I would not have gone part-time and sacrificed career advancement if I did not believe that I would be making a significant positive impact on the outcome of my children. I am more likely to see positive outcomes in my children as being directly related to my input, rather than what would have happened regardless if I was there or not.

If you believe that outcomes are solely genetically determined, then parenting no longer becomes important, and you may as well excel at work and farm out childcare. Equally, if you have chosen to excel at work and farm out childcare, it would suit you very well to believe that “it’s all about G”.

So here’s the route to Big Sis’s poetry success and how come Lil Bro is playing chess at 5 years, and you can decide for yourself on the G and E in these instances.

Big Sis:

Big Sis is good with words. She is interested in them and from as young as 3 years she would always ask questions about the meaning of words:

Big Sis: What does imagination mean?

Me: It’s something that you think about in your head.

Later, when I asked her to concentrate on colouring within the lines:

Big Sis: What does concentration mean?

Me: It’s when you use your head to think about something.

Big Sis: No. That’s your imagination.

At that point, I bought her a dictionary so that she did not need to rely on my lack of defining prowess; the point being that she was interested in words and their meaning from a young age and I provided her with the tools to pursue this.

In addition, I read to Big Sis (and Lil Bro) every night from the age of 1 year, until they could read chapter books for themselves, and I will still read to them more challenging books when we are on holiday. I will define (to the best of my ability) difficult words and ask questions to check that they understand what I have read to them.

I have a book of poems my sisters and I wrote when we were Big Sis’s age. My father encouraged us to write them and he had them bound in a fancy book. They are absolutely hideous (all basic rhymes and no substance – “I love school. It’s so cool.” – you get the tragic idea) but strangely appealing to young children. Sometimes I would get this book out and read them to the children.

When I found out that Big Sis was studying poetry at school, I went to Waterstones to buy TS Elliot’s “Old Possum’s Book of Practical Cats”. We have a well-loved cat, and so I thought that this would be an accessible poetry choice for Big Sis. Indeed it was. We read all the poems together. Lil Bro takes to Macavity, Big Sis to the Pekes and the Pollicles. We will soon be taking advantage of the return of the “Cats” musical at the West End.

In one poem, TS Elliot says “How else can a cat keep its tail perpendicular?”

Big Sis asked for a definition of “perpendicular”.

I explained that it means when something is at right-angles to something else. I stand up and demonstrate with my arms perpendicular. At that moment, our cat jumps out from under the bed with her tail up. “There look” – I say pointing, “that’s what it means to have a tail that is perpendicular.” Big Sis understands.

“But”, I say to Big Sis, “I think that Mr Elliot has another meaning when he asks this.”

“Show me what you look like when you are sad or ashamed of yourself.”

Big Sis, the master of drama, slumps and hunches over; slinking away.

“Now show me how you look when you are proud.”

Big Sis sits up straight and tall.

“Look”, I say, “You are “perpendicular” to the ground when you are proud. I think this is what TS Elliot means; he is talking about pride rather than the position of the cat’s tail.”

Later, Big Sis is practising ballet moves in the hallway.

“Mum!” She shouts.

“My leg is perpendicular.”

 

Lil Bro:

Lil Bro has always had excellent spatial awareness. One Christmas just after his second birthday I thought about presents to get him. Being Chinese, the first toys that come to mind are educational ones. I thought I would get him a jigsaw, something he could realistically manage like a 3-piece. His Aunty, who is also Chinese and so of the same “educational toys” mind set also buys him jigsaws – Thomas the Tank Engine ones; only, she has no children and so did not appreciate how many pieces a 2 year old could realistically do – and bought him 6, 10 and 12 piece jigsaws.

One evening, I was cooking dinner so I put Lil Bro at the table with the 3 piece jigsaws. He wanted the Thomas ones, so I put those out as well, just to keep the peace while I cooked. The next minute, I turned around and there he was sitting with the 6 piece puzzle completed. I nearly dropped my saucepan.

“OK, then clever clogs” I thought, here’s the 10 piece.

That was also pretty much consumed.

My Christmas present was a complete waste of money, he never did 3-pieces. By the time he was 3, 24-35 piece jigsaws were no problem. We even played “Jigsaw-offs” – infant versus geriatric; where Lil Bro and my mother would race as to who could finish an identical 24 piece jigsaw faster. Lil Bro was victorious.

By 4 years old 50 and 72 pieces were fine. By that time, I had emptied out several toyshops of their jigsaws.

At weekends, when Big Sis was at her swimming lesson, Lil Bro and I would sit in the coffee shop next door and eat porridge. The coffee shop had chess and draughts sets for customers to play with. To kill the time, I taught Lil Bro to play draughts and then chess. I am not the greatest chess player myself. I tend to take pieces with no overarching strategy; pretty much ending most games with no conclusion as my bishop and king chase the opponent’s knight and king hopelessly around the board. Still, by 4 years, Lil Bro knew how the pieces moved. I installed a chess game on to the ipad at home and encouraged the children to play it.

By chance, there is a chess club that runs in the same community centre that the children go to Chinese classes at (they go to be at one with being “Chinese” – their Chinese is even more hopeless than mine). One day, Lil Bro, aged 4 years said “I want to go there and play chess”. Given that the time clashed with their Chinese class. I said it wasn’t possible, but when it came to the summer holidays, I asked if they wanted to go to Chess Summer Camp for a week.

Big Sis was not keen.

I said to Lil Bro, “Your sister doesn’t want to go. Are you sure you want to go, even on your own?”

He said yes.

I went to check with the Chess Camp leader – wasn’t he too young?

The Chess Camp leader said some of the best players in the club were 5-6 year olds. Still, I wasn’t happy to send Lil Bro on his own and I eventually managed to twist Big Sis’s arm to go with him.

After a week of chess camp, and the initial enthusiasm, we carried on playing chess occasionally now and then. I didn’t think anything further on it. Then 3 months later, Lil Bro says to me “I want to go to chess club”.

Man! I thought. I wrack the local websites for chess clubs that are not going to clash with their Chinese class and are not too expensive. Finally, I find a cheap club on a Saturday afternoon at the local library. It’s good, but there is one teacher to eight children at greatly varying ages and abilities. Plus, smack bang in the middle of Saturday afternoon is not the most convenient time.

I get the chess teacher’s contact details. I ring around a few mothers I know whose children might be interested in chess. I set up a chess club for 3 boys after school in a local coffee shop.

So…what do you make of it?

My view is this: clearly, both Big Sis and Lil Bro have genetic predispositions to be good at certain things. I come from a family of mathematicians and engineers; Banker from a family of lawyers and linguists. Go figure that these genes are knocking about our chromosomes.

But can that be all?

What if I hadn’t been there to notice?

What if I had noticed but done nothing about it?

What if I had noticed it but derided intellectual pursuits and tried to knock it out of them?

I am pretty sure that Big Sis would still have enjoyed and been good at writing and Lil Bro would have found chess by himself at a later age. But would they have been in the final of a poetry competition at age 7 years, and been playing chess aged 5 years?

No.

Do these things matter?

Might they not reach the same end-point in adulthood?

That is the more interesting question that is so hard to answer because of the lack of the counter-factual. But my view is this: if life is a journey and your outcome is your destination; genes will drop you off at the airport. If you are lucky it will be London City Airport, if you are not so lucky it will be Luton Airport Parkway. Parenting provides your back-pack: it can be empty; or it can be full of maps, restaurant and hotel reviews, travel guides, good books, a compass, a thermos of cocoa and a bag of chocolate chip cookies. It might not be everything you need, but it sure helps you on the way.

Ultimately, where you go from there is up to you.

Shrink grows kids: One year on

One Year on

Shrinkgrowskids is officially a year old, and I am so glad that I have made it to this milestone! Thank you to the 117 subscribers and the many more regular visitors. Shrinkgrowskids is being read in 102 countries worldwide, and especially in the UK, USA, Australia, France and Brazil. If you are reading this in Brazil, “Hello!” I do not know who you are but thanks for your time!

When I started writing a year ago, part of the impetus was as I was frustrated that a Consultant Child Psychiatrist was unable to find work that fit in with parenting responsibility. During the school day I wanted to do something with my knowledge, not just the dishes. I would meet up with other women (lawyer, business consultant and tech consultant) in local coffee shops complaining about the career paths that we had given-up out of necessity, not truly free will. Over the year, I have come to realize that times-they-are-a-changing and that there is nothing that can hold back the tide of change for equality any longer.

Employers will increasingly be encouraged to promote women

Men will become increasingly involved in parenting

Men and women will become treated more equally at work

Parents will not automatically be assumed to be mothers

Children will be happier raised by parents of both genders

I am finally seeing and living through change. I might get to witness the end-game of feminism in my life-time. Thanks to the major research funding bodies colluding to only fund research in institutions that are putting in place strategies for gender equality, over the last year, my University has been falling over itself to send women like me on Women’s Development Programs and Mentoring schemes. Although some schemes need fine tuning and we are yet to confirm if lip-service converts into true commitment; with a gun-to-its-head it really looks like progress is going to be made on this. Thank you funding bodies!

This leads me to believe that progress and change can and will eventually filter to all professions, we just need more “financial-guns-to-heads”. Many of my friends in the city say “yes, but it won’t work in banking/ law/ accountancy/ consultancy”; because “of the nature of their work” and “client expectations”. Yet, who dictates “the nature of their work” and why do “clients expect” things to be delivered at awkward times of the day (or rather night)…? We as a society do not have to accept the status quo. We can press for change. Given incentive everything can change.

It reminds me of the arguments made by people opposed to the European Working Time Directives (EWTD; European laws that prohibited doctors from working more than a 48 hour week) for doctors when I was a trainee. In those days, we worked 96 hours a week. On some weekends, we worked Saturday 9am through until noon on Monday. I’m telling you the sleep deprivation of motherhood was nothing compared to this and after this experience all-night breast feeding was a doddle. Believe me, it is far easier to wake up and slap a baby to your breast than it is to wake up to catheterise a gentleman. It was thought “impossible” for the system to change to allow doctors to work less because of the “vital” work that we doctors were doing. How could patient care be transferred safely from one doctor to another? Impossible!

Well, as it turns out, all doctors have now moved to shift work without a massive rise in the death rate of patients. Indeed arguably care is better as doctors have had a decent amount of rest. I can never forget the poor patient that sat in hospital for a whole week without being seen by any doctors as my colleague on a weekend shift had forgotten to put his name on our patient list. The medical system was forced to change by financial penalties for non-compliance, bringing with it a surge of female applications to medical school. Medicine is still not ideal, men still dominate the upper echelons and prestigious specialties, but at least the days of long hours culture is gone. It is not beyond the wit of man to change systems in other institutions to afford their employees a better work-life balance; their talented junior women a real shot at success and their talented junior men a shot at being a decent father. They just need the financial incentives, because at the end of the day, money is the only cattle prod that works.

Indeed, it is money (or rather lack of it) that will likely be the solution to my other bug-bear: the lack of high-functioning part-time jobs in medicine. After struggling to find a position in London happy to take me on a part-time basis, it turns out that the NHS are so short of money that they are now happy to employ part-time Consultants. Not because they value retaining female staff or work-life balance, but because they no longer have enough money to pay for full-time consultants. Either way, it is good for me and other parents who wish to work part-time as a Consultant in the NHS. Fingers crossed that over the coming years something will turn-up for me. In the mean-time I’m thoroughly enjoying my University position that allows me to interact with some of the greatest minds in Child Psychiatry, and on my days off, as waiting lists have exploded in the NHS; private practice is booming. It is hard to argue against well-paid work that can easily be fit in between the school drop-off and pick-up. It’s sad that this can only be done in the private sector, particularly for a die hard NHS supporter like me.

What of my coffee-morning compatriots? After a period of part-time work at a lower level, the lawyer has succumbed and returned to full-time work at Big Law Firm and has employed a nanny. The business consultant has set up her own successful business, which operates on her terms within school hours. The tech consultant moved out of London and is content to be a stay-at-home mother. We all moved on, and its now pretty hard for any of us to find time for a cuppa. Maybe its that the children are growing, maybe its a sign of the times, but good women can no longer be kept down.

The other day a younger male friend who just got engaged told me he was thinking about taking his wife’s name…

Who knows where we will be a year from now?

In the meantime, I hope you will continue to read my blog. Here are some of my reflections on parenthood from the last year.

mum

Mothers and Motherhood

Did you get Maternal Adjustment Disorder (MAD)?

_GSB5183

The changing role of fathers

swimming

Pass on a passion

How to choose your child’s nursery

Nursery

It is ironic that for many of us one of the first major choices we have when we become a parent is about who else is going to “parent” our baby. If you are going down the nursery route, this decision often has to be made prenatally depending on the length of time you wish to take for maternity leave and the waiting list time on your local nurseries.

When I first went about looking for a nursery for Big Sis, I didn’t have a clue what I should be looking for. Inevitably, I made a wrong decision and I was unhappy with the nursery (Nursery A) that I initially chose for Big Sis. The problem being that when you are required to make this decision, you are still in the mind-set of someone without children, someone whose priority is themselves and their work. Not yet a parent, whose priority is their child. With this hat on, decisions regarding childcare are made with the priorities of cost, convenience and ease of getting to and from work, not necessarily the priority that you have once you actually ARE a parent.

I had chosen Nursery A as it was close to the tube station, was located in a beautiful Victorian house, was brand new and had designer furniture for children, a computer room, a sensory room, a music room and offered baby yoga and science lessons. I was given my own electronic fob to get in and out of the nursery building and on-line access to the nursery’s CCTV cameras allowing me to see what Big Sis was up-to from the comfort of my computer at work. Formula milk, nappies, sun screen etc. were all included in the fees meaning all I had to do was drop off my baby in the morning, and the nursery operating hours were long (early drop off and late pick-up) so I could meet my work commitments. Staff advertised themselves for evening babysitting sessions. Oh, and there was an organic kitchen on-site. Why wouldn’t any working parent choose this nursery?

It was only when I realised my mistake (that I had been woo-ed by aesthetics and meeting my own needs) and moved Big Sis along with Lil Bro to a different nursery (Nursery B) that I realised what a nursery was supposed to be about. The child.

Nursery B was further from the tube station, had more modest grounds, smaller and more old-fashioned classrooms, no designated music room or computer room, no electronic fobs or CCTV, late drop-off and early pick-ups (making getting to work on time pretty hard) and the requirement to provide your own milk, nappies, and sun screen (such that there were regular rebukes from staff when you forgot one thing or another). Yet it had a waiting list a mile long. Both nurseries had a similar fee. I realised that none of the “extras” were relevant. The management and staff at Nursery B were excellent. That is all that matters. Nursery B’s operation was aimed at the children, not designed to suit and woo parents. But how can you tell this when you visit?

Here are my tips for what to look for so you can get it right first time:

Standard no-brainers:

“What is the atmosphere like?”

“Do the children there enjoy going to the nursery?”

“What is the food like? Is it cooked on site?”

“What activities do the children do?”

“What are the facilities like?”

“Where do the children sleep?”

“Are the premises clean, safe, inviting and child friendly?”

“What is the policy for children with special needs/ allergies/ medical conditions?”

“What are the policies for if your child is sick?”

“What are the nursery opening and closing times and how many days of the year is the nursery open?”

“Do the staff appear warm, competent and knowledgeable?”

“Is there any outdoor space?”

“What are the fees?” – I don’t think you’ll forget this one. Remember to bring a hanky as the response will be eye-watering.

Additional gems:

Check the Ofsted Report

I cannot stress the importance of checking out a nursery’s Ofsted report and rating. Ofsted is the government agency that inspects all schools and childcare provisions in the UK. They report on all manner of things from the built environment, health and safety procedures and management. This might all seem extremely mundane and irrelevant when all you want is lovely, bubbly, staff that are going to welcome and cuddle your baby, but for anyone that has worked for any type of institution or business before, the competence of management matters. Within the NHS, it is evident that competent managers can instil high service standards, efficient service and good employee morale. The reverse is also true, and this is as true for nurseries as the NHS. If you can, go for an Ofsted Outstanding nursery. Big Sis’s first nursery had newly opened and had not been inspected at the time Big Sis started, but when it was inspected, it achieved a “satisfactory” ranking (two levels below “Outstanding”) which confirmed my doubts about it and precipitated my moving her to Outstanding nursery B, which lived up to its Ofsted rating. Prior to experiencing first hand the difference between “satisfactory” and “outstanding”, I thought – it can’t make much difference – “good” is “good” right? Well orange squash also tastes pretty good until you try Champagne. As most people choose a nursery and stick to it, they never usually get to know just what a difference a nursery can make. If you feel you have made a wrong choice like I did, it is ALWAYS worth changing.

Experience the management

As well as checking out the objective management ratings on the Ofsted report, check it out for yourself. A well-managed nursery would ensure that the phones were answered promptly and that if they say they will get back to you, they do. How well organised and managed is the viewing that they give you of the nursery? How senior are the staff that are showing you around? If you do not think that these administrative things matter, then think about how much they would matter if your child were at that nursery. What if no one answered the phone when you were ringing the nursery to convey an important message about your child? What if staff tell you they will do something for your child, but they don’t? If senior staff are not there to show you around, are they ever there? The best functioning services are ones where administration and front line staff are both working efficiently under effective and accessible senior management. At nursery B the senior manager was on site every day and knew the name of every child.

Ask about staff turnover

In my mind, effectively looking after young children is not something that can easily be done if you are not happy (if you don’t believe me you can extrapolate this from lots of post natal depression literature). If a nursery has high staff turnover then I cannot imagine that the staff can be very happy working there. During Big Sis’s 18 month time at nursery A, her “mentor” or “Key worker” changed 3 times because of staff resignations. The nursery manager also changed 3 times. This discontinuity of staff cannot make for stable attachments and relationships with the children and indicate that there is something unsatisfactory systemically that is preventing people from wanting to remain employed there. If staff are unhappy in their jobs, how can they provide the highest standard of care for your child? The average time that the key staff had been in place at nursery B was 9 years. As the fees for both nurseries were the same, it was clear that where one had chosen to spend the fee on aesthetics and extras to woo parents, the other had chosen to spend on training, valuing and retaining key and experienced staff. I know which matters more to me.

Ask about incident forms and how they manage difficult children

Big Sis was bitten or scratched by other children in her class at least 10 to 15 times in her 18 month career at nursery A. Other children in her class were also being bitten and scratched and we parents almost had to form a line to sign the incident forms when we collected our children. We would be told that a new toddler had been admitted to the class who had not yet been “socialised” by the nursery but that they would get the child under control soon. Only then, they would admit another “unsocialised” child. Eventually I had to sign an incident form saying that Big Sis had bitten another child (although she never bit anyone at home), and to tell the truth, I was rather glad that Big Sis was retaliating rather than being a teething ring for the other children. After Big Sis transferred to the nursery B she was bitten once and scratched once in a period of 28 months. She didn’t bite anyone. Lil Bro, who has only known the outstanding nursery has never been bitten or scratched and has never bitten another child at nursery. He has bitten his sister at home so it is not as if he is a particularly placid non-biting child. In my experience, biting is a very normal aggressive reaction in children and most children in the 0-3 year age group will do it at some point. Initially when Big Sis was being bitten at nursery, I was sympathetic to the nursery as I am aware that “all children bite”, however, on witnessing how much less this type of behaviour was occurring at a well- run nursery I am pretty sure that the level of biting was related to the nursery’s care (or lack of).

The nursery may not tell you, but it is worth asking about the level of incident reports as this is data that they are obliged to collect, so they should have it (although of course bear in mind that the very worst nurseries will have the lowest levels of incident reports, as they will be negligent on keeping up their reporting).

Examine how well the staff know the children

It is difficult to assess this. All nurseries will put forward their best people to do viewings with prospective parents. It is important to view as many staff as possible and be able to quiz them, and ask them questions, rather than limit questions to the member of staff showing you around, who will have been selected as knowledgeable. In real life, this person will likely have little to do with looking after your child as they are too busy showing other prospective parents around. Try and ask a random member of staff questions like:

“Do you like working here?”

“How long have you worked here?”

“How many children are in your class?”

“How many children are you directly responsible for?”

“How many children in your class have got food allergies, who are they and what exactly are they allergic to?”

Point at a random child and ask: “What’s this child’s favourite activity?”, “Who are his friends?”, “What makes him upset?”

If you have a child with food allergies like I have, it is absolutely paramount that all members of staff know who your child is and their allergies. I have heard of nurseries where children have been given foods that they are allergic to. Nursery B went the extra mile. Not only did all staff know Lil Bro and his exceptional dietary requirements, rather than excluding Lil Bro from cooking activities on account of his dairy, wheat and egg allergies, they bought him his own mixing bowl, and baking utensils. It’s this attention to detail that makes a nursery “outstanding”.

Interrogate parents of children that already attend

As well as confirming the standard information, find out how well the staff know the parents. At nursery A, the majority of staff, aside from the staff in Big Sis’s room had no idea who I was even though I dropped off and picked up Big Sis almost every day. I would have to say “I’m Big Sis’s mum” daily. At nursery B, everyone from manager, kitchen staff, to receptionist to teachers in other classes knew whose mother I was on sight. This is really good, and a credit to the management. You might think this is irrelevant, but it shows stability of staff and how aware staff are of the children in their care. Knowing who mothers and fathers are is important as it shows that they are interested in the children they are looking after and their families. Your child is not just “a child” that they are paid to look after.

Another difference that I found between the two nurseries was that many parents were coming from a very long way to drop their children at the nursery B, whilst most at the convenient nursery A by the tube station lived in close proximity. This makes sense, as if a nursery is very good, then people are willing to travel long distances to go there. If a nursery has many parents travelling a long way to attend, you can take it that this nursery is good.

Ask about the Early Years Foundation Stage

All childminders and nurseries are required to provide “early education” in line with the Early Years Foundation Stage document. If you want to be very mean and test the nursery’s knowledge, you can read the document and test them on it. I personally wouldn’t, but I might just want to check that staff don’t look at me blankly if I mention it .

These are just a few suggestions. In the end, you will have to make up your own mind, but bear in mind that early childcare is an important decision. Many parents spend much time and many sleepless nights researching and visiting a child’s secondary or primary school options, but just put their babies into the nearest nursery to allow them to get to work. I know; I did this. In addition, the research, visits and crucially the decision is often one made single-handed by a heavily pregnant woman who really would rather a sit down and a nap.

Yet if you work full time, like I did, your children will be spending more hours per year at nursery than at any future school in their life. Further, brain development is at its maximal in the preschool years, meaning the child’s learning potential from its environment is maximal at this age and may have long lasting impact on brain development. Time and time again, research has shown that it is not the “type” of childcare (childminder, nanny, nursery) that matters, it is the QUALITY (see my paper: Liang, 2013).

Shouldn’t choosing a nursery be a serious consideration for both parents rather than a quick decision made by a brain addled, third-trimester mum? Hopefully my tips will help.

Reference:

Liang, H., Pickles, A., Wood, N. & Simonoff, E., (2012) Early Adolescent Emotional and Behavioural Outcomes of Non-parental Preschool Childcare. Social Psychiatry and Psychiatric Epidemiology , 47, 399-407.

Why there is no autism epidemic

ICD

Strictly speaking, the term “epidemic” should be reserved for infectious diseases. I realise that the term has now bled into everyday language to mean a large rise in prevalence rates for anything (e.g. obesity epidemic), but the original clinical definition was to describe the spread of infectious diseases (e.g. ebola epidemic). I’m a clinical terminology pedant; I lose sleep over people that call a “fascination” an “obsession”, so you can imagine my loathing of the headlines of “autism epidemic” to describe the increased numbers of people being given a diagnosis of autism. The reported autism prevalence rates have increased from around 1/100 to 1/68 (that’s about one child in every 2 state school classrooms). However, even if the lay terminology is accepted, the rise in numbers of people diagnosed with autism has more to do with changing diagnostic classifications and awareness than an environmental hazard that shock-headlines would like us to anticipate. There are many press and internet articles that discuss this, but I didn’t feel that they fully explored the territory, so here is a researcher and clinician’s view of the reasons for increased rates of autism.

Why do boundaries in classification change?

Autism is primarily a genetic disorder and the genetic basis of autism is pretty much undisputed now. Although environmental hazards may play a role, these are generally on the basis of a pre-existing genetic vulnerability. There are several known genetic disorders already identified that highly predispose to autism (e.g. Fragile X, tuberous sclerosis, neurofibromatosis), but these disorders account for only a small proportion of the total incidence of autism. The bulk of people with autism have what is called “idiopathic autism” the genes for which have yet to be identified (although several genes are suspected and are undergoing rigorous going over by scientists, none have been conclusively proved).

The identification of genes for autism is a tricky problem, as it is not a single gene that is wonky in autism. If it were, then it would have been identified long ago, like other single gene defects (cystic fibrosis, tuberous sclerosis) and we would be able to test for it readily with a genetic test. It is likely that there are multiple genes, say 6 (this is an educated guess), that are all required in order to generate the disorder. These genes are common, and both you and I are probably carrying several of these genes right now and have already handed them over to our children. Like in the National Lottery though, it is quite common for individuals to have a few of the numbers that come up, but it is much rarer to have all 6 numbers together. In the case of autism, only the people with all 6 genes get autism. Also like in the National Lottery where 5 numbers will get a small pay-out, people with 5 genes may get a watered down version of autism.

Scientists have been using all the tricks available to them to try and elucidate the precise gene combination. A few years ago, the computer capability to do Genome Wide Association Studies (GWAS) (where you sequence the entire genome of subjects with autism and the entire genome of subjects without autism, bung the lot in a very big computer and get it to output the combinations of genes that are common to people with autism but not present in the people without) was supposed to lead to a major breakthrough in autism research. It didn’t. The reason being that as all scientists know; if you put sh*t data in, you get sh*t data out. The conclusion amongst researchers was this: the people that we are defining as “autistic” and “not autistic” are wrong. If there are non-autistic people in the “autistic” group; or more likely, autistic people in the “not autistic group”, this will mess up the results.

How are we currently diagnosing autism and is it correct?

The current classification manuals for diagnosing autism (and other mental health problems) are the DSM (used in the USA) and ICD (used in Europe) manuals. My husband has a similar book for “diagnosing” if a mushroom that he finds on the heath is poisonous or not. There is no blood test or scan, only the basic science of observation and interrogation. You might, (and some do) dispute the validity of such classification manuals, but it has thus far served my husband, who has a penchant for putting foraged fungi into his mouth, well (i.e. he has correctly been able to avoid the death cap by consulting his book). A hundred or so years ago, manuals like these were used to diagnose everything from brain tumour to Down’s syndrome (doctors of old diagnosed brain tumours from symptom check-lists including things such as headaches and vision problems, and having round faces and “Mongolian eyes” suggested Down’s syndrome). By fine tuning the classification and studying the people identified, it has become possible to find causes and cures. If classification had not initially taken place, cures would not have been found. This is where we are currently at with autism, fine-tuning the classifications based on new research findings, the precursor to elucidating cause and generating treatments and cures.

The by-product of fine-tuning the classification manuals is a change in disorder prevalence rates. Old classification manuals stated that all children with autism had a learning difficulty, this was found not to be true and newer classifications reflect this. Older classifications state that autism is largely a disorder that only affects boys; newer classifications describe what symptoms may look like in girls. In previous classification manuals, it was stated that if a child had ADHD, they could not have autism, this is now known not to be the case and indeed 30%-50% or so of children with autism have ADHD. New classifications allow this diagnosis to be made. Thus, over the years, with increased research pointing to a wider distribution of the core symptoms of what “we” scientists and clinicians see as autism, and with each revision of the classification manuals, the description of “an autistic child/ person” has changed vastly. An intelligent, inattentive girl with core features of autism, diagnosed with autism today would not have received a diagnosis even 50 years ago, and I am pretty sure that our current classification will not be the last revision.

Some might call this changing boundary of diagnosis pharma and clinical collusion to “medicalise natural variation”; but as I mentioned previously, I prefer to see it as a scientific journey we are halfway/ dare-I-even-believe three quarters of the way through, towards an understanding of aetiology and generation of treatment and cure. Who knows, when aetiology is found, the boundaries may yet shrink back.

The conclusion to the journey may not be far off. Whilst geneticists are relying on better patient classifications to do genetic studies on, neurophysicists are relying on better patient classifications to do neuroimaging and functional neuroimaging studies on. We are already almost at the stage where a computer can accurately predict if a person has autism or not based on their brain scan (Ecker 2010). It may be within my life-time (my grandpa lived to 104 years so I have an optimistic life-expectancy) that the diagnostic classification manuals can be ditched for a brain scan or set of genetic tests; just as has already happened in the case of brain tumour or Down’s syndrome.

Improving awareness

Raising awareness of health conditions is a great thing. Many people have benefitted from the increased awareness of autism over the last 10 – 20 years. Autism is a condition that babies are born with and that they will grow and live with life-long. There is no current treatment for the core symptoms, let alone a cure, but the correct support for the child, family and school, can have a significant impact on outcomes. Improving awareness encourages people to come forward for assessment and diagnosis and access support; improving awareness leads to requests for more and better services; improving awareness leads to higher profile and political will to spend on autism; improving awareness leads to better acceptance and understanding of people with autism. I can say nothing but good things about raising the profile and awareness of autism. In 1988 when Rainman was first released, I had never heard of autism. I think if a film about autism was released now, the majority of people would have heard of the condition. Without a doubt, the number of families seeking autism assessments for their children has increased, and this can only mean increases in diagnostic rates.

An epiphenomenon to improving awareness that has also contributed to increased prevalence rates is due to what can be discretely called “diagnostic inflation”; or what can be better understood as “overdiagnosis” or “misdiagnosis”. It is an unpopular but real notion. It is one thing to “raise awareness” of autism, but it is another to educate about autism. I think if I surveyed a group of 100 parents, they would all have heard of autism but I think that only a handful of the 100 parents surveyed would be able to give a passable definition of the core symptoms of autism.

Why stop at parents? Teachers, GPs, paediatricians, child psychologists and child psychiatrists, especially those that trained ten or twenty years ago when autism was relatively unknown and unsexy may not be up-to-date on autism and certainly many fewer will have completed and maintained specialist training on autism diagnosis. Couple this with the improved awareness from parents of the diagnosis and the political will to allow access to substantial resources (welfare and educational) only for a diagnosis of autism and you have a system that will favour increased diagnosis.

I think that now that the job on awareness has been done, we need to work harder on the education front.

Has there been any real increase in autism at all?

This was the topic of discussion at the last Royal College of Psychiatry conference I went to. The consensus was that there was, but that this real increase was much less dramatic than the increase accounted for by classification changes and increased awareness. Many studies have focused on insults in pregnancy and environmental toxins. The research on these has yielded minor or inconsistent results, certainly nothing that alone would account for the real rise seen. The only factor that was given significant credibility was that of the increased age of the mother AND FATHER of autistic children.

Whilst awareness of the effects of maternal age on children’s outcome has been well-publicised (increased risk of Down’s syndrome as one well-known example), the risks of older dads has been less so. Yet, paternal age has long been established as a risk factor for schizophrenia (Malaspina 2001), and there is now emerging evidence for association of paternal as well as maternal age with autism (Reichenberg 2006; Durkin 2008; Sandin 2012).

It is ironic that many people sought to blame a vaccine for increasing levels of autism, in some instances sparking fears of a real epidemic (of measles), when in fact, like so many other health problems, the cause may prove to be within our own life-styles.

References:

Ecker C, Marquand A, Mourão-Miranda J, Johnston P, Daly EM, Brammer MJ, Maltezos S, Murphy CM, Robertson D, Williams SC, Murphy DG. (2010 ) Describing the brain in autism in five dimensions–magnetic resonance imaging-assisted diagnosis of autism spectrum disorder using a multiparameter classification approach. Journal of Neuroscience. 11;30(32):10612-23.

Malaspina D, Harlap S, Fennig S, Heiman D, Nahon D, Feldman D, Susser ES. (2001) Advancing paternal age and the risk of schizophrenia. Archives of General Psychiatry, 58(4):361-7.

Reichenberg A, Gross R, Weiser M, Bresnahan M, Silverman J, Harlap S, Rabinowitz J, Shulman C, Malaspina D, Lubin G, Knobler HY, Davidson M, Susser E. (2006) Advancing paternal age and autism. Archives of General Psychiatry. 63(9):1026-32.

Sandin S, Hultman CM, Kolevzon A, Gross R, MacCabe JH, Reichenberg A. (2012) Advancing maternal age is associated with increasing risk for autism: a review and meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry. 51(5):477-486.

Durkin MS, Maenner MJ, Newschaffer CJ, Lee LC, Cunniff CM, Daniels JL, Kirby RS, Leavitt L, Miller L, Zahorodny W, Schieve LA. (2008) Advanced parental age and the risk of autism spectrum disorder. American Journal of Epidemiology. 168(11):1268-76.

My Cape Town Top 10 for Families

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After a busy year, we felt like taking it easy over the Christmas holidays and guaranteeing ourselves a “White Christmas”. That’s white sand, rather than white snow. Banker and I lived and worked for a while in Cape Town some 12 years ago. He was already a banker and I was doing psychiatric research surveying adolescent experiences (of sex, drugs, bullying, self-harm) in high schools throughout the Western Cape. It’s like a second home and we still have a lot of friends there.  When we lived there, it was all reading books on the beach, drinks at sunset (sundowners) and clubs, but nowadays with the kids in tow, we find that Cape Town still has a lot to offer both parents and children as a holiday destination. As an ex-resident and regular visitor, here’s my Top 10 to do in Cape Town.

 1. Table Mountain & Lion’s Head

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Table Mountain is the city’s icon. A massive mountain slap bang in the middle of the city. Traditionally, you should climb it, but with kids in tow, it is acceptable to take the cable car. Kids love cable cars so it’s a sure fire winner. Think fantastic views of the whole city. Ring ahead to check the cable car is operating to avoid disappointment though, as in strong winds it shuts down and if clouds are on the mountain (the table cloth) you won’t be able to see anything. If, like us, you have children old enough to do some walking and climbing, try climbing Lion’s Head instead (the smaller peak next to Table Mountain). It is a shorter climb and still extremely satisfying in terms of the view and sense of achievement. Our 5 year old made it to the top with only a bit of help, but make sure your children are ones that like scrambling up rocks and don’t mind the occasional scraped knee. Most children I know like this sort of thing, even our Princess who whinged and complained up the first short section that is gravel road hitched up her skirt and scrambled and climbed in delight up the remainder which is bare rocks with the occasional ladder. Finish off with drinks and gourmet picnics on the lawns of the roundhouse (www.theroundhouserestaurant.com) nestled in the foothills of the mountain.

2. Clifton and Camp’s Bay

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Cape Town is a good family beach holiday destination despite the cold Atlantic water. There are 4 beaches at Clifton and 1 at Camp’s Bay. Traditionally each has it’s own atmosphere. Dogs are allowed on 1st beach, 2nd and 3rd are more secluded and therefore more partial to romantics and 4th is the trendy beach for beautiful people. I’m not keen on the beach – like most Chinese people the idea of turning browner has no appeal, but Banker is a typical South African sun worshiper and in his youth he was a Clifton life guard. I accept that beaches are good for children and so I do occasionally make a beach sojourn, but all-day, every-day grates against my Chinese genes which require me to see local sites and take selfies.Over the years, Banker and I have therefore reached an agreement where we rent a flat right on the beach so he can take the kids there every morning while I have a lie-in (bonus!) and we can DO something for the main part of the day. So he and the kids build drip castles, explore rock-pools and jump waves daily. He even did a science experiment with the kids by hauling back a litre of sea water in an empty bottle and boiling it on the stove until all that was left was salt (in-situ educational activities – I know I have trained him well haven’t I? FYI Clifton sea water has a salt concentration of 40g per litre). He and the kids even go and pick mussels right off the rocks. They get enough to make Christmas lunch of Moule et frites. Seasoned with sea salt.

3. Penguins at Boulders

Cape Town 6Penguins are such comical creatures; kids cannot help but love’em. See all the African penguins you could ever wish to see at Boulder’s Bay near Simon’s Town.

4. Kalk Bay & Olympia Cafe

Cape Town 7Nostalgia always takes us back to Olympia Cafe at Kalk Bay, a great little bakery and restaurant where hippies have been using the side door for decades. It retains it’s shabby chic Bohemian feel, whilst always serving great food. It’s right next to the harbour where the catch is brought in, so fresh line fish is always on the menu. If you visit the toilets, you have to overlook its proximity to the kitchen, but in all my years dining there I have never had food poisoning. Here’s the kid-friendly part: if you take a wander to the dock, you will be sure to encounter the sea lions. If you are lucky, they might even come out of the water to say “Hello”. There is a nice parade of quirky shops along the main street and plenty of Zimbabwean street vendors selling the beaded or wood crafted curio of the year. We already have the giraffes and hippos (so last decade); this year, thanks to an on-line comparison website, it is meerkats. It’s amazing how many shops you can browse pester free if you promise a kid a Meerkat at the end of the day. We each pick our own rodent likeness in Jacaranda.

5. The Old Biscuit Mill

Cape Town 10OK, this one is more for the parents, especially ones that like to shop and eat. But at R18 to a pound at the moment making everything extremely cheap for Brits, it’s got to be done! The Old Biscuit Mill was an empty old Mill in an arty but down at heel area of Cape Town called Woodstock when I lived here 12 years ago. It’s now gentrifying rapidly and the Old Biscuit Mill with it’s quirky and arty homewares shops and internationally ranked restaurant “The Test Kitchen” is central to the area’s rejuvenation. Book well ahead for “The Test Kitchen”, Banker called up a few weeks prior to our trip to make a reservation and was told they were fully booked till May. Other good food is also available, and on Saturdays there is a Neighbourhood Market where local produce and all manner of yummy food is sold from stalls to be eaten off lines of “tables” made from front doors on trestles.  

6. Victoria and Alfred Waterfront

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This high end shopping mall just keeps getting bigger and better. Shop till you drop to your heart’s content. There are plenty of children’s clothes shops too so the kids are now set for summer clothes and Crocs and I stock up on MAC make-up. The favourable exchange-rate and the 14% tax back for tourists makes shopping guilt-free. There is also a fantastic Aquarium, one of the best that I have been to with kids, and other venues for child friendly activities. When we were there “The Art of Brick”, which we missed in London was on and so we went to see that, but there was also another installation on at the same time called “Dinosaurs Live”, so there is always plenty for children here. Eat sushi and drink £3 Mojitos upstairs at the Harbour Restaurant. The boats that go out to Robben Island also go from here. As we are regular visitors to the Cape, we are saving this for when the children are old enough to understand, but if it’s your one time out, you shouldn’t miss it.

7.  City Centre and Green Market SquareCape Town 12

Take a walk around the city centre to really get a feel of the city. See part of the Berlin Wall that stands near Green Market and have a go at haggling at the main curios market in Cape Town. The children’s favourite eaterie in Cape Town was “The Food Lovers Market Cafe”, a large canteen selling everything from pizza, burgers to sushi in the old Offices of the Cape Argus Newspaper. The food is not exceptional, but there is a large sweet pick-n-mix and dip your own donuts into your choice of sprinkles stand which may have swung it.

8. The Winelands and Spa!

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Drive out of Cape Town into the Winelands and there are plenty of beautiful wine farms. The child friendly flavour of the moment for those in the know is Babylonstoren (www.babylonstoren.com), a wine farm, hotel and spa halfway between Paarl and Franschoek. Pictureseque vineyard set within acres of laid gardens growing everything from papaya to lawns of camomile and thyme which you are encouraged to prance over barefoot. Book early for the Hotel, we couldn’t get a booking but managed to come for the day-spa. Banker and I are great fans of spas, but most do not welcome children or have nothing for them to do. I am not keen on sending children to creches on a family holiday, so Banker and I always take turns for treatments and childcare, and here there is a child friendly swimming pool, acres of garden to explore, a fake beach, a coffee shop and free roaming animals – so there is no need to fret that the children are not having fun when its your turn to indulge in your Dr Hauschka facial.

Of course, there is also the wine!

In the evening, I thought it only fair to give our children a “spa” treatment in our flat. They get to lie under a towel with a face-pack while I trim their finger and toe nails. They have a great giggle and love it so much they are urging us to go back to the spa – WIN-WIN!

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9. Kirstenbosch Botanical Gardens

We didn’t get to go this year, but I love this place, it is like a Southern Hemisphere Kew Gardens, plenty of the national flower the Protea. The gardens are strewn with African sculptures and in Summer there are concerts in the evening. Guinea fowl roam the grounds and its a lovely place to take a picnic.

10. Cape Point

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This is an old photo from a previous trip. If you are only visiting Cape Town once, it is worth coming to see where 2 Oceans collide. There are plenty of baboons and buck to spot too.

Further Afield:

Township tours are available and I do think that people visiting South Africa should be conscious of South Africa’s past and continued inequalities. I am not personally keen on making a “tourist attraction” out of poverty and inequality, but the income generated may be helpful to populations in poverty. I have visited several Townships in Cape Town when I worked there and it is pretty sobering stuff and although I wish my children to learn how lucky they are, I’m not quite sure they are at the right age or maturity for it yet.

If you are planning for a longer trip, take a drive along the Garden Route. There is whale watching in Hermanus, and there are Ostrich farms where you can feed, ride and eat ostrich (tastes like beef, but much healthier). Further along the coast towards Knysna, the Knysna elephant park is great for kids and allows adults and children to feed, touch and walk with elephants (www.knysnaelephantpark.co.za) and at Plettenberg Bay, there is Monkeyland (www.monkeyland.co.za), both of which are great for kids.

Cape Town Further Afield

Cape Town is a great place to holiday. I know that for many people the security is a concern, not one South African I know does not know someone personally that has not been affected by violent crime. However, the South Africans know that tourism is its major industry and relatively few tourists come to harm. Petty crime is common, my bag got stolen once from the back of my chair in a nice restaurant so you do have to be a bit careful, but if you are sensible and stay in the touristy areas then chances are you will be fine. Just say “No thanks” if your husband tries to tempt you into dinner at that “great restaurant” in the townships…

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