Category: Child development

Fear and Phobia in Children


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



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

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

Social hierarchy in 4 year olds

Social hierarchy

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

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

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

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

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

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

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

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

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

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

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

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

Interaction with peers

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

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

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

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

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

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

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


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

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

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


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


How to assess your child’s social ability part 2

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

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

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

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

Basic Social Skills

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

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

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

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

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

Intermediate social skill

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

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

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

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

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

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

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

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

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

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

How anxiety in pregnancy can lead to anxious children

Fire engine

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

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


Animals stressed in pregnancy give birth to anxious baby animals

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

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


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

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

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

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

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


Who cares about animals? What about humans?

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

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

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

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


Interesting finer details

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

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

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

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

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


How does this relate to you and me?

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

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

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

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

References and Influences:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Y and Z factor

Everyone knows about the X factor, that “Je ne sais quoi” that leads to desirability, fame and fortune. But what of the other attributes that lead to success (in those of us that are not blessed with the looks of Zac Efron or the appeal of Kylie)?

I can’t claim to know the answer, but I think I have spotted 2 new factors: “Y” possessed by Big Sis and “Z” possessed by Lil Bro. They are both of course bound for success, so I might as well spill their secrets now.


Big Sis is the oldest in her school year. This meant that in her reception class, she was often given a prominent role in class assemblies due to her relative maturity (in one class assembly she played Little Red Riding Hood, Mummy Bear and led the closing prayer). By Year 1, the other children in the class had gained in maturity and confidence and so the lines became more evenly distributed, as I would have expected. Big Sis came home from school upset. Here is our conversation:

Big Sis: I have only been given one line in the class assembly.

Me: [With a knowing smile and having perused the script] Everyone has only one line. It’s got to be fair. Everyone needs a chance to perform.

Big Sis: But I want more lines.

Me: Well, maybe in the rehearsals if you say your line really, really well, the teacher will give you some more lines.

Big Sis nodded.  I felt smug that I had handled the situation well, given sensible advice which had been taken in. That’s why I was surprised the next day when we had this conversation:

Big Sis: I didn’t get given any more lines.

Me: Oh dear, what a shame. Sometimes that happens even if you do a really good job. What happened?

Big Sis: The teacher asked if there was anyone that didn’t want to say their lines, but everyone wanted to say their lines so I didn’t get given any more lines.

Me: Hang on, why did the teacher ask the whole class if there was anyone that didn’t want to say their lines?

Big Sis: Because I asked the teacher if I could have some more lines.

Me: [incredulous at the gall] What? What happened to our plan to do your line nicely then see if the teacher will give you some more lines?

Big Sis: No. I just asked the teacher for more lines instead.

That my friends, is what I call the “Y” factor. Not least appropriate because for the most part this type of self-assurance and audacity is currently found mainly in men (Y chromosome). I bowed to Big Sis’s superior nature after this conversation and vowed never to give her any more of my rubbish advice. I realised that although the advice that I had given her was genuinely how I would have dealt with things, and was probably inherited from my parents – “Work hard, do a good job and you will be rewarded”, it was actually total BS. It reminded me of the reasons given for the gender pay-gap: women never ask for a pay rise or a bigger bonus, women don’t put themselves up for promotion, women beaver away at their work thinking that good work will eventually pay dividends, meanwhile being stepped over by male colleagues that push themselves forward, that step up to the plate. I wondered if these women had been told by their mothers to “keep quiet, say their lines nicely and maybe the teacher would give them some more lines” when they were six years old. I’m so glad that Big Sis took no notice of me, and in fact has taught me a great lesson in what my genuine and well-meant advice might do to my children. Inflict them with my own weaknesses and foibles.

Here’s to Big Sis becoming that woman that will ask for that pay-rise.


Self-assurance, confidence, self-worth, balls, gall, the “Y”- factor; whatever you want to call it. It’s great, but for those that are not in possession of it, there is another way.

Lil Bro had his nursery sports day recently. He came home from practice despondent. Here is our conversation:

Lil Bro: We had practice for our sports day today.

Me: That’s good. How did it go?

Lil Bro: [in hushed tone as if it were top secret] Mummy, I am not the fastest runner in my class.

Me: That doesn’t matter!

Lil Bro: But I want to win!

Later that week, I was reminiscing with Big Sis about her nursery sports day.

Me: Big Sis, remember that boy Adam that won all the races at the sports day?

Big Sis: Yes, he was really fast.

Lil Bro: [Quietly contemplative, then in serious tone] Mummy, how did he do it?

Me: Huh?

Lil Bro: How did Adam win all the races? Can you call his mummy? I want to ask him.

We never got to ask Adam the secret to his success, but his mother told me this: once on holiday, he ran twice around a 400m track. On the second lap around, he was extremely tired (being only 6 years old!), but kept going to the finish saying to himself “If Mo Farah can do it; Adam can do it”.

So it turned out that Adam, like Lil Bro, had a desire to win and a determination to work to this endeavour. I was totally impressed that 4 year old Lil Bro could not only articulate a desire to win, but was also self-aware of his own capabilities and had devised a strategy to help himself improve. He was not afraid to ask for help and saw opportunities to gain mentorship. This self-awareness linked to drive for self-improvement, perseverance, determination and a desire to succeed is what I call the “Z” factor. This silent but steely, and oft-over-looked factor is the one that lets the slow and steady tortoise win the race against the brash and overtly talented hare.

I have no doubt that Lil Bro will succeed in bounds, not least because he wants to. Sadly, I wasn’t articulate enough to be able to convey these thoughts to Lil Bro. The best I could muster was:

“Just move your legs really, really fast…”

Nurturing nature

glassesEveryone (I hope) recognises the existence of genes and their effects. Most people are happy to “believe” in genetic effect in hair colour, blood group and genetic medical disorders, but where “personality”, “intelligence” and “mental health”, come into it, most people prefer to see environmental causation. Part of the problem in selling genetic explanations is in the fear of “determinism”: the thought that your lot in life could be determined at birth and that human will and struggle are for nought. The funny thing is that “nurture” the proxy term for “environment” can also have its own form of determinism, with many people struggling to escape from the prison of their family and birth environments. Funnily enough, it is when things go wrong, when a child becomes “out of control”, that people flock to a genetic explanation, absolving themselves of responsibility. “They were born that way. It had nothing to do with our parenting.”

Outcome is clearly about both nature and nurture. What interests me is the interaction between genes and environments. It’s a wonder how the nature vs nurture debate has lasted so long, as the two are so intertwined. At the most basic level the success of a gene is purely based on its suitability for the environment. At a more complex level, a parent will give to their children both genes and environment, genes will seek out their own environments (e.g. a child with “intelligent genes” will ask to go to chess club), and evoke their own responses from the environment (a child with genes for physical attractiveness will generally evoke more favourable responses from others).

It is a misconception that you can have “good genes” and “bad genes”. Genes are like nature’s version of trial and error. A new combination is attempted at every conception, and the genes that are successful within an environment survive, the ones that don’t fall away. Thus the success of a particular gene is purely judged on environmental adaptation. A “good gene” in one environment may be a “bad gene” in another. Take genes that cause sickle cell. This is generally thought of as a “bad gene”, causing anaemia. However, in some parts of Africa, where Malaria is endemic, the sickle cell gene is a “good gene” as it is protective against malaria. This is palatable when talking about a medical condition, but the same applies for genetically determined personality traits.

Take aggression. Elements of aggression are genetically determined. It easier to think about dogs when talking about this: certain breeds of dog make for better security and attack dogs. No one would ever have a pug dog or poodle as a security dog. Yes, you can rear a poodle or pug dog to be aggressive certainly, but not as readily or to the same extent as an Alsatian or Pit Bull. There’s something in the genes. However, aggressive genes are not in themselves “bad genes”. In certain environments (the end of the world/ lost in a dark forest with wild animals surrounding you, a competitive job market), they may be the best genes ever.

Another reason for fear of genetic explanations is in the fear of genetic modification, gene selection and “tampering with nature”. You either feel it will end in a slippery slope to eugenics or you feel there is nothing that can be done with genetic predispositions and you just have to live with them. The thing is; it’s much simpler than that. In this day and age; we are able to cheat nature. My genetic predisposition to short sightedness has been environmentally sorted by living in a country with access to an optician. By all rights, had this not been the case, I would be dead by now, probably having gone to hug a grizzly bear that I mistook for my mother. The most common genetic predisposition in the world; that for having dark hair; is environmentally corrected around the world on a daily basis by bleach from a bottle.


Well, it strikes me that as parents, we are able to drastically manipulate our child’s environment, especially the early environment, which is thought to be one of the most important periods of environmental influence. This is not only by providing safety, books and toys, but exposure to language, music, models for good social interaction, peer group, selection of nursery,  primary and secondary school, and critically, love, warmth and understanding . By learning via observation about our children’s “genetically determined” personality traits, we are able to best shape their environments to suit their needs. All parents are doing this already off course, when you select your child’s nursery, primary school and secondary school, you are thinking not only about the values of the school you wish to impart on your child, but the attributes of your child and how they will fit into the school. It would be an oversight to send a small, intelligent boy with a love of learning and loathing for the outdoors to a school specialising in outdoor sport with a relaxed attitude to bullying, for instance. If your child has particular needs, for instance a learning difficulty, for all the medications and new age therapies; thinking hard about school and environmental placement is the most effective treatment.

A child with average genetic susceptibility to aggression can become very aggressive if brought up in an aggressive community. Equally, a child naturally predisposed to aggression can succeed perfectly well if the environment (parents, schools and society) show understanding and help shape the aggression so it is controlled and pro-social outlets found: competitive physical sport (though not biting other players), some occupations where controlled aggression is valued e.g. some businesses. A child naturally predisposed to aggression can only become a menace to society if parents, schools and societies allow it to be so.




Assess your child’s social ability

doll party


I am posting again on my infant 360 degree appraisal series. Moving on from ‎core abilities, I will now focus on social ability.

Social ability is probably as important, if not more so than cognitive ability. There are plenty of people with excellent cognitive ability who somehow don’t succeed as well as they might because they find being with other people difficult (or others find difficulty in being around them), and we all know people who are not the brightest spark, but get very far being affable, cheeky and great fun to be around. The funny thing is that although maths and English are actively taught at school, social ability is not a taught course. Children must somehow divine social understanding from what they observe or experience going on around them. Luckily for most of us, evolution has imparted us with specific hardware within our brains to assimilate and use such information about our social world. Not so lucky for children where this hardware is impaired (e.g. in autism).

Babies will typically smile at around 6 weeks of age. Isn’t it strange that this relatively useless developmental milestone is acquired so early? Not really, when you think about the evolutionary advantages gained by a smiling baby. If you are running from a flood, would you be more or less likely to take your baby with you if it was always smiling adoringly at you? Yes their smiles are evolutionarily engineered to aid their survival, we parents are such suckers.

Another early developmental marker of social ability is a preference to look at faces, and in particular eyes. The centre of human communication is a person’s face. This is the input and output zone for verbal communication and where non-verbal communication is the most expressive. Most adults can tell what another adult is thinking by looking at their face even if they are not saying anything. Even when the person is saying something, the face can convey a different message. There are lots of emails that I have received where I have been unsure about the meaning (joke- or not joke?) because I have been unable to judge the face/ tone of voice with which the email has been written, which exemplifies the importance of non-verbal communication. So common is this problem and so useful is the face, that we now commonly use a face picture in our emails to depict the meaning of emails that we send! Typically developing babies and children are born with in-built ability to hone their attention to people and faces because they know this is where the bulk of social context is going to be gained (Chawarska 2013). No one teaches a baby to do this, you either have it, or you don’t. Early on as a parent, you can check your baby’s social ability hardware by checking whether he/she prefers to look at your face/ eyes and if their eyes follow you Mona-Lisa like around the room.

Babies and young children are primed to attend to their parents’ every action and imitation is present from a very young age. If you make faces at a young baby, chances are, at some stage you will see the baby trying to move his/her face to copy your expression. There are hours of fun to be had doing this. This is early social learning. Later on, they will imitate the vocal sounds that you make, the embryonic stages of speech development, another critical branch of social development.

Babies and young children are also primed to attend to their parents’ emotions, particularly of fear. I acutely remember breast feeding Big Sis while watching a horror movie late one night. At one point, I held my breath in anticipation of something horrible happening on screen. It would have been imperceptible to most people as I did not move or make a sound, and yet, Big Sis stopped suckling, tensed and looked at me. It’s no coincidence that if you start having an argument with your baby in the room, they start crying.

Humans are social beings, they live in communities and societies, they typically like to socially interact. Early social interaction and turn-taking can be assessed by playing with your baby. The typical Peek-a-Boo game (hide your face, then show your face making your baby laugh) popular to all parents and babies is part of the Autism Diagnostic Observation Schedule (ADOS)[1]. It is an early indicator of ability to turn-take, an understanding of social reciprocity, of an interaction between two people, a precursor to to-and-fro conversation, to give-and-take in a relationship.

If you are an autism specialist, a first birthday cannot pass without performing a simplified version of the “baby’s birthday party” test from the ADOS. This test is where you set up a dolly’s tea party and play. Many typically developing children are able to give a baby doll a pretend drink from a toy tea cup at the age of 1 year, particularly if they see their parent doing it. If your child is not doing this, don’t worry, many typically developing children acquire this ability to pretend later on, but if they are doing it at age 1 year, as my children were, then it is a sigh of relief that one aspect of their social ability mechanism (pretend play) is functioning.

These building blocks to social ability develop at varying times during infancy in different children, but should be in place by the time of school start. The Autism Diagnostic Observation Schedule has recently been revised to include a Toddler module as it is now recognised that traits are observable at this young age, and in an attempt by professionals to gain early diagnosis to allow children and their families help from as early a stage as possible. It is really helpful to have an early heads-up on potential social problems because school is like the “Hell’s Kitchen” of social ability. Children can get away with pretty poor social skills at home with their parents and adult company, because contrary to popular belief, most adults are nice to children. Children, on the other hand take no prisoners – and going into reception with immature or absent social understanding and ability is truly hard.

When you throw a bunch of children together, that’s when things get really interesting and I will write about this in my next blog on this topic.



Chawarska et  al. 2013. Decreased spontaneous attention to social scenes in 6-month-old infants later diagnosed with autism spectrum disorders. Biological Psychiatry, 74, 195-203.

[1] The Autism Diagnostic Observation Schedule (ADOS) is one of the gold standard diagnostic tools for assessing Autistic Spectrum Disorder. Children and adults with autistic spectrum disorder have deficits in social interaction and communication (as well as repetitive behaviours and restricted interests). The schedule involves games and set conversations to be enacted with the child or adult to press for social interaction and exchange. It is designed so that the assessor initially allows the child to display their natural social ability, but then allows the assessor to give staged prompts to get the best ability out of a child if it is not naturally forthcoming. Scores are given for deficits in social interaction and communication, and autistic spectrum disorder is suspected once a threshold is crossed. Most typically developing children and adults, even the very socially able, will score something on the ADOS, and it would be highly unlikely for someone to score 0, so just because your child has some deficits, it does not mean that they are autistic or on the autistic spectrum. Despite tools such as the ADOS and the Autism Diagnostic Interview (ADI), Autistic Spectrum Disorder diagnosis remains a specialist clinical judgement.

How to get into the best grammar school


A friend’s daughter turned 11 years old this year. As such her class cohort has just been subjected to the highs and lows of the 11+/ secondary school application process. For many children this is a very stressful time, albeit nothing compared to the trauma it is for the parents! I am pretty sure from my friend’s discussions that more parents lost sleep than children. At least I hope this is the case as most parents should be protecting their children from the burden of expectation, as feeling a “failure” at 11 years of age can have lasting consequences. The feeling from the school playground banter which can sometimes approach hysteria, would appear to be that it is substantially harder to get your children into a decent secondary school these days than at any other time in history, however I am never sure if every generation feels this (just like every generation of teenagers feel like they invented sex) and justifies it with current concerns (baby boom, “tiger parented” immigrants taking all the places etc.), or if it is actually true. The word on the London street these days is that if you are sending your child to a state primary school, they have “No chance” of getting into a selective grammar or independent school, unless they are receiving private tuition from at least the beginning of year 4. I have even heard some say that they need tuition from reception, and others say that you need to have their name down with the best tutors at year 1, as they all have mile long waiting lists. If you cannot afford private tuition, then they should be going to Kumon (after school maths club) at least; and the proliferation of Kumon classes across London attest to the power of this notion. If you are sending your children to a prep school, then even they may require private tuition from at least year 4 depending on how your child is doing or the quality of the prep school. If your child is not academically excellent, you could try and sneak them into an academic secondary school by way of a music or drama scholarship, in which case, investment into private music/ drama lessons would have been a requirement from well ahead of year 4, as to audition for a music scholarship at a prestigious school requires a distinction at grade 5 (grade 3 for less prestigious schools). All in all, one wonders about the truth of these rumours or if this is one big ruse to boost the nation’s economy and employment level by increasing consumer spending on “must have” educational add-ons. More worryingly, if this is the truth, then where does it leave children from less well-off families who are unable to afford extra tuition and music lessons?

My eldest child is in year 1, so I am currently in a position to be skeptical about the hysteria. By year 4, Big Sis may well be signed up to the best and most expensive tutor that money can buy to secure her place at “the best selective secondary school in the world ever that is her only salvation from failure, alcoholism, teenage pregnancy and delinquency”. However, from my current armchair standpoint I can only look on with bemusement. I am in the rare position for a Londoner of living in the same area where I spent the majority of my childhood, and having the possibility of my daughter sitting for entrance exams at the same school that I went to: “the best grammar school in London”. Her education and circumstances up to that point will have been somewhat different given my economic circumstances are somewhat better than that of my parents. That said, here is a commentary on how getting into the best grammar school was done in the late 80s.

My sisters and I attended a local state primary school in Wales. My mother, having been a secondary school science teacher in Taiwan, taught us maths after school every day. Since she could not speak English, she did not teach us English but attempted to teach us Chinese. Both my parents encouraged us to read in English and took us to the library to borrow books every Saturday. They also encouraged us to write stories and poems in English. When I was 8 years old, my parents moved to London where both my mother and father had found employment. Since my mother now started working full-time, we had no further additional educational input outside of school, albeit constant encouragement, and expectation of hard work and achievement. My eldest sister was at that important secondary transition stage. Contrary to the at-length planning of most parents these days regarding secondary transfer, my parents, uninitiated in “the system” took a “pitch up and see” attitude. My sister was enrolled directly into the local comprehensive as my parents could not afford private school and she had missed all the entrance exams and procedures for the grammar school. My second sister and I were to go to the local primary which was, and still to this day remains, at the bottom end of the primary school league tables. My eldest sister had many a happy lesson making wooden pencil cases and large clay sculptures of birds of prey, whilst effortlessly coming top in every academic subject. My other older sister and I spent many lessons re-learning how to read and write English with the largely “first language not English” class.

Contrary to the current parental angst over school decisions, my parents took the oft-forgotten-in-current-times view that if it all went a bit Pete Tong, then we could change schools. Within the year, both my sisters had aced entrance exams to the grammar school, one at common entrance, and the other for year 8 entry as a position had opened. I was transferred out of the state primary in our area, to a state primary in the further, but much wealthier suburb next door. How? My parents just applied. Children leave good schools all the time for all sorts of reasons, and if you play the waiting game, chances are you’ll get a place without the furor and hassle of making out that you live on the school’s doorstep at common entrance.

In contrast to my previous school experiences, primary school in leafy suburbia was a delight. Whilst at previous schools my work stood out, in this wealthy neighbourhood intelligent children were in ample supply, such that academic equals and superiors were available. Of the 30 children in my class in this primary school, I know that one other joined me at Cambridge. Another went to Yale and another two went on to study medicine at Oxford and at Bristol, and I am sure there are other successes that I have not heard of. It was my parent’s intention that I should follow in the foot-steps of my sisters into grammar school. Their naivety of the education system meant that they saw this as a foregone conclusion. No tuition was brought in, no music lessons arranged, no past papers ordered up. I remember being called out of class one day by the school’s head of secondary transfer shaking a yellow form at me saying “Your parents have put down a highly selective school as the only option on your secondary transfer form! What if you don’t get in? They must put down alternative options!” To which my genuine response was “But they’ve bought my school uniform already.” I had no idea that entrance heavily depended on my performance, it was just a FACT that this was the school where I was going and I just had to go and sit an exam and attend an interview to formalise the process. Thinking back, this is probably not the best strategy for parents to adopt, as it would have hit me hard if I had not followed my sisters into that school, but my parents were blissfully ignorant of the fierce competition as they were both working flat-out full time and barely spoke to any other parents.

I did nearly blow my chances of going to the grammar school “for Young Ladies” as it was then suffixed. In those days, following the Maths and English paper, you were subjected to an interview with the headmistress. The headmistress was exactly the kind of headmistress I would imagine for a school purporting to educate “Young Ladies”. An upper class lady with portly stature, portent demeanour and penchant for port; all blue rinse and pearls. I had to describe a painting by Braque that was presented to me on a postcard. I had to read aloud a passage of written text about rainfall. It contained the word “percolate”.  Here the headmistress requested a definition and I was at a loss. Trying to garner as much information as I could from the surrounding text, I offered a clearly wrong definition. No matter, the headmistress took it upon herself to educate me on the meaning of the word “percolate”. “You know, when you make coffee, you must let the water filter though the spaces between the coffee grounds to get the flavour. You have made coffee before haven’t you?” “Yes” I said. “I put a spoon of the granules into the cup, add hot water and stir. Is that what percolate means?”

Thankfully, being of the Nescafe-drinking classes may have excused my ignorance of the definition of percolate, and I was in. But that was the thing in those days. Raw ability got you through – not primed responses and taught vocabulary.

I am rather saddened to hear that my old grammar school has done away with the interview and rely on an IQ style test to screen candidates prior to entrance exam. On the standard IQ test, there is a 6 point test-retest advantage (this means that purely by having done the test before, the average person can improve their score by almost half a standard deviation). For clinical purposes if you want to get an accurate picture of a child’s IQ you should not test a child more than once a year. If however, you want to inflate your child’s IQ for a one off entrance exam, repeated exposure to IQ type tests can really do it, and schools will not be getting an accurate measure of “intelligence”. I can only imagine that doing away with interviews is a pity as however subjective, I still think there is something to be said for the spark in an eye and a quick-witted response.

In addition, from my current standpoint, although I value hard work and wish to pass this ethos on to my children, and although I know that hard work can greatly increase a child’s ability and potential, there comes a point where you as a parent have to recognise the innate (genetic) ability of your children, and pushing beyond ability can definitely have negative consequences. We would all like to believe that our child is the brightest bulb in the pack, but all except one of us would be wrong in this assumption. We might all like to believe that if our child “just did this/ or was given this opportunity/ or was helped more by their teacher” that they would become the brightest bulb in the pack, but again, the majority of us would be wrong in this assumption. For some reason, no one seems to want to admit the obvious, that some people are just cleverer than others – no ifs-ands-or-buts about it. Around the school gates, whenever a child’s exceptional reading or maths ability is discussed, someone will inevitably mutter “Yes, but you know what that parent is making the kid do at home…”, whilst my response is always – “great, it really helps everyone to have bright kids in the class”.

My gestalt realisation that ability is unevenly distributed happened at Cambridge University. I looked around me and thought “Not in a million years and working 24/7 will I ever be as smart as some of these people”. Accepting yourself and not feeling a loser about it is really satisfying, and I think we need to have the same reality check sometimes with our kids. Although aspiration and pushing to achieve potential is a positive, not all children have the same academic potential and ultimately we need to accept, appreciate and love them – in the words of Brigitte Jones’s Darcy “just the way they are”. My current view is therefore that if my children do not get into the most prestigious academic school then they probably would not have got on there. I would much prefer my children to perform in the top half of a less academic school, where they can feel “clever” and become confident in their academic abilities than flounder in the bottom half of an academic school. I saw many people at my school and university suffer crises of confidence (despite being exceptionally bright), due to being in the bottom half of a highly academic environment. Some of the negative effects lasted well into adulthood, and may well be life-long. In my view confidence, security, self-assurance and happiness are the solid foundation that childhood needs to build; academic excellence is definitely welcome, but never at the expense of the former.

I am desperately hoping that the rumour mill is hype and that old fashioned clever kids will still end up where they deserve to go and that good education does not become the preserve of the wealthy, but also that I will be strong enough in my current principles to follow through should my children not be “old fashioned clever kids”.

How smoke exposure in pregnancy can cause aggressive kids



Wellies in summer are about as useful as aggression in Barnes


This is part 3 of the “How to improve the success of your kids before they are even born” blog series. See Part 1 and Part 2.

If folic acid is the Austin Powers of womb environment, then Dr Evil has got to be cigarette smoke. O.K., O.K., there are plenty of other bad guys obviously – thalidomide, heroin, alcohol. The reason I am casting cigarette smoke as the bad guy here is that whilst you have total control about exposure to the others, passive smoking is harder to control. The US Department of Health and Human Services (2006) estimated that more than 126 million non-smoking adults continue to be exposed to second-hand smoke in the US. Some of these millions are likely to be pregnant. Thank goodness for the U.K. law banning smoking in bars and restaurants. This was great for winter time, but having had both pregnancies through spring and summer, it was a real pain to anticipate a delightful al-fresco meal in the fresh air, only to find, given the laws prohibiting smokers from dining inside that all the outdoor tables at pubs and restaurants were over-run with smokers. Worse still, I found that friends would continue to light up in front of me in social situations when I was pregnant. Most of the time, I would alert them to smoking and pregnancy but this usually meant they moved a few paces away and tried to blow smoke in another direction with varying degrees of success. I’m not a smoking killjoy. I enjoyed cigarettes in my youth, and drinking in other people’s smoke used to bring back good memories, but when I became pregnant this changed and my mind would shout “TOXIN, TOXIN” if ever smoke touched my nasal hairs. Sometimes, not to cause a scene I just grinned and bore it, but images of damaged children would always run through my mind.

Most everyone knows that you shouldn’t smoke in pregnancy, but I’ll bet you didn’t know why? Studies have shown that there are over 4,000 chemicals in cigarette smoke and more than 40 of these are known to be linked with cancer (Thielen et al., 2008; US Department of Health and Human Services, 2010). Many of these chemicals, including nicotine, are able to cross the placenta into the foetus’s blood stream where, due to differing mother and baby physiology, concentrations can build up to higher levels in the foetus than in the mother (Lambers & Clark, 1996). Every time you have one, that’s two fags for the baby. There is evidence that links exposure to smoking in the womb to an increased risk of spontaneous abortion, pre-term delivery, and the baby going on to develop asthma, allergies, breathing problems and even cancer in later adult life. If you are a pregnancy smoker, you know all this and are as immune to this as being presented with a photo of a messed up smoker’s lung in the doctor’s surgery when they suggested you quit. What may influence you and what were my main concerns, were with the lesser known associations of smoking: with higher levels of aggression, conduct problems, attention problems, impulsivity, memory, speech and language and intelligence (Knopic 2012). It shouldn’t really sway you more, but put it this way, if your child develops cancer in adult life, it’s a long way off and is largely their problem to deal with. If your child is prone to aggression, that’s going to be your problem in a matter of months to years! If you did already know that, then I bet you didn’t know how cigarette smoke does this?

If you do then you are well ahead of the scientists! Scientists are still hard at work on this, but their current hypotheses surround the fascinating ideas around foetal programming and epigenetics. The theory of foetal programming is attributed to David Barker. David studied a group of mothers who were pregnant during the Dutch famine of 1944-1945 and followed up on the consequences of the children who were in utero during the famine. These mothers suffered malnutrition and stress, the children exposed to maternal starvation and stress were found to have lower birth-weight which is of no surprise. However, despite the end of the famine and a return to plentiful food supply, these children went on to have worse adult outcomes than children conceived just after the famine ended. These included cognitive deficits and higher likelihood of type 2 diabetes, heart problems and obesity. Barker’s theory is that there is a mechanism for Darwinian adaptation to environment occurring right there in our swollen abdomens that has probably been responsible for the success of our species. He postulated in the 1980s and 1990s that the developing foetus could take on information from the mother’s womb environment and use this to “forecast” the state of the environment into which it would be born. It is then able to prepare itself by adapting to be able to best survive the predicted environment (generate a predictive adaptive response); in much the same way that we might reach for the umbrella, coat and wellies on hearing a weather forecast for rain. Thus, if the developing foetus finds itself in an environment in which nutrients are scarce (such as the Dutch Famine) it thinks to itself “Bugger, I’m in for it when I get out, if my mother can’t find enough food to eat, there’ll be no damn food for me!” It therefore adapts (programmes) itself to be small and thrifty (conserve and use minimal resources) in order to be able to best survive the harsh environment it will face on birth.

Through this mechanism our ancestors lived to survive droughts and famines long enough to reproduce and eventually generate us. The foetuses that did not adapt themselves in this way would have died in infancy and childhood not being resourceful enough in their physiology to withstand periods of deprivation. The problem occurs if the forecast is wrong as adaptations made at these early stages of development are generally permanent. In the Dutch famine group, conditions improved after 1945 and food became plentiful again. The small and thrifty babies turned into children and adults that continued to store everything they ate and basically became more obese and prone to obesity related diseases, compared to children from similar backgrounds born just a year or so later. This is the fool in his heavy overcoat, wellies and umbrella at the beach in 30 degree heat cursing Michael Fish’s dodgy weather report.

How the foetus is able to use womb environment information to affect changes in its development is thought to be by epigenetic effects. In essence, epigenetics is the study of which sections of DNA gets expressed. In my analogy of DNA as a large manual for human construction, epigenetics is the study of the post-it notes put into the manual to instruct the builder which instructions to follow and which to ignore. Scientists have discovered several ways in which these post-it notes can be inserted, one of which is by a process called “DNA methylation”. Smoking has been shown to affect this process and others implicated in epigenetics which activate changes in the placenta (which can then affect the development of the foetus) and foetal development directly (Knopic, 2012). Epigenetic changes can also be inherited and can continue to influence at least 2 generations of descendants (at least in insects-Matthews & Philips 2010), thus what you do in pregnancy now may not only affect your children, but also your grandchildren!

A foetus exposed to high levels of toxins (like cigarette smoke) might prepare itself by bolstering its immune defences. On being born to a toxin free environment, the hypersensitive immune system gives rise to asthma and allergic reactions, which are essentially immune responses to normal everyday surroundings. It is harder to understand the adaptive nature of the psychological associations of prenatal exposure to cigarette smoking (aggression, impulsivity), but it makes sense that if toxins are part of what can be described as a “hostile” environment, that the newborn baby and subsequent child should be prepared to look out for danger and fight its way in the world. Aggression, hypervigilence and risk-taking behaviour would be beneficial traits to aid survival of a toddler in an Armageddon situation, but probably not so beneficial in a 3-bed semi in Barnes.

I went to a Justin Timberlake concert when I was pregnant with Big Sis and she came out ready to dance! Does that count?


US Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general. Atlanta, GA: Centers for Disease Control and Prevention.

Thielen, A., Klus, H., & Muller, L. (2008). Tobacco smoke: unraveling a controversial subject. Experimental and Toxicologic Pathology, 60, 141–156.

US Department of Health and Human Services. (2010). A report of the surgeon general: How tobacco smoke causes disease: What it means to you. Atlanta, GA: Centers for Disease Control and Prevention.

Lambers, D. S., & Clark, K. E. (1996). The maternal and fetal physiologic effects of nicotine. Seminars in Perinatology, 20, 115–126.

Knopic, V.S., Maccani, M.A., Francazio, S. & McGeary, J.E. (2012). The epigenetics of maternal cigarette smoking during pregnancy and effects on child development. Development and Psychopathology 24 (2012), 1377–1390.

Matthews, S.G., & Phillips, D.I. (2010). Minireview: Transgenerational inheritance of the stress response: A new frontier in stress research. Endocrinology, 151, 7–13.