Today, I have been at the British Mecca for Psychiatrists, the annual conference of the Royal College of Psychiatrists. We have taken over the ICC in Birmingham where the entrails of the Tory party conference are still being tidied away. I did have a double take moment of “Lord, I’m at the wrong conference” when I was greeted with the “A Country That Works For Everyone” signage which dwarfed our college’s diminutive logo. The juxtaposition being even greater because within the medical profession, the psychiatrists are probably the most left leaning, our life’s work being in the care of some of the most discriminated and disadvantaged in society who are not usually the Conservative party faithful.
I’m not really a “conference” person. Brown-nosing and networking brings me out in hives, but I have been around long enough to know just enough people to make small talk to. At shrink-fest this usually involves grumbling about:
- Lack of in-patient beds
- Being mistaken for a psychologist
- Not being recognised as “proper doctors”
- Lack of medical students wanting to train in our wonderful specialty
Mostly, I am robust enough to endure colleagues darting-off mid conversation to talk to someone else of greater importance. Occasionally, I bump into old supervisors and I have to admit to them that I’ve chucked in my research and pretend to be blissfully happy about this decision. Other times I catch sight of another female ex-researcher and we indulge in metaphorical hand-holding and sighs of “it’s so hard with children”. If it gets too much, I hide out in the loos checking social media. People post me pictures of dead animals (anti-hunting friends – don’t ask).
It might sound awfully depressing, but I also learnt these amazing nuggets:
From the wonderful Dr Andrea Danese, an Italian contemporary who heads up the Stress Lab at the Institute of Psychiatry. He once gave me a good recipe for pesto and today, he taught me this:
- If you get a nasty cut that gets infected, the skin gets red and “inflamed”. If we took a sample of your blood, we would find raised levels of proteins e.g. C-Reactive Proteins which are called inflammatory markers.
- Stress can cause an inflammatory response, just like an infection in quality but milder. This is to prepare the body to fight stress, in the same way that your body prepares itself to fight an infection.
- Children and adults with depression have raised inflammatory markers.
- These markers are even more raised if there was evidence of early life stress such as childhood maltreatment.
- Adults with raised baseline inflammatory markers are more likely to have recurrent and chronic depression which does not respond to traditional anti-depressant treatments.
- Anti-inflammatory agents usually used as pain killers after surgery (COX-2 inhibitors) have been successful in treating depression, particularly in people with high baseline inflammatory markers.
I know, this sounds dull to you, but to shrinks this is like: Yay! Another drug (cheap too) – maybe they won’t confuse us with psychologists anymore?
I also learnt from Professor Ian Goodyear (Head of Child Psychiatry at Cambridge University) that in his longitudinal studies of depression he divides us parents into the following groups which form a measure of “suboptimal family environment”:
- Optimal (that’s me of course)
- Aberrant (well-meaning but missing in action or clueless)
- Discordant (bickering and self-interested)
- Hazardous (deliberately cruel and abusive)
- Not surprisingly, the majority of children raised by “hazardous” parents end up with all kinds of mental health problems.
And from Professor Eric Taylor, the grand don of my field neuropsychiatry:
- 20-70% of children with ADHD continue to have symptoms into adulthood.
- 50% have another psychiatric diagnosis by age 27 years (mainly anti-social behaviour, drug misuse or depression).
- Children with ADHD with no friends and unsupportive, hostile parents at age 7 years are more likely to develop conduct problems and antisocial behaviour.
- If a child with ADHD lasts to age 17 years without engaging in anti-social behaviour, their parents can heave a large sigh of relief because they will very unlikely ever engage in this type of behaviour (they may still be susceptible to depression unfortunately).
The best part of conference?
The hotel to retire to overnight. Totally kid-free: gym, luxuriating bath, telly, bed and totally guilt-free and legitimate because “I’m working!”.
Roll on day 2!
Over the last few weeks I have been asked by a few people to write something on managing behaviour of children. This is one of the biggest challenges for parents, and yet I had put off writing about this as it is not as easy to give advice on this as it sounds. The “tips” that friends were asking for basically amount to what we in the industry call “behavioural management”. Ways in which parents can magically “change” or “manage” their children’s behaviour. Sadly, there is no magic tip, only all the things that you have already heard of and tried. Behavioural management tries to spell out what is and is not desirable behaviour and strategies try to tip the balance of choice towards behaviours that are desirable. Well known strategies include “the naughty mat” or “time out”, “ignoring” your child’s mild bad behaviour and also the blessed “reward chart”. If you want to read up on behavioural management an excellent book is “The Incredible Years” by Webster-Stratton. I won’t précis what I feel is a thorough account of good behavioural management, but instead ask:
Does behavioural management work?
The answer in theory is unequivocally “yes”.
But, so often in practice is “no”.
This is because behavioural management is easiest to implement when your child is “typical” and has no other problems, and you (the parent) are brilliant, have no problems and are super consistent in everything you do both with your co-parent and school.
Which basically means “no” or only “a bit”– as when does the above situation ever happen?
Here are two reasons why your child may not be “typical”:
Neurodevelopmental problems, in particular learning difficulty can heavily impact behaviour. In young children, aggression and temper tantrums are typical responses to frustration, but by school age, some control should have been gained over these behaviours. If a child is developmentally delayed, then their ability to behave should be compared to their developmental age rather than chronological age. A 16 year old boy with the developmental level of a 4 year old; can be expected to behave in line with a 4 year old. For a four year old, temper tantrums and hitting out are common responses to frustration, the trouble is that being hit by a 16 year old boy in a temper tantrum has very different consequences to being hit by a 4 year old, and yet, the child “can’t” help responding in this way. These children are often clients in child mental health services as parenting children with severe learning difficulties can be extremely challenging. Other neurodevelopmental disorders also cause behavioural problems. In ADHD children with problems with attention cannot listen to or follow instructions as well as other children. They will tend to act without thinking and may do things that they regret later because they acted without thinking. Children with Autistic Spectrum Disorder may have behavioural problems as they are having difficulty in understanding what is being expected of them and poor social understanding can lead to many more frustrations on a daily basis. Standard behavioural management may not work in these groups of children and behavioural management needs to be adapted to the child’s difficulties. In general it is harder to implement and with more varied results than in children without neurodevelopmental difficulties.
Children who are having emotional problems may have difficulties in behaviour. Emotions and behaviour are inextricably linked. When we feel down or stressed out, our behaviour changes. Some of us reach for chocolate, some for alcohol, some people become withdrawn and unsociable, other people become irritable and angry. It is important to assess emotional aspects of your child’s life if their behaviour changes or deteriorates. Children may not always volunteer their states of mind to you. They may not be able to label their emotions, or to express themselves. They may be afraid to talk about these things. Their unhappiness and frustrations are displayed in their behaviour rather than in words. It is your responsibility as a parent to notice, to ask, to label for them, to give them words, to give them permission to talk about their difficulties. To guess and to investigate from asking teachers and friends if nothing is forthcoming. It may be that they are being bullied at school, it may be that they are picking up on the stress in your marriage, it may be something trivial, but if you don’t notice/ enquire, you won’t know and their change in behaviour will just be called “bad behaviour” or “acting out”. In these cases, behavioural management will not work well. Rewards will feel irrelevant, ignoring and punishment will feel like persecution, negative attention will be better than no attention and rejection is a welcome confirmation of their own self-loathing. Finding out what is wrong, offering security will work better here. Unattended emotional problems in children can impact personality and aid development of long-lasting traits that can lead to “bad behaviour” becoming habitual and “part of” a person’s personality that can no longer be easily mended.
In children without these additional problems, the limiting factor to good behaviour is usually the parent not the child.
Lack of sustained motivation:
In the defining clinical trial for children with ADHD where they compared medication to behavioural management (The MTA Study), behavioural management achieved equal outcomes compared to medication. But wait, here the behavioural management programme used highly trained psychologists to work with highly motivated parents and teachers to obtain this outcome. Real-life trials (what we call pragmatic trials) using existing services, which tend not to heavily involve the schools (as the Department of Education is separate from the Department of Health), and non-selected patient groups, that have looked at the efficacy of community parenting and behavioural management programmes have netted unimpressive results. It is not that children’s behaviour cannot be managed; it is that the will of society and parents, is insufficient.
I know this all too well. Big Sis has a weekly spelling test. On the weeks where I have my act together, we sit and learn the words and I test her on the words each day to make sure that at the end of the week, she gets full marks and I reward her for this attainment. This is basically behavioural management in action: co-working towards a set goal that is achievable, achieved and rewarded. This works fantastically well, thumbs up and smiles all around. Once she has done this for a few weeks, I get complacent and I think, well now – maybe I can just give it a skip this week, she and I can both have a relax and we’ll just have a quick look at the words the night before. She gets a couple of mistakes. That’s basically my anecdote for behavioural management. It genuinely works until one day, you can’t be bothered and it all goes a bit wobbly again. The limiting factor is me, not Big Sis.
Wobbles in my behavioural management can also be seen when I am stressed or distracted. One time when I was very stressed waiting for a phone call regarding a job offer; the children were extremely badly behaved – “for no reason”. I was snappy and shouted at them and they just wouldn’t do what they were told – “it was as if they knew exactly when to wind me up”. Eventually, the phone call came, and I had got the job. That afternoon, they were very well behaved. The change had been in me, and their behaviour merely reflected my state and parenting capability, not something innate in them.
Unrealistic parental expectation:
When we talk about “bad behaviour” we all mean different things and we all have different thresholds as to what is meant by “bad”. Some friends and relatives come by our house and make “tutting” sounds when they see our kids glued to the TV, leave the table at meal times on a whim to dance around the kitchen, bonk each other on the head with cushions and generally shout at each other and at us. To me, this is not bad behaviour – this is just life in our household! Equally, I raise a brow when I see children that never say “please” or “thank you” and run away from their parents on the street, while this is not something that bothers them. When parents complain that their children “Will not do as they are told”, the severity of the issue rather depends on what they are being told to do. If they will not do 60 minutes of piano practice every night, that is rather different from refusing to do their homework, or refusing to stop watching TV; and “good” and “bad” behaviour is sooo dependent on what the parental and school expectation is. Often there are cultural and generational expectations of how children should behave. A normal child in a school with high behavioural expectations may be deemed to have “bad behaviour”, a normal child in one culture may be deemed badly behaved in another. The behaviour is relative and in order to assess behaviour properly, it is important to first evaluate that the expectations are reasonable. There is a limit to how much a child can “change” and they will not bother to attempt to change behaviour if they feel that the bar is being set too high.
One of the main saboteurs of a good behavioural management programme is “other people”. The well-intentioned/ or not so well-intentioned other half who disagrees with what you are doing. By not supporting you, they are de facto sabotaging the behavioural management plan because children are such buggers that they can spot disagreement a mile off and work it to their advantage. Much like MPs claiming expenses and benefit fraudsters, they are not averse to trying to get away with as much as they can. Playing one parent off the other must be a favourite game for children. In my opinion parents who want to succeed at behavioural management need to get on board together, or not bother. A similar conundrum exists with the school. If children are told one thing at home and another at school, the “authority” of “the rules” is undermined. It is a good idea when implementing behavioural management to discuss plans with the child’s school so that the same message is delivered to the child.
So in summary, if emotional problems are excluded, behavioural management delivered consistently and well will definitely improve your child’s behaviour, even if they have additional difficulties; but it is by no means a magic wand. It takes hard toil, stamina, guts, persistence and tears, but can reward you with likeable human beings. Isn’t that the essence of parenting?
If you want to know more about behavioural management please buy/ beg/ steal/ borrow: The Incredible Years, by Carolyn Webster-Stratton. This is the programme recommended by my colleague Professor Stephen Scott OBE of the UK’s National Parenting Academy. I have read it cover to cover and it’s good common sense.
Carolyn Webster-Stratton. The Incredible Years. ISBN 978-1-892222-04-06. http://www.incredibleyears.com
The MTA Cooperative Group (1999) A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Archives of General Psychiatry. 56:1073-1086
It’s International Women’s Day again! Last year I griped about the career prospect inequalities for women and I am pleased to say that although it’s not exactly “all change at the top”, I think that the world is waking up to women in the workplace and the agenda for change here has started rolling into place. So this year, I am moving the gender agenda on…
A few months ago I attended a fascinating talk on the impact of post-natal depression in mothers on their children. As you can probably already guess, the impact is not just for the duration of the mother’s depression, but due to the massive development of the baby’s brain in the first year of life in response to its environment, problems in its “environment” (which is largely provided by the baby’s primary carer) can be life-long. For mothers to get depression (or worse still, psychosis) at this time is crippling as not only does it affect them for the duration of their illness, but can impact the child LIFE-LONG. I don’t think any other mental illness can have such a profound effect.
The talk went into much detail about the observed negative outcomes in children and the mechanisms that led to these outcomes. In brief, lack of love, warmth, responsive parenting, talking and interacting with babies in “motherese” lead to abnormal or insufficient normal brain connections in the baby (motherese is the repetitive and sing-song baby-like voice that mothers adopt when talking to babies that is infinitely nauseating to non-parents – isn’t it darling? Yeees-it is! Yeees –it is!). Many clinical trials have been undertaken to treat post-natal depression to prevent these negative outcomes in children, such as cognitive behavioural therapy (CBT) and anti-depressant medication, but all with marginal effects. Really interesting stuff that I am sure I will blog about in more detail another time.
A PhD student had done some interesting work around the ability of depressed mothers to differentiate between a distressed cry and a non-distressed cry from various recordings of a baby crying. Depressed mothers can typically not differentiate the cries and find all cries aversive. Interestingly though, depressed mothers that had been musically-trained (played grade 4 or above piano) continued to be able to distinguish a distress cry from a non-distressed cry from her baby presumably because of their superior ear in differentiating musicality in sounds. This led to the suggestion that training in music may be protective in some way for the negative impact of maternal depression as these mothers preserved the ability to identify distress in their babies. Someone suggested teaching mothers the piano in pregnancy.
When questions went to the floor, other people suggested a blast of oxytocin nasal spray. Oxytocin is the “mothering” hormone released in pregnancy and during breast feeding and given to apes has been found to increase “maternal behaviour”.
Tentatively, I put up my hand. From the back of the hall (I have not yet escaped my student-style sitting at the back of packed lecture theatre habits) I wait my turn to be picked. “Umm – wouldn’t it just be easier to ask the dads to step up and do the parenting bit?”
It struck me as obvious that if the best anti-depressants were contra-indicated in breast feeding, and available anti-depressants were not achieving good enough effects and CBT was taking too long to treat mothers, that one should look not to new and under-developed drugs like oxytocin or expensive and frankly bizarre suggestions of NHS funded piano lessons for mothers to “cure” the mother; but to additional support that could take over the “warmth, love, responsive parenting, engagement and social interaction” with the baby. The clue was in the term “parenting”. Dads are parents too.
What amazed me was the response.
Maybe I had asked a silly question. Maybe there were already piles of research, unread by me; that excluded fathers from nurturing a baby. There was an awkward silence as if I had breached some sort of sacred unspoken code of conduct. There followed mutterings from the row of my esteemed male colleagues sitting in the front row. I imagined that they were saying “Trust her (rampant feminist implied) to bring this up!”
The speaker responded to my question thus (as verbatim as I can remember but cannot be vouched to be word for word): “Yes, but people don’t respond well to being told to do things, and of course there is already a large role for fathers to support their wives. Often fathers are at work and are not available to do this.”
I wondered if I had time travelled to the 1960s.
Can it be that in the 21st century, my esteemed, brilliant, talented, caring profession is still stuck in a time-warp? Decades after my predecessors saddled mothers with terms such as “Refrigerator mother”, “Schizophrenogenic mother”, “Good-enough mother”, “Tell me about your mother” and volumes on the paramount importance of maternal bonding and maternal attachment – can it be that we have not moved on from the primeval importance of mothers to babies? I am not disputing Bowlby here; I agree that attachment is vital. My dispute is with the gender requirement. Why can’t fathers bond and attach to their children – particularly if the mother is down or out?
My view on the issue is this:
Parental bonding and responsive parenting to babies is vital.
Biology provides some mothers with an advantage over fathers for bonding through pregnancy, birth and breast-feeding hormones. This hormonally driven advantage is lost once mothers stop breast feeding. In the UK, less than 1% of mothers last to 6 months of breast feeding. The hormones do not make mothers “better” at bonding, but makes them “desire” to bond and care for their young – kick starting the supposed “maternal instinct”. If there is a strong “desire” to parent, maternity hormones are completely unnecessary, which is why mothers who adopt babies are still perfectly wonderful mothers without having exposure to any maternity hormones. Believe me when I say that it was not oxytocin that told me that if my baby is crying I should pick her up, and if my baby is crying and her nappy stinks that I should change the nappy. That’s just common sense and I don’t need hormones for that.
Some mothers lack this advantage over fathers (having low levels of hormones or being unresponsive to hormones) and have no “maternal instinct” and are uninterested in babies (in the same way that many men lack the “aggressive instinct” that they are supposedly stereotyped to possess). Many men possess a “nurturing instinct”, in the same way that many women possess an “aggressive instinct”.
Some mothers get post-natal depression and are completely incapable or are severely handicapped in bonding and responsive parenting.
The conclusion should therefore be that fathers who have a strong desire to bond and care for their babies are no worse parents than mothers. Once mothers have stopped breast-feeding, they and their husbands are equally placed biologically to provide the love, care and nurture that is required to support a baby’s development. If a mother has post-natal depression or is uninterested or incapable of parenting for whatever reason, than the father is better placed to provide the love, care and support (provided he is not also disinterested or depressed), and particularly if he is warm and loving.
And yet, no one is shouting this from the rooftops, because there is no evidence to support this.
Just piles and piles of research on the bad outcomes for babies raised by mothers with problems.
Why is that?
Because in the past, it was the mother’s role to nurture babies and look after children. The body of evidence regarding mothers has built up over time. People writing research proposals and funding bodies granting money for research want to see an evidence base for the work that researchers they fund are building on. There is very little that has been done on fathers as the main carers for babies because up until the last few decades, this just happened so rarely. Even today, the vast majority of funded research in the parenting area relates to looking at mothers and their children. There is no evidence that fathers can care for babies, but equally, there is no evidence that they can’t. There remain large personal and societal incentives for many people and organisations NOT to produce research and data that may support equality in parenting capability. Yet, anecdotally, the gay dads that I have met (both personally and professionally) have largely been fantastically capable of love, warmth and responsive parenting and I am just sad for the many children whose lives are inordinately altered by mothers with post-natal depression where fathers have not stepped in.
The next stage in gender equality is surely to evaluate if the skewed evidence that we have been fed by parenting researchers who lived through a different society is scientifically relevant going forward, and to generate new evidence on parenting; where parenting is not just a proxy for “mothering”. My profession should be at the fore front of this, advocating for this research to take place and stamping out the gender bias in parenting. For if going forwards we are moving towards equality within the workplace (which we are), are we as child psychiatrists going to hinder this progression by continuing the rhetoric of hanging the responsibility of childcare on to aspirant mothers, or are we going to apathetically hang back and allow governments to enact it’s solution: to hand childcare over to the state? I believe we should speak with one loud voice for parental responsibility for parenting. Both parents in concert where possible and gender being irrelevant.
I am reminded of Harlow’s controversial primate experiments. The baby monkey chose to lay with the wire frame dummy covered in faux fur that gave it warmth and comfort, rather than the wire frame monkey that gave it milk. It is love that matters not mammary glands, and I am confident in my assertion that mothers and fathers are equally capable of that.