Lil Bro: Mummy – I can’t sleep
Me: Please, its past nine o’clock, what are you doing still up? You have to go to sleep now or you’ll be exhausted at school tomorrow! [Plus I just got started on this week’s episode of “This is US” and a tub of ice cream and I really fancy a rest!]
Lil Bro: But I can’t sleep.
Me: Just close your eyes and lie still! [Grrr]
I’m sure many of you are nodding in sympathy at this experience. Lil Bro who usually has no difficulty getting to sleep is having a spate of “I can’t get to sleep”. We have tried cuddling, cajoling, comforting, reassuring and now we are at the frankly fed up stage.
Children with poor sleep can have difficulties with poor concentration, over-activity, behavioural problems, day-time sleepiness, bed-wetting, obesity, increased clumsiness, depression and worse academic performance. Equally bad, the lives of their parents and entire family are also grossly affected. As parents of infants, we have all been there, but somehow I’ve taken immense umbrage at this recent spell of poor sleep because Lil Bro is now 7 years old and well able to put himself to sleep.
When Big Sis was a wee mite, I was the rabid sleep-deprived mother heckling the sleep experts flown in from abroad to teach us doctors about sleep EEG’s: “Can you tell me why, WHY, how, HOW can a baby go from stage 4 deep sleep to AWAKE and CRYING just by a 10 degree tilt to lay them in the cot????!!!! Give me the EEG on how that happens…!!!! What’s the possible mechanism???!!!”….zzzzzzzz – bonk.
So, I must now be the envy of most mums, as for the last few years I have had the pleasure of working with Paul Gringras a.k.a. the Professor in charge of the national Sleep Medicine centre at The Evelina Children’s Hospital. I have been working with him on an international multi-centre drug trial for sleep medication in children with neurodisability (mainly autism), which he is leading. His centre is hi-tech with observational sleep bays where children can sleep-over and be observed on video to capture what is going on, often plugged into electronic equipment that monitors breathing, brain and movement activity and I was fortunate enough to be able to sit in on consultations with Consultant Paediatrician Dr Mike Farquhar. It all sounds very medical. What then has a shrink got to do with sleep?
Well, it turns out that the majority of sleep problems in children are “behavioural”. Yes, there are known medical causes of disturbed sleep, e.g. restless leg syndrome, obstructive sleep apnoea, sleep walking and so on, but for the majority of cases in children who are otherwise fit and well, it is what children and their parents are in the “habit” of doing that is keeping them all awake.
What constitutes a sleep problem?
The definition of a “good night’s sleep” is variable from person to person. As a student, a full 10 hours was a requisite for me often causing tardiness to morning lectures. At weekends waking before 10am was unheard of. As a junior doctor, 4 hours sleep constituted immense good fortune and developed in me the very useful skill of being able to sleep anywhere, anytime – zzzzzz-bonk. These skills came in handy with babies that hadn’t read Gina Ford. The early years of parenthood are a sleep-deprived blur, but once the youngest had reached the milestone of 3 years, a more acceptable routine of 10 hours of continuously sleeping children was established –albeit the 6am wakenings were still somewhat painful.
In reality sleep requirements differ between children of different ages, but also between different children. Average daily sleep duration ranges between 10-17 hours at 6 months to 8-11 hours at age 11 years. This variability colours people’s ideas of what constitutes a sleep problem, and I am often bemused by some parents who come in desperation seeking medication for 10 year old children that sleep from 7:30pm to 6am: thinking with a mix of incredulity “What planet are you on? That’s almost a full 11 hours!” and admiration “Please tell me how on earth you get a 10 year old to go to bed at 7:30pm!” With these children who are getting hours of sleep within the acceptable range, the sleep is only classified as problematic if it represents a dramatic change to sleep pattern and/ or if there is any evidence of daytime sleepiness. If the answer to both is “No”, then one should feel reassured. However, for a psychiatrist, we know that often a parental cry for help of “My children don’t sleep!” is actually a cry of “I’m struggling to cope with my children when they are awake!” This differentiation is critical as the treatment strategies for the two problems are entirely different.
Aside from these perceptual sleep problems, the three main problems involving sleep are: struggling to fall off to sleep, waking in the middle of the night and co-sleeping.
Struggling to fall off to sleep
Problems falling off to sleep are often cited as a struggle. Sleep latency (to give it its fancy name) averages 19 minutes in 0-2 year olds and 17 minutes for 3-12 year olds. Anything over 30 minutes is classed as problematic. However, these average latency numbers involves the child actually wanting to fall asleep and lying in their bed in the dark, and any of the children’s wonderfully inventive delaying tactics “One more story”, “I need the toilet”, “I need a drink”, “Mummy sing to me” are clearly “behavioural” and not really to do with a “medical” sleep problem.
As part of our natural sleep cycle, we all wake at some stage in the night. Most of us are able to close our eyes and will quickly fall back to sleep again such that we don’t realise that we were ever awake or close to waking. Where night waking is problematic is where children are unable to settle themselves back to sleep and start playing the drums and waking the entire neighbourhood in the middle of the night. Typically these children then decide to fall asleep at around 7am, just when they need to go to school, and then they either miss school as their parents are unable to drag them there, or they doze off in the classroom and can’t learn effectively. You can imagine the impact of this on their parents.
OK I am as seduced by the lovely mental images of canoodling up with my young children for a snooze as the next parent. Many parents are seduced into this as children love it and it often helps them to fall asleep more quickly, but each time you get the inkling that this might not be such a bad idea, I would like you to imagine you sleeping with your 15 year old son or daughter. If you don’t do something to nip it in the bud while your children are young, they might not “grow out of it” and it will be a battle to get them out of your bed and are not used to falling asleep alone. I would suggest that you turf them out of sleeping in your bed by age 7 years otherwise it may get horribly entrenched. Of course, the early morning “I’m awake” cuddles in bed are still fine!
So what can we do to help our children to sleep?
My paediatric colleague Dr Jess Turnbull who is starting up the community Evelina Sleep Centre off-shoot in my work-place has the following advice for encouraging good sleep habits:
- Physical exertion in the afternoon – encourage daily exercise in children in the day-time. This will wear them out and make them physically ready to sleep.
- Consistent daily bedtime – as with all things behavioural, if there is an established routine and children know what is going to happen and that they cannot get out of it, then compliance is more forthcoming.
- Last drink 1-1.5 hours before bed – this reduces the likelihood of children needing to get up to go to the toilet in the night, which may make it harder for them to fall back to sleep.
- Avoid sugar/ caffeine – fairly obvious really.
- Try and have a routine wind-down regime in the hour before bed time (calming activities such as reading, bath, calming music). The idea is to try and calm your child down so that they are in the right physical and mental frame of mind to sleep.
- NO SCREENS (TV, phones, tablets) for at least an hour before bed. TV programmes, phones and tablets are all designed to capture interest, attention and brain activity. Ideally, you want to be winding down your child’s brain activity in the hour before bed so turning off screens is desirable. I know that many parents are tempted by having a TV in a child’s bedroom to keep them quiet and contained in the day, but it then requires discipline for children to stop watching it late into the night. Only be happy to provide a child with a TV in their room if they possess such discipline or you are happy for them not to sleep.
- Having a transitional object (eg. a soft toy) to develop sleep confidence and a healthy sleep association. This can be particularly helpful for younger children.
- Working towards your child falling asleep by themselves in their own bed. If a child is used to sleeping with you, then you should gradually withdraw yourself. For instance, first get the child accustomed to sleeping with you sitting next to them, then in a chair in the room, then outside the room in sight, then outside the room out of sight. It takes time, patience and grit to do this as some children will really dig their heels in, but if you view this as ultimately for their own good (which it is) then it is more possible to undertake.
- Limit setting on ‘fussing’ after ‘lights out’. If you draw out the bedtime process with attending to the child’s fussing, then it defeats the purpose as it will get later and later and only teaches children that you will give them attention for their fussing which encourages them to continue to do it.
- Reducing attention given after ‘lights out’ to prevent reinforcing messages of attention (e.g. avoid eye contact and conversation): good old pursed lips and silent treatment. There is a rule in my house that after the official bedtime, “Nice mummy” goes to bed and “Horrible mummy” her doppelganger comes in her stead. Nice mummy cannot be accountable for the actions of horrible mummy and so it is much better for children to just go to sleep.
But I had done all this and still, Lil Bro could not get to sleep. This was even more annoying and I was starting to put it down to “naughtiness”.
The next day, I was lucky enough to be chairing a talk on Smith Magenis Syndrome (a genetic disorder which was frequently associated inverted sleep cycle – i.e. day time sleepiness and night time waking) and my colleague Paul Gringras was the invited expert. Half-way through his talk, he spoke about the solution to keeping these children awake in the day was by using blue light to cut off melatonin secretion in the day. Melatonin is the natural hormone our pineal glands secrete to tell us it is night time and aids sleep. It’s pharmaceutical form can be bought over the counter in the USA as a treatment for jet-lag and is a commonly prescribed sleeping tablet.
Hang on a minute, Lil Bro had recently been given a fantastic blue Star Wars light sabre light that he had been insisting on turning on as a night light when he went to bed….this type of blue light is used to KEEP CHILDREN AWAKE….aargh. We had been inadvertently switching off our son’s natural melatonin secretion via Luke Skywalker’s weaponry.
I double checked Jess Turnbull’s list of advice and saw that I had overlooked: “Use a red coloured light if night light is needed (does not interfere with natural melatonin production)”. That evening, I told Lil Bro that an important sleep expert had told me that his special blue light was keeping him awake. Lil Bro likes science and reason and he felt good that there was a reason for his insomnia and that it was not just “bad behaviour”. It’s silly mummy’s fault for letting you have that light on (he likes not being to blame). Releasing him of anxiety about insomnia and allowing the release of melatonin by switching off the offending blue light sabre led to zzzzzz-bonk!
The info from this post came from: Turnbull & Farquhar 2016. Fifteen-minute consultation on problems in the healthy child: sleep. Arch Dis Child Educ Pract Ed 101: 175-180.
Last week I was pleased to hear about the Sense about Science report on children’s food allergies which stated the scientific misconceptions regarding food allergies and their prevalence. It would seem from the school playground that every other child has some form of food allergy or intolerance and from the hysterical behaviour of some parents that their darling offspring are at constant threat of anaphylactic death. One study in the Sense about Science report stated that whilst 34% of parents said their child had an allergy, only 5% actually did. Worryingly, the report suggests that many children are suffering from malnutrition due to exclusion diets, often initiated on whims and estimates rather than on hard evidence.
You can take it as read that I am a non-believer in food allergy and intolerance being the harbinger of learning difficulties, inattention, anxiety, bad behaviour and the other ills that some people believe. In fact, aside from coeliac disease which is a bona fide gut condition where gluten should be excluded from the diet, I don’t really buy into intolerance at all. You could say that I have an intolerance for intolerance. I’m sure that it does exist in some people in severe and debilitating form, but I am also sure that for most people who claim to be intolerant of something that a bit of bloating and flatulence do not a disorder make.
Typical then that Lil Bro should have a list of allergies as long as my arm.
It started with a spot of eczema on his forehead when he was 3 months old. Despite plenty of emollient creams, by 4 months it had spread to his cheeks and become wet and weepy eczema. I was concerned about infection and he was treated with antibiotics. It didn’t go away. The GP suggested that I cut out dairy, eggs and nuts from my diet as I was breastfeeding. I duly did this albeit reluctantly as I am an avid consumer of milky teas and cake and get quite grumpy when both are denied.
Nothing much happened even on this exclusion diet. Lil Bro’s eczema got worse. He was prescribed a second course of anti-biotics. On Valentine’s day evening, Banker and I abandoned our romantic dinner plans to spend the evening in A&E as Lil Bro was covered in raw-red wet and weepy rash from scalp to toe. Was it an allergic reaction to the anti-biotics I had wondered?
His scalp to toe eczema continued despite applications of weak steroid creams. My beautiful baby boy had skin that was painful to look at, the facial eczema being the worst. Despite twice daily emollient applications and infrequent oily baths, it didn’t get better. At night time, despite short nails and gloves on his hands, he would scratch himself till he bled, and I could hear his wriggling and itching movements in his cot constantly. Often I lay awake tearful holding him in my arms to sleep so that I could prevent his scratching. The final straw was when one time I was driving and I could hear him crying in the baby seat behind. By the time I had pulled over, his face was covered in blood as he had scratched himself across the face where the eczema had been red and raw.
I took him to see Dr Atherton at Great Ormond Street Hospital. A friend who worked at GOSH as a Consultant advised me that he was the best dermatologist in the country. Lil Bro was prescribed wet wraps and Protopic cream. The small print on Protopic mentions a risk of cancer, but Dr Atherton assured me that this was small print and quoted the statistical risks. I was happy to go with the medication, I was desperate. It helped stabilise the eczema, but it by no means got rid of it. Lil Bro was wet wrapped for a total of 6 weeks. Dr Atherton had mentioned that most parents gave up by 3 weeks and was surprised when at 6 weeks, Lil Bro was still in full body wet wrap. I confessed though that I was at breaking point, but at least Lil Bro’s eczema was under some control. Skin was red, but no longer wet and weepy. The wet wrapping, as well as soothing the itch also prevented any skin damage from scratching. The twice daily wet wrapping though was getting me down. Lil Bro was basically bandaged like a mummy all day. I refused to let wet wrapping ruin Lil Bro’s life. I looked into his beautiful, brown eyes that poked out from the bandages with all my love, and often, being the sweet darling baby that he was, he beamed back. Despite his troubles, he was the sweetest, happiest child. We went to mother and baby groups, and it didn’t bother me if children asked me why he was wearing a mask (which was like a balaclava made of dressing material), they just seemed curious. Big Sis had no problem with the mask at all, but it sometimes got a bit much when other parents came up to me with their little ones saying that they wanted their child to play with him so that they could be “accepting of children who were different”. Other people asked me if I put the mask on him because it was cold. I really didn’t understand these people – did they think that I thought bandages were a substitute for a hat and scarf…?
Dr Atherton recommended an allergist Professor Gideon Lack. I asked around my medical colleagues and confirmation came that Professor Gideon Lack was the best allergy specialist in the country. His prodigy Dr Adam Fox is now often in the media as the go-to allergy specialist, but why go to the doctor when you can see the Professor? By the time we saw Gideon Lack, I was pretty sure that Lil Bro had food allergies. Having breast fed for 6 months, I tried to wean him onto formula. After several desperate attempts that resulted in wholesale visceral rejection of formula (cow’s milk and soya) our food allergy fears were confirmed in skin prick tests and blood tests. Along with allergies to milk, eggs, all nuts, all seeds and soya, he was also testing allergic to wheat, beans, peas, pulses, lentils, banana and kiwi. Professor Lack was sceptical about the wheat allergy as this is very rare. He advised us to try him on wheat pasta at home. We did, and wheals appeared almost immediately on ingestion confirming a positive allergy to wheat. Lil Bro was prescribed Neocate formula, a disgusting tasting blend of amino acids that only the truly allergic could stand. Once Lil Bro started on this formula, his skin came under control without wet wrapping.
The funny thing about being told that Lil Bro had allergies was that my first concern was not about his health and diet, but about his psychological outcome. Maybe this is not so strange, but a consequence of my profession and prejudice. My first thoughts were: I don’t want him to be the skinny, snivelling, wimpy kid that has to sit out of football games puffing on an inhaler or sit in the corner of birthday parties telling people how he can’t eat things while eating his own carrot sticks from a paper bag brought from home. I wanted him to be a participater, a life-enjoyer. I want his allergies to have no bearing on his life at all.
Thankfully, as we saw a leading expert in the field, we were given expert advice, which I fear is not given to the majority of parents. Whilst we were given Epipens, we were explicitly told that the likelihood that he would have an anaphylactic reaction was only to peanuts and that this risk amounted to the risk of being run over by a car (i.e. not very likely). We were explicitly told that the majority of children outgrow all their food allergies by adulthood, save for peanut allergy which only resolves in 20%. We were told that the skin prick tests and blood tests are grossly unreliable and are mere rough markers for what may or may not be an allergy and that if a child was able to eat the food without a reaction within 2 hours; then they were probably not allergic to it at all. Lil Bro tested positive on blood and skin prick tests for many other things such as corn, but we knew that he had had no allergic reaction on physically eating this and so could not be allergic to it. We were encouraged to continue to allow him to eat all the things he could eat without a reaction. We were told that the jury was out on exclusion as being the best course of practice and that clinical trials for exposure and desensitization were ongoing. That there was a possibility that exposure could actually help not hinder overcoming allergies.
It is amazing how little one can eat, if you have to exclude the list of food that Lil Bro was allergic to. The majority of dairy-free products substitute milk with soya, which was no good for Lil Bro either. Who would have known that meat pastes and pates usually contain soya? At home it was possible to concoct a meat and two veg type meal and we joked about his Chinese and Irish heritage as rice and potatoes were his main starch staple given bread and pasta were out of the window. It was travelling that was tough. But as I mentioned we were not going to let allergies hold him back, and we travelled widely with our suitcases stuffed full of oat cakes, tins of tuna and sweet corn; staples that we knew he could eat, if push came to shove and we couldn’t find anything for him. For his first birthday, as I couldn’t fathom how a cake could be made without flour, eggs, butter or milk, we bought a hefty joint of beef and wrapped it in a cake frill and stuck a candle on top. It was important to me that he was going to enjoy his birthday cake! Later, I found a decent recipe for a wheat, egg and dairy free chocolate cake that involved pureed prunes and his second and third birthday cakes were sorted.
As was foretold, Lil Bro outgrew many of his allergies. On an annual basis, we tested his allergies and if ever we were told there might be a possibility that he had outgrown an allergy, we billed our insurance company for a food challenge. The elation of overcoming the soya allergy at 2 years was only off-set by failing to outgrow his wheat allergy, but, slowly by slowly, the list of contraband food grew slimmer and slimmer. I watched carefully at the conduct of food challenges that took place in hospitals, and for a few items on Lil Bro’s list; I conducted food challenges at home. The sooner Lil Bro could eat a normal diet the better, and the annual NHS appointments that we had were not soon enough for me. If he could eat something, I wanted him to be eating it. Lil Bro still has an allergy to cow’s milk. This shows on skin prick and blood test, but from home food challenges, we know for a fact that he is able to eat milk that has been thoroughly cooked, although he still reacts to a few sips of a glass of milk. Home food challenges were not advised by the hospital, and I am not advising other parents do this (I am after all a doctor). In fact, I am frequently chastised by the hospital nursing staff “Why did I want to take the risk with a home food challenge?”, but the sight of Lil Bro tucking into a crème brulee, which is his favourite food, is enough justification for me. Why should he miss out? Lil Bro’s current allergies are now only peanuts, cashew nuts, pistachios, raw egg and uncooked milk. He enjoys a varied diet including all the nuts that he was previously allergic to: almonds, hazelnuts, pecans, walnuts and brazils. He has not a spot of eczema on him and only rarely uses an inhaler.
What has puzzled me is the attitude of some parents. Coming from a standpoint of having a child who could eat virtually nothing, and the immense strain on family life that this caused, I found it difficult to understand why anyone would want to inflict this on their families without strong evidence that it was indicated by allergic reaction. Yet many parents seem to be rushing to exclude vital food groups from their children’s and entire family’s diet. In the allergy clinic waiting room, there is almost a frenzied competitive element to the number of allergies your child has, whereas for me, I’d give anything to be the loser in that competition and have Lil Bro be able to eat anything he wanted. I can only imagine that some people don’t enjoy food as much as I do. For me food is life. People that enjoy food tend to enjoy life, and I intend for Lil Bro to enjoy his.
I am not an allergy specialist, I am just writing about my experience, but please check out the Sense about Science website for sensible allergy advice.
OK, I have to fess up. I am moving house this week and have nothing prepared. So here is an essay I wrote a while back to explain my work in gene-environment interaction. I know, it sounds scary, but its really simple and I’m sure that this “story” will help you understand.
I’m here at Mr. Almighty’s Cloud Street Headquarters to interview him on his plans for a family friendly casino.
“Mr. Almighty, it’s great to meet you! Tell me the concept for your casino.”
Mr. Almighty: It’s ingenious really. My casino actively encourages participation of whole families. Although single people are encouraged to come, it’s in the hope that when they have children, they can continue to come here as a family and I’ll have a continued source of customers!
“Very clever. What sort of gambling facilities will you have? Slot machines, roulette, ‘Blackjack’?”
Mr. Almighty: Ah, well! I’m a ‘Blackjack’ man myself, but my enthusiasm spreads to all card games and so I’ve dedicated my casino to cards. We’ll have ‘Poker’, ‘Snap’, ‘Bridge’, ‘Old Maid’, ‘Rummy’, as well as ‘Blackjack’ off course. In fact, you name a card game and we’ll certainly be playing it. I’ve divided the venue into sections so that a different card game will be played in each, so called ‘gaming environment’.
“A very catchy name.”
Mr. Almighty: Yes. I think our advertising boys did a good job on that one.
“What’s so special about a casino dedicated to card games for families?”
Mr. Almighty: Hah! Well, unlike other casinos, there’s a twist. My casino will be exclusive: ‘Members Only’ I mean…
“There’s nothing new about that!”
Mr. Almighty: Wait, I haven’t finished. On joining, I deal all members 14 playing cards. They must play with the same 14 cards that they were dealt on joining for the duration of their membership. The only exception will be for members’ children. We anticipate there’ll be several billions as the casino expands, so I’d be here all day dealing out cards to kids if there was no exception made! So, I’ve devised a simpler plan for them. They will be blindfolded and asked to randomly pick their cards from the hands of their parents: half from their mother, and half from their father. From then on, the same rules apply: “You play with the cards you’re dealt”! That’s the slogan our advertising department is adopting for our poster campaign!
“But there’s a terrible flaw in your plan! What if I joined and received a terrible hand? I’d have to play with that for the duration of my membership and keep losing! I might as well give up!”
Mr. Almighty: No, no – that needn’t happen. You, like so many others, see things at face value and don’t see the complexities in the matter. Whether you win or lose depends not only on your cards but a whole host of factors. For starters: how well you play the game. Parenting is potentially important for this, at least in the beginning. Even if a child has a great hand, if his parents haven’t taught him the rules of the game, he’s pretty sure to lose.
“Yes, I suppose so.”
Mr. Almighty: Later on, he might have more chance to play with friends or have tuition from teachers and be able to learn skills for card playing from them.
“So, his chances of success and failure might be influenced by his peer group and school environment?”
Mr. Almighty: Indeed.
“But, once you’ve learnt the rules of the game, your potential winnings are still dictated by the cards you’re dealt. You’d be stuffed if you had no ‘Aces’ or ‘Picture cards’.”
Mr Almighty: Not so! That’s the beauty of my casino. There are many chances to win. As I’ve said, we play all the card games in the world here, not just one! The ‘Aces’ and ‘Picture cards’ might serve you well in a game of ‘Bridge’, where high scoring cards are valued, but in ‘Old Maid’ where they are penalized, they will cause you nothing but grief! And in ‘Snap’, well, a ‘two’ is as good as any ‘Ace’ so long as you find a pair.
“O.K. So how well you do depends on the interaction between your cards and your ‘gaming environment’. A hand full of ‘Aces’ in a ‘Bridge’ game spells success, but the same ‘Aces’ when playing ‘Old Maid’ spell disaster. So the handicap I predicted isn’t necessarily so, and it’s a matter of finding the optimal combination of game played and cards possessed.”
Mr. Almighty: Exactly!
“Even so, how well you do in the long run is still dependent on your cards isn’t it?”
Mr. Almighty: In some respects. I can’t say that your cards will not ultimately limit your potential but there are still further factors that could influence prospects.
“Besides your cards, acquired knowledge of the game and the game being played, I can’t think of any thing else that would influence progress.”
Mr. Almighty: I see you’re not a regular card player! Otherwise you would know that there is a lot more to card playing, not least the abilities of your opponents, or ‘gaming society’ as our advertising boys like to call them.
“O.k. I suppose if I were playing with novices, I’d certainly have a better chance of winning.”
Mr. Almighty: Now you’re catching on! As you can see, there are lots of ways you can still win with a deficient hand of cards. You choose a game you’ve been taught to play well, a ‘gaming environment’ where your cards are valued and where your fellow card players are suited to allow you to thrive.
“So, I could look at my hand and in effect change my prospects by selecting a ‘gaming environment’ dependent on my cards.”
Mr. Almighty: Yes, indeed there’s likely to be a great deal of correlation between your cards and your selected environment. But it’s not always easy to tell from the outset which is the best ‘environment’ for your hand. I’m not going to label the environments ‘Professional Poker Player’s table – avoid unless you have a Royal Flush’ or ‘Beginner’s Bridge – you’ll win big here even if you have no Picture Cards’. What usually happens is that there is a fair amount of trial and error before some satisfactory environment is found.
“But clever manipulation of the ‘gaming environment’ can make good from a poor hand.”
Mr. Almighty: Indeed. And these are just factors I’ve thought of so far. I’m sure if more research was done in this area, more significant environmental and social factors will be found to allow players who receive a poor hand to win.
“That’s amazing! But tell me, how can this venture possibly make money? You’ve said players with terrible cards can still succeed by choosing the correct ‘gaming environment’. If players got wise they’d keep winning and you’d go bankrupt!”
Mr. Almighty: Well, I have a few tricks up my sleeve. I didn’t wish to impose this restriction, but the reality is that to stay economically viable as a business, I must. I have had to impose a cost attached to changing ‘gaming environments’. You will have to start playing in the same ‘environment’ as your parents. Otherwise, I’d be bankrupt by the babysitting fees alone! If you want to change environments, you or your family will have to pay a fee, and it’s not cheap. It’s sad but true, some poor buggers get stuck in an environment totally at odds with their cards and they just carry on losing.
“Let me get this straight. If my parents play ‘Poker’, then I have to start off playing ‘Poker’ even if my hand is better suited to ‘Snap’. In order to play ‘Snap’ and make it big, I need financial backing?”
Mr. Almighty: Yes. That’s the gist of it. I have to make money somehow! If only the government would give us casino proprietors more money, I’d love to let my members play in their optimal ‘gaming environments’ and watch them flourish. Unfortunately, I can’t afford to do that.
“Isn’t there another way? What if between my parents they have the cards to give me a ‘Royal Flush’ which would make me almost guaranteed to win at ‘Poker’. Couldn’t they pay a fee to engineer it so that they select which cards I inherit, rather than my picking them randomly? Or, could I modify my hand and change certain cards for ones that might suit my circumstances better?”
Mr. Almighty: That certainly would allow you to win. It’s a contentious issue though! Some would even call it cheating! But I can see where you’re coming from. If I was constantly playing to lose with no prospect of winning, and with the knowledge that my children would inherit a poor hand and little financial resource to change their lot, I’d quite wish to be able to do the same thing too. I often see players with no ‘pairs’ or ‘Picture cards’ continuously losing their savings at the ‘Poker’ table and I think, what if I could give him a pair of ‘Aces’ or two. Unfortunately, if I sanctioned card changes, all my members would be queuing up to change their cards and I would have no peace! As it turns out, there are many intelligent members who’ve devised ways of ‘card modification’. But there’s no point changing your cards willy nilly. The trick is to research your ‘gaming environment’ and ‘society’ and strategically find the correct card to change. By changing specific cards, some have been able to turn the tides of their fortune. Sometimes, it can rejuvenate whole families who’d lost hope, not to mention the benefits to their future generations. Other times it’s used for the wrong purposes, and I totally disagree with it, but am powerless to stop it. It’s really up to members to decide how much ‘card modification’ they can tolerate. There’s a committee that monitors it. I try to keep out of it, though they often try and bring me in to their debates!
“But it could ultimately affect your business. If all this ‘modification’ was allowed to go on, everyone would have ‘Aces’ and ‘Royal Flushes’ in their hand and you’d go bankrupt!”
Mr. Almighty: Not necessarily. The members can modify cards behind my back all they like, but they need ultimately to bear in mind that if everyone had ‘Aces’ and ‘Royal Flushes’, the whole ‘gaming society’ would change. There’d be no members with losing hands and you’d have to be an even better card player to succeed. There will always be winners and losers just the same. In any case, don’t you know the first thing about casinos? The house always wins. I have one last trick up my sleeve and that is, I have the right to close down any ‘gaming environment’ I choose, at any time.
“How would that insure your success?”
Mr. Almighty: Well, if all my members were gaining ‘Aces’ and ‘Royal Flushes’ to win at ‘Poker’, then they would be taking a large gamble. I could close down all my ‘Poker’ tables and turn them into ‘Old Maid’ gaming environments at my whim. That way, I could turn all the winners into losers and losers into winners whenever I choose!
“Caution and the importance of environment is the order of the day then?”
Mr. Almighty: Indeed.
“It certainly sounds like a fascinating venture! One thing I wondered though, your advertising guys seem to have coined great names like ‘gaming environments’ and ‘gaming societies’, but couldn’t they think of a more catchy name for the cards?”
Mr Almighty: Yes, they’re working on that, so far, they’ve only come up with ‘genes’.
“‘Genes’. That might just take off! Tell me, what are you going to call your new casino?”
Mr. God Almighty: Well, actually, the prototype has already been running successfully for several millennia, and I think I’ll launch the real thing with the same name as it’s a good a name as any. I call it ‘LIFE’.
I was recently asked for some advice, as is an occupational hazard. “We’re about to have a second child. How do we prepare our child for the arrival of a sibling, because of the inevitable jealousy?” To my surprise, even before I could answer; my husband who has been well versed in my opinions answered for me.
“She has zero-tolerance on siblings not getting along.”
I was surprised at his succinct synopsis of my position, but “yes”, that is indeed my view. For me, the bond that I have with my two sisters is very important. Even though personality-wise we probably would not have been in the same circle of friends had we been peers, as sisters we are closer than the pre-election polls. Even though I rarely socialise with my siblings outside family events, if anything in my life happened, they would be the first people that I would contact and vice versa. I would never be alone in a crisis because I know that they would be supporting me – come what may. Friendships and marriages may come and go, parents will pass away, but siblings are with you, living in your time and generation – for life.
This is not just me being whimsical but is born out in science. Warm, supportive sibling relationships that lack conflict are related to having better psychological wellbeing as children and into adulthood (Buhrmester and Furman1990; Buist et al. 2013; Kim et al. 2007). The reverse is also true; hostile and aggressive sibling relationships are associated with higher levels of anxiety, depression, low self-esteem and anti-social behaviour (Campione-Barr et al. 2013; Dunn et al. 1994a, b; Padilla-Walker et al. 2010; Stocker 1994).
Maybe this is nothing to do with sibling relationship, but related to parenting and genetics? Argumentative parents have argumentative children that don’t get on and become argumentative and anti-social adults. This doesn’t seem to be the case. In fact, the literature suggests that warm, collaborative sibling relationships instill resilience (an invisible protective shield if you will) in children. For example, there is evidence that good sibling relationships protect children from all manner of adversity from bickering parents that fight all the time, negative life events (such as natural disaster and death of a loved one), high risk neighbourhoods, low-income backgrounds and bullying (Jenkins and Smith 1990; Tucker et al. 2013, Gass et al. 2007, Criss and Shaw 2005; Widmer and Weiss 2000, Bowes et al. 2010). Very recently published work suggests that siblings can even protect against the negative impact of parental mental health problems. Keeton (2015) found that in children of parents who met clinical criteria for anxiety disorder, the psychological impact of having a parent with anxiety disorder on children was moderated by the quality of the relationships between the children. In effect, the closeness of siblings allowed children to protect each other from the negative impact of a parent suffering a significant mental health problem. All in all, the evidence suggests that sibling relationships are just as important in a child’s psychological development as parents and friends.
This makes sense to me. Much adolescent and adult unhappiness comes from feeling “alone”/ “unaccepted”/ “friendless”/ “unsupported”. I have met many unhappy adults in my time as an adult psychiatrist of whom I just thought “You know what? You’d be fine if you just had a supportive friend.” That’s just exactly what a brother or sister could and should be; and whilst as parents we have little or no say in who our children choose to be friends with in adolescence and adult life, we have much control over whether siblings get along or not, and are perfectly placed to ensure that our children, via their siblings, have a strong support network for life.
So why have we as a population of parents come to expect sibling rivalry and discord? When we see it happening, we shrug our shoulders and say “siblings –eh?” We may take some cursory action “Don’t hit your sister”, “Get off your brother’s back and put down that brick that you were using to pummel his head”, but all in all, we assume that this is run of the mill sibling behaviour. In effect, we at best tolerate it, at worst encourage it. Romulus and Remus were raised by a wolf. I am not sure what happened with the Millibands…
My own childhood experiences were different. My mother came from a family of 7 extremely close siblings. Even though they live on different continents and their ages outspan a decade, they still go on holiday together and skype each other regularly. They laugh, joke, bitch and support each other as much now as pensioners as they did when they were children. My mother told me that in her family the older children were each allocated a younger child to look after growing up. Second Uncle had to piggy back my mother on long outings and my mother in turn had to rock third Uncle to sleep. I am sure that this responsibility and encouragement of care fostered an affection that has lasted into their old age.
In turn, I remember very clearly my mother explicitly saying to my sisters and I as children “You three are best friends. You are all each other have and must support each other.” I remember thinking sulkily at the time; I am so not best friends with these two. That one has just pulled my hair, and that one has just scratched my face. But we moved several times as children, first from Taiwan to Wales and then Wales to London, changing primary schools 4 times in 8 years, and so it turned out to be true. While friends came and went, “Laurel and Hardy” as I liked to imagine them then or “The Two Ugly Sisters” (to my narcissistic Cinderella off course) were always with me. And guess what, as adults, we are like best friends.
So what of my own children?
Banker was right. I take a zero-tolerance view of siblings not getting along. Like my mother, I insist to them that “they are best friends” daily, whether they like it or not. Sure they fight all the time, but underneath I know that they love each other dearly. When Lil Bro had a hard day in the school playground, Big Sis gave him advice. When an umbrella at a cafe blew over and grazed Big Sis spilling her drink, Lil Bro immediately gave her his. And in the evenings when they snuggle up together, I swear, its the sweetest moment for a parent.
Here are a few other things that I did/ try to do, all of which being non-scientific and are just my interpretation of what might help siblings get along.
- My number one advice is to ensure that your children feel loved and secure in themselves. Children who have “secure attachment” to their parents have all manner of better prospects throughout childhood and into adulthood. The more secure a child feels in themselves, the less prone they will be to jealousy, and the more generous they will be to their siblings. So ensuring a child grows up feeling secure from the outset helps a great deal.
- Prepare for a new sibling. Throughout pregnancy, the prospect of Lil Bro’s arrival was talked about as a massive positive. A little brother for you to help me look after. A little brother to play with you. Read books about new babies and about siblings that get along (Topsy and Tim is good for this). Buy your child a baby doll and play together at looking after it. Be as realistic about this as possible as this will help role play and rehearse what is to come. Massively praise any caring actions and discourage rough handling.
- Allow a bond to be made with a new sibling. I know that parents can be precious about babies, but being overly-guarded and excluding a child from their baby sibling can lead to loss of opportunity for siblings to bond, and also the older sibling feeling somehow excluded. Where possible, always involve siblings. Place the baby on the sibling’s lap and help them cuddle the new sibling and play with them. This is perfectly safe as long as children are well-prepped and you are supervising.
- Deal with jealousy. Jealousy between siblings will be inevitable at times even with secure children, but how you manage it can dampen or amplify its existence. Firstly, you must anticipate situations where this may occur and notice it when it happens. Then, rather than ignore it, it should be addressed as soon as possible. For instance, when there is competition for attention, this should be verbalised, acknowledged and problems solved. “I know you want me to play with you, but I am feeding your brother. But tell you what, he will be asleep after this, and then I can play with you.” Or when they get older “I know I am spending the day with your sister because I am taking her to see her favourite ballet, but next week, I will take you to the zoo.” Many young children feel angry and frustrated when they feel excluded or unfairly treated in favour of another, but cannot understand the reasoning behind it or be able to label it as “jealousy”. It’s up to parents to notice it and label it and explain it. Jealousy is a natural emotion; it is how we handle this emotion that needs to be addressed rather than attempting to avoid or suppress an irrepressible natural feeling. Unaddressed jealousy may lead to lashing out, aggression towards their sibling, or deliberate misbehaviour in order to get attention which is never a good thing.
- Behavioural management always applies. The tenet of behavioural management is to heavily praise and reward behaviours you wish to see again and to ignore and discourage behaviours that you do not wish to see again. If you wish to see caring behaviour between your siblings, you need to reinforce it with praise and rewards. If you would rather they did not bicker and fight, there need to be consequences each and every time this happens. I know that some parents think that siblings should “just naturally love each other” and I am as happy-clappy as the next person, but even I know that “love” can be manipulated to some extent. Some people refuse to praise and reward things that they “expect” children to do naturally, but I’m a great fan of praise (see my previous blog post on this) and evidence shows that behavioural management works.
- Us vs them. During my family therapy training I read somewhere that the only healthy grouping of people within a family is parents vs children. Families that have any other combination are more vulnerable e.g. a family which splits into two with a mother and son vs father and daughter or mother and children vs father. Keeping the healthy dynamic should always be borne in mind. Using this dynamic, it is possible to foster closer sibling unity as people tend to unite against a common oppressor. Yes, you the parents are the oppressor in this scenario. Don’t be tempted to side with a child, enjoy your role as the villain and reap the rewards of sibling cohesion.
- Encourage collaboration. Treating children as a team can be helpful to collaboration. Rewards can be given to both children as a team, punishments doled out to both as a team. This will facilitate helping behaviour and help siblings see each other as partners rather than competitors. Encourage mutual praise. For families in a rut that come to see me for therapy, I tend to suggest that before bedtime, each child is to say something good that the sibling has done that day and praise them. It may be forced praise to begin with, but even forced praise is better than no praise and over time it may and likely will become genuine and overspill into the everyday (particularly with young children).
- Promote exposure and shared experience. One way to help them get along is to allow them to have common experiences and exposure to each other. This is not possible if they attend different schools. This may be a bit unpopular in the UK where for some reason boys and girls from 4 onwards are farmed off to single sex schools, or siblings of different abilities are segregated early on into selective schools. I am totally and whole-heartedly in favour of keeping siblings in the same school, especially at primary school where I think education should play second fiddle to social and emotional development. A close sibling relationship is more important to me than KS2 results. A supportive sibling is there for life, who of us can remember our primary school grades? My children go to co-ed school. This way, their support for each other can start young. I am delighted to hear that Big Sis crosses the playground to give her Lil Bro a kiss and hug when he needs it. Not possible if she is not there.
- Adopt a policy of zero-tolerance on siblings not getting on. Expecting and or accepting that siblings do not need to get on, and that this is “normal” is the main reason for inaction. So this last point is probably the most important, because action is the first step.
Bowes, L., Maughan, B., Caspi, A., Moffitt, T. E., & Arseneault, L. (2010). Families promote emotional and behavioural resilience to bullying: evidence of an environmental effect. Journal of Child Psychology and Psychiatry, 51, 809–817.
Buhrmester, D., & Furman, W. (1990). Perceptions of sibling relationships during middle childhood and adolescence. Child Development, 61, 1387–1398.
Buist, K. L., Dekovic, M., & Prinzie, P. (2013). Sibling relationship quality and psychopathology of children and adolescents: a meta-analysis.Clinical Psychology Review, 33, 97–106.
Campione-Barr, N., Greer, K. B., & Kruse, A. (2013). Differential associations between domains of sibling conflict and adolescent emotional adjustment. Child Development, 84, 938–954.
Criss, M. M., & Shaw, D. S. (2005). Sibling relationships as contexts for delinquency training in low-income families. Journal of Family Psychology, 19, 592–600.
Dunn, J., Slomkowski, C., & Beardsall, L. (1994a). Sibling relationships from the preschool period through middle childhood and early adolescence.Developmental Psychology, 30, 315–324.
Dunn, J., Slomkowski, C., Beardsall, L., & Rende, R. (1994b). Adjustment in middle childhood and early adolescence: links with earlier and contemporary sibling relationships. Child Psychology and Psychiatry and Allied Disciplines, 35, 491–504
Gass, K., Jenkins, J., & Dunn, J. (2007). Are sibling relationships protective? A longitudinal study. Journal of Child Psychology and Psychiatry, 48, 167–175.
Jenkins, J. M., & Smith, M. A. (1990). Factors protecting children living in disharmonious homes: maternal reports. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 60–69.
Kim, J., McHale, S. M., Crouter, A. C., & Osgood, W. (2007). Longitudinal linkages between sibling relationships and adjustment from middle childhood through adolescence. Developmental Psychology, 43, 960–973.
Padilla-Walker, L., Harper, J. M., & Jensen, A. C. (2010). Self-regulation as a mediator between sibling relationship quality and early adolescents’ positive and negative outcomes. Journal of Family Psychology, 24, 419–428
Stocker, C. M., Burwell, R. A., & Briggs, M. L. (2002). Sibling conflict in middle childhood predicts children’s adjustment in early adolescence.Journal of Family Psychology, 16, 50–57.
Tucker, C. J., Holt, M., & Wiesen-Martin, D. (2013). Inter-parental conflict and sibling warmth during adolescence: associations with female depression in emerging adulthood. Psychological Reports, 112, 243–251
Widmer, E. D., & Weiss, C. C. (2000). Do older siblings make a difference? The effects of older sibling support and older sibling adjustment on the adjustment of socially disadvantaged adolescents. Journal of Research on Adolescence, 10, 1–27.
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.
Strictly speaking, the term “epidemic” should be reserved for infectious diseases. I realise that the term has now bled into everyday language to mean a large rise in prevalence rates for anything (e.g. obesity epidemic), but the original clinical definition was to describe the spread of infectious diseases (e.g. ebola epidemic). I’m a clinical terminology pedant; I lose sleep over people that call a “fascination” an “obsession”, so you can imagine my loathing of the headlines of “autism epidemic” to describe the increased numbers of people being given a diagnosis of autism. The reported autism prevalence rates have increased from around 1/100 to 1/68 (that’s about one child in every 2 state school classrooms). However, even if the lay terminology is accepted, the rise in numbers of people diagnosed with autism has more to do with changing diagnostic classifications and awareness than an environmental hazard that shock-headlines would like us to anticipate. There are many press and internet articles that discuss this, but I didn’t feel that they fully explored the territory, so here is a researcher and clinician’s view of the reasons for increased rates of autism.
Why do boundaries in classification change?
Autism is primarily a genetic disorder and the genetic basis of autism is pretty much undisputed now. Although environmental hazards may play a role, these are generally on the basis of a pre-existing genetic vulnerability. There are several known genetic disorders already identified that highly predispose to autism (e.g. Fragile X, tuberous sclerosis, neurofibromatosis), but these disorders account for only a small proportion of the total incidence of autism. The bulk of people with autism have what is called “idiopathic autism” the genes for which have yet to be identified (although several genes are suspected and are undergoing rigorous going over by scientists, none have been conclusively proved).
The identification of genes for autism is a tricky problem, as it is not a single gene that is wonky in autism. If it were, then it would have been identified long ago, like other single gene defects (cystic fibrosis, tuberous sclerosis) and we would be able to test for it readily with a genetic test. It is likely that there are multiple genes, say 6 (this is an educated guess), that are all required in order to generate the disorder. These genes are common, and both you and I are probably carrying several of these genes right now and have already handed them over to our children. Like in the National Lottery though, it is quite common for individuals to have a few of the numbers that come up, but it is much rarer to have all 6 numbers together. In the case of autism, only the people with all 6 genes get autism. Also like in the National Lottery where 5 numbers will get a small pay-out, people with 5 genes may get a watered down version of autism.
Scientists have been using all the tricks available to them to try and elucidate the precise gene combination. A few years ago, the computer capability to do Genome Wide Association Studies (GWAS) (where you sequence the entire genome of subjects with autism and the entire genome of subjects without autism, bung the lot in a very big computer and get it to output the combinations of genes that are common to people with autism but not present in the people without) was supposed to lead to a major breakthrough in autism research. It didn’t. The reason being that as all scientists know; if you put sh*t data in, you get sh*t data out. The conclusion amongst researchers was this: the people that we are defining as “autistic” and “not autistic” are wrong. If there are non-autistic people in the “autistic” group; or more likely, autistic people in the “not autistic group”, this will mess up the results.
How are we currently diagnosing autism and is it correct?
The current classification manuals for diagnosing autism (and other mental health problems) are the DSM (used in the USA) and ICD (used in Europe) manuals. My husband has a similar book for “diagnosing” if a mushroom that he finds on the heath is poisonous or not. There is no blood test or scan, only the basic science of observation and interrogation. You might, (and some do) dispute the validity of such classification manuals, but it has thus far served my husband, who has a penchant for putting foraged fungi into his mouth, well (i.e. he has correctly been able to avoid the death cap by consulting his book). A hundred or so years ago, manuals like these were used to diagnose everything from brain tumour to Down’s syndrome (doctors of old diagnosed brain tumours from symptom check-lists including things such as headaches and vision problems, and having round faces and “Mongolian eyes” suggested Down’s syndrome). By fine tuning the classification and studying the people identified, it has become possible to find causes and cures. If classification had not initially taken place, cures would not have been found. This is where we are currently at with autism, fine-tuning the classifications based on new research findings, the precursor to elucidating cause and generating treatments and cures.
The by-product of fine-tuning the classification manuals is a change in disorder prevalence rates. Old classification manuals stated that all children with autism had a learning difficulty, this was found not to be true and newer classifications reflect this. Older classifications state that autism is largely a disorder that only affects boys; newer classifications describe what symptoms may look like in girls. In previous classification manuals, it was stated that if a child had ADHD, they could not have autism, this is now known not to be the case and indeed 30%-50% or so of children with autism have ADHD. New classifications allow this diagnosis to be made. Thus, over the years, with increased research pointing to a wider distribution of the core symptoms of what “we” scientists and clinicians see as autism, and with each revision of the classification manuals, the description of “an autistic child/ person” has changed vastly. An intelligent, inattentive girl with core features of autism, diagnosed with autism today would not have received a diagnosis even 50 years ago, and I am pretty sure that our current classification will not be the last revision.
Some might call this changing boundary of diagnosis pharma and clinical collusion to “medicalise natural variation”; but as I mentioned previously, I prefer to see it as a scientific journey we are halfway/ dare-I-even-believe three quarters of the way through, towards an understanding of aetiology and generation of treatment and cure. Who knows, when aetiology is found, the boundaries may yet shrink back.
The conclusion to the journey may not be far off. Whilst geneticists are relying on better patient classifications to do genetic studies on, neurophysicists are relying on better patient classifications to do neuroimaging and functional neuroimaging studies on. We are already almost at the stage where a computer can accurately predict if a person has autism or not based on their brain scan (Ecker 2010). It may be within my life-time (my grandpa lived to 104 years so I have an optimistic life-expectancy) that the diagnostic classification manuals can be ditched for a brain scan or set of genetic tests; just as has already happened in the case of brain tumour or Down’s syndrome.
Raising awareness of health conditions is a great thing. Many people have benefitted from the increased awareness of autism over the last 10 – 20 years. Autism is a condition that babies are born with and that they will grow and live with life-long. There is no current treatment for the core symptoms, let alone a cure, but the correct support for the child, family and school, can have a significant impact on outcomes. Improving awareness encourages people to come forward for assessment and diagnosis and access support; improving awareness leads to requests for more and better services; improving awareness leads to higher profile and political will to spend on autism; improving awareness leads to better acceptance and understanding of people with autism. I can say nothing but good things about raising the profile and awareness of autism. In 1988 when Rainman was first released, I had never heard of autism. I think if a film about autism was released now, the majority of people would have heard of the condition. Without a doubt, the number of families seeking autism assessments for their children has increased, and this can only mean increases in diagnostic rates.
An epiphenomenon to improving awareness that has also contributed to increased prevalence rates is due to what can be discretely called “diagnostic inflation”; or what can be better understood as “overdiagnosis” or “misdiagnosis”. It is an unpopular but real notion. It is one thing to “raise awareness” of autism, but it is another to educate about autism. I think if I surveyed a group of 100 parents, they would all have heard of autism but I think that only a handful of the 100 parents surveyed would be able to give a passable definition of the core symptoms of autism.
Why stop at parents? Teachers, GPs, paediatricians, child psychologists and child psychiatrists, especially those that trained ten or twenty years ago when autism was relatively unknown and unsexy may not be up-to-date on autism and certainly many fewer will have completed and maintained specialist training on autism diagnosis. Couple this with the improved awareness from parents of the diagnosis and the political will to allow access to substantial resources (welfare and educational) only for a diagnosis of autism and you have a system that will favour increased diagnosis.
I think that now that the job on awareness has been done, we need to work harder on the education front.
Has there been any real increase in autism at all?
This was the topic of discussion at the last Royal College of Psychiatry conference I went to. The consensus was that there was, but that this real increase was much less dramatic than the increase accounted for by classification changes and increased awareness. Many studies have focused on insults in pregnancy and environmental toxins. The research on these has yielded minor or inconsistent results, certainly nothing that alone would account for the real rise seen. The only factor that was given significant credibility was that of the increased age of the mother AND FATHER of autistic children.
Whilst awareness of the effects of maternal age on children’s outcome has been well-publicised (increased risk of Down’s syndrome as one well-known example), the risks of older dads has been less so. Yet, paternal age has long been established as a risk factor for schizophrenia (Malaspina 2001), and there is now emerging evidence for association of paternal as well as maternal age with autism (Reichenberg 2006; Durkin 2008; Sandin 2012).
It is ironic that many people sought to blame a vaccine for increasing levels of autism, in some instances sparking fears of a real epidemic (of measles), when in fact, like so many other health problems, the cause may prove to be within our own life-styles.
Ecker C, Marquand A, Mourão-Miranda J, Johnston P, Daly EM, Brammer MJ, Maltezos S, Murphy CM, Robertson D, Williams SC, Murphy DG. (2010 ) Describing the brain in autism in five dimensions–magnetic resonance imaging-assisted diagnosis of autism spectrum disorder using a multiparameter classification approach. Journal of Neuroscience. 11;30(32):10612-23.
Malaspina D, Harlap S, Fennig S, Heiman D, Nahon D, Feldman D, Susser ES. (2001) Advancing paternal age and the risk of schizophrenia. Archives of General Psychiatry, 58(4):361-7.
Reichenberg A, Gross R, Weiser M, Bresnahan M, Silverman J, Harlap S, Rabinowitz J, Shulman C, Malaspina D, Lubin G, Knobler HY, Davidson M, Susser E. (2006) Advancing paternal age and autism. Archives of General Psychiatry. 63(9):1026-32.
Sandin S, Hultman CM, Kolevzon A, Gross R, MacCabe JH, Reichenberg A. (2012) Advancing maternal age is associated with increasing risk for autism: a review and meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry. 51(5):477-486.
Durkin MS, Maenner MJ, Newschaffer CJ, Lee LC, Cunniff CM, Daniels JL, Kirby RS, Leavitt L, Miller L, Zahorodny W, Schieve LA. (2008) Advanced parental age and the risk of autism spectrum disorder. American Journal of Epidemiology. 168(11):1268-76.
I know, I know, it’s so cliché. Another Chinese nerd banging on about boring maths. Believe me; I have fought hard to escape this stereotype. Banker and I didn’t get off to a good start as when we first met as students he guessed that I was a maths student. Maths meant to me geeky Asian with no social skills, so I wasn’t much impressed.
However, now as an adult in the working world I am thankful for my maths skills and am only regretful that they are not better. As a mother, I positively lament the lack of emphasis on maths in the infant school curriculum and I think that this is of detriment to our children and indeed our country. Britain has produced some of the world’s best scientists, engineers and economists so it is not for want of genetic stock or tradition. Yet why does the Far East continue to dominate the international student abilities (Pisa Test) League tables for maths and science? Nosing around Russell Group Universities, I found a higher proportion of Asians lurking in the corridors of Maths, Engineering and Science departments than in the Humanities departments. Why?
From my own up-bringing which I may be erroneously extrapolating to the rest of Asia, education is extremely highly valued. Within that, maths and science is valued above other subjects. So much so that my parents dictated to my sisters and me that we had to limit our A-Levels to 3 of: Maths, Physics, Biology and Chemistry. Despite having achieved better marks in Art and History at GCSE than science, I was to be a scientist. Mad and maddening maybe, but my parents had seen a national focus on science, maths and engineering education allow their country (Taiwan) to gain economic wealth, and unprecedented development within their lifetime. On the backs of engineers, Taiwan is now a developed country and a world player in technology, despite being the size of Wales and having started in the 1940s from a much more disadvantaged base.
From a cultural origin of mathematical reverence it is quite bizarre to experience the irreverence to maths in the UK. Whilst an engineer is admired in the Far East, they are depicted as “Anoraks” in the UK. Whilst maths is a subject that both boys and girls are expected to excel in, maths in the UK is for boys, and even then – just for the boys who are born with “that logical, mathematical mind”. Whilst inability to do mental arithmetic is associated with derision and sympathy in the Far East, it is expected, sometimes even boasted about in the UK. I was shocked to find that many fellow well-educated mums were openly admitting that they would struggle to help their children with 11+ maths revision. The reason they were openly admitting this was because they were somewhat proud and not the least bit ashamed to be weak at maths, whereas I doubt anyone would openly admit to struggling to read or write at the level of an 11 year old. This would be regarded as shameful. It has become socially acceptable among the well-educated to be bad at maths. Surely this should not be?
Whilst reading is heavily pushed in infant schools, maths seems to be relatively neglected. In the UK reading and debating is cool. Law and politics is aspirational. PPE at Oxford is the Holy Grail. I have no problem with that, but why does it have to be at the detriment of maths and science? If we are a country that believes that children should be allowed to flourish and become what they want to be, doesn’t this include parity of encouragement for numeracy and literacy so that there is a level playing field of areas within which to flourish?
From a basis of low National aspiration in mathematical ability, it is no wonder that Banker states that the majority of banks are recruiting their quantitative skills staff from Asia. These skills are so sought after that my sister (who possesses a maths PhD) had no problem acquiring a highly paid job within 2 weeks of arriving back from the USA after deciding to return to the UK to be a more present Auntie. I am sure she would have found it harder to find a highly paid job had her PhD been in English Literature/ Greek Philosophy/ Viking History. At the population level one wonders whether the average Joe and Joan Blogs could calculate their expected monthly increase in mortgage repayment if the Bank of England were to increase interest rates by .5%. Yet these sorts of calculations are vitally important to keep roofs over heads and food in mouths. Maths is a vital and sought after skill, why are we not investing in it at the very grass roots?
Probably it is because the people in power don’t value or understand maths and science. Shockingly only 1 MP out of 650 has a background as a primary science worker as reported by The Guardian, and headlines of “Only scientist in Commons alarmed at MPs ignorance [about science]” in The Independent say it all. Only 70 out of 650 MPs are even registered as having “an interest” in science at all (reference here). That’s probably less than the number of MPs who are actively writing history books alongside their Parliamentary careers. I am a great supporter of the arts, but am also a strong believer that the basic level of maths and science needs to be raised and society can change this. As a social observer I see that a culture that values maths produces a society with strong mathematical ability. As a psychiatrist I know that “intelligence” is more likely to have a uniform rather than varied profile (so most children who are good at English should be as good at maths). Children with a varied profile are more likely to encounter difficulty and see a Child Psychiatrist, but over the general population they are a minority. As a researcher in behavioural genetics, I know that “g” (geneticist’s annotation for genetic “intelligence”) is generalist meaning that it applies across the board for all areas of intelligence and children who are genetically advantaged in English are also genetically advantaged in maths. Specialism or differentiation on the other hand is environmentally mediated (Kovas et al 2007). This means that in general, whether an intelligent child chooses to specialize in maths or English is due to its environment (parents, school, society); and even more crucially, where a child performs well in English but does less well in maths, this is also due to the environment (parent, school, society).
Back in the Shrink household. Big Sis’s state primary school pushes reading. So they should. All parents are expected to read with their children every night. The school challenged Big Sis at reading so much so that in Reception she was given “chapter books” to take home for her to read to me. At 5 and a half she was expected to read books containing the word “obsessed”. She could read the word but had no clue what it meant nor was she able to understand it when I tried to explain it to her. Big Sis began to hate reading and cried every night when I asked her to read to me. I persisted in thinking “if her teacher has given her this book, she must be capable of reading it”. After a few weeks of this, I gave up and thankfully went with my own judgement that these books were frankly too hard. I must be the only “Chinese Tiger Parent” to have written to the class teacher to say “Excuse me, but I think that you are over-estimating my child’s ability, can you put her reading books down 3 levels please”. At the same time, while we parents were expected to battle to help children achieve advanced literacy, there was no expectation on us to do any numeracy with our children regularly. I don’t blame the school (it’s a great school), it’s not in the National Curriculum, no state school that I know in the UK encourages numeracy in this way, but I am pretty sure it happens in the Far East.
When I received Big Sis’s report card from Reception, she achieved “exceeding” scores in literacy but achieved “expected” scores for maths. My initial response was “How is this possible? She comes from a family of scientists and mathematicians! Maths is a family tradition.” Truth be told, I would have been happier with “expected” scores for literacy. To make matters worse, when I asked Big Sis if she was struggling with maths, she said “Maths is too hard. Maths is for boys”!
Rather than accept that “maths is hard, and she has not been born with a mathematical mind (she is a girl after all)” I set about setting Big Sis a few counting and maths problems every morning, to balance the reading that was set by the school every night. My view was that of course Big Sis’s literacy was better than her numeracy – I was required by the school to support her literacy on a daily basis but not required at all to support her numeracy. Since then, Big Sis’s maths has come along and she was rated of equal ability in maths and literacy by the end of Year 1. She will now confidently say “I am good at maths”, and attempt maths problems rather than avoid them. The solution was so simple, yet why are schools not breaking down maths to simple parts and pushing numeracy in line with literacy from reception? I’m not talking about solving quadratic equations, but if children are encouraged to count and add sweets/ pocket money/ count the number of days until Christmas etc. daily from a young age, does this not take the “difficulty” stigma out of maths?
I have found that the majority of children enjoy doing the things that they are good at. Some children are naturally good at certain things (Lil Bro is maths minded and will seek out for himself mathematical problems; he was a voracious consumer of jigsaws), however this is rarer and the majority of children become good at things. Once a child is good at something, then they will invest in doing these things and become even better at them. By the time that the National Curriculum suggests that children start doing the core of maths, their expertise and skill in literacy is far ahead of their mathematical ability. At one stage Big Sis was reading Roald Dahl’s “Fantastic Mr Fox” at school but did not know what 2 x 2 was- to me this seems completely unbalanced. Literacy and English become the favoured subjects and maths will be relatively challenging and therefore more unloved. The opportunity to sell maths to children is hijacked by literacy being given the advantage of earlier exposure and active encouragement. In the Far East, 5-6 year old children will learn their times tables up to 12 by rote. Before you utter “We in the UK are not rote learners”, think about the reception classes up and down the land chanting their jolly phonics sounds “igh, igh, igh”; “Ph”, “Ph”, “Ph”; “ee”, “ee”, “ee”; “ai”, “ai”, “ai”. This is rote learning as who could fathom that “igh” is pronounced “i”?? Once the connections are entrenched by rote learning, it is possible to learn about the Latin and Greek from which words are derived, in the same way the meaning of relationships between numbers can be learnt. The rote learning gets you started.
I am pretty sure that had I not taken action to support Big Sis’s maths in the same way that I was required to support her literacy that Big Sis would not now confidently declare that she was “good at maths”. Without a sound understanding of maths, the enjoyment of the sciences would be in jeopardy. Isn’t it time that we put numeracy on equal footing to literacy in early years education, as only then can we really say that we are allowing our children equal opportunity to select for themselves their strengths be it science or the humanities?
The Genetic and Environmental Origins of Learning Abilities and Disabilities in the Early School Years. Yulia Kovas, Claire Haworth, Philip Dale & Robert Plomin. Monographs of the Society for Research in Child Development, Serial no.288, vol 72, no.3, 2007.
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. 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 (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.
 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.
 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.