Tag Archives: parenting behaviour

Looking after kids: it’s lovely but is it work?

Last week, I sent this tweet:

My wife had gone on a well-earned break for the day with a friend, leaving me in sole charge of our two-year old son and five-month old daughter.

We spent the morning around the house, slowly getting dressed, fed, washed and dressed again (we have a five-month old, remember). Finally, blessed with some gorgeous weather, we made it to the local park in the afternoon, before back for tea, bath and bed. Phew!

My point, squeezed into a snippy 140 characters, was in reaction to those who can be heard saying something like: “I put earplugs in/don’t do the night feeds/need lie-ins at the weekend (*recycle as appropriate) because I’m the one who has to go to work.”

I’ve certainly heard it. In my experience, always from men, many of whom I’m fond of and respect. I assume that when it is said, it’s usually from men, given the societal bias for women to take the extended parental leave, though I’m relying mostly on anecdote and supposition.

But, as I was changing the fourth nappy (diaper, my American friends) of the day with a two-year old playing ‘horsey’ on my back, I thought: “this feels on awful lot like work”. And at my office, I can make regular cups of tea, zone out for five minutes to check the news/Twitter and (usually) go the toilet when I want. I would like to see the bladder infection rates amongst parents, because I find myself ‘holding it in’ an awful lot.

From Men’s Health News

Don’t get me wrong, I had a lovely day and adore spending time with my kids. But it is hard graft.

Which is why this attitude really grates. My wife, who is currently on her second period of maternity leave, looks after the kids for the five working days, with our two-year old being at nursery school (preschool, my American friends) a couple of mornings the only partial respite. I did it for one day and felt the pinch.

But as Ian Curtis sang, routine bites hard. Day after day, going through those endless cycles of nappies, changes of clothes, feeding, shushing to sleep, is draining. And when you’re drained, doing it all over again sets up a tiring negative feedback loop.

This becomes even more acute when one considers that stress and lack of support can increase the risk of post-natal depression. Even without leading to such extreme consequences, it is beneficial for a child’s development for the parents to be less stressed. In fact, one study showed that minor daily hassles, which all mothers experienced regardless of background or family set-up, were related to more child behaviour problems, less satisfied parenting and poorer functional family status. The study also emphasised maternal emotional support, either from friends, communities or partners, as an important buffer from these adverse effects and to maintain mothers’ psychological well-being. I can’t even begin to imagine what it’s like to be a single parent, but find my anger rising as society moves to remove support for this group.

Again, I should say, we both get so much joy from looking after them and wouldn’t change them for the world. But it IS hard graft, and is why my wife’s break was more than fully earned.

Obviously, everyone’s situation is different. Many, many partners who ‘go to work’ are committed to helping a stay-at-home partner in the evenings and at weekends. Many people’s work is also incredibly demanding and stressful (more than mine), and this post is not a prescription of what ‘working’ parents ought to do, as it will depend hugely on circumstances.

But if you find yourself justifying an act with, “well I’m the one that works”, then you may want to have a second think.

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How to engage a baby

When you share a laugh with your baby, it can be one the warmest feelings as a parent. But is this a genuine mutual exchange, and how does it come about?

This is a video of what is now a classic experiment in developmental psychology. It shows a mother happily engaging face-to-face with an equally happy baby. The mother then ceases all facial engagement – the “still face” – to which the baby reacts by trying, with all its might, to reestablish the happy interactions. It’s quite a marked and powerful effect:

A historical review of the experiment quotes the researchers who first documented the effect:

“the infant first “orients toward the mother” and “greets her expectantly.” But then, when the mother “fails to respond appropriately,” the infant …

… rapidly sobers and grows wary. He makes repeated attempts to get the interaction into its usual reciprocal pattern. When these attempts fail, the infant withdraws [and] orients his face and body away from his mother with a withdrawn, hopeless facial expression.”

The experiment, in this form, was first presented at a scientific conference in 1975, but it wasn’t the first to document what happened when infants are exposed to varying social interactions. It was, however, the first to use “then-novel videotape technology” on the conference hall’s big screen. Adamson and Frick, in their historical review, suggest that the  immediate and dramatic illustration of the phenomenon contributed to the broad interest this experiment gained. An early lesson in the power of ‘modern’ technology for effective science communication and to maximise research impact.

This may all seem a little obvious to some parents. You may feel that you don’t need a psychologist with a video camera to tell you that a baby is happiest when you are engaging them face-to-face. But there are a number of reasons why the methodical description of this effect has had profound and lasting influence.  

What this experiment first showed, by deliberately manipulating the parent’s engagement, was that the baby is an active player in this exchange. The infant’s social behaviours can influence the parent’s level of engagement, just as the parent can influence the baby, and it can subtly alter these depending on the context. It’s not simply the parent reacting to the baby’s randomly generated cues. It has even been detected in babies as young as a few weeks old.

As Jason Goldman at The Thoughtful Animal says:

“The still face experiment demonstrated that very young infants already have several basic building blocks of social cognition in place. It suggested that they have some sense of the relationship between facial expression and emotion, that they have some primitive social understanding, and that they are able to regulate their own affect and attention to some extent. The infants’ attempts to re-engage with their caregivers also suggest that they are able to plan and execute simple goal-directed behaviors.”

But one reason why this experiment has been so important and enduring is that it provided a standard and reproducible way of measuring children’s social emotional development.

By using the same set-up time-and-time again, it has shown how a child’s social and emotional development becomes richer as they grow older. The response becomes increasingly complex with age, and can include deftly timed facial cues, dampened smiles, sideways glances at their parent and yawns. Adamson and Frick cite a lovely example for the original set of experiments in which a five-month old boy, upon encountering a still face, stopped being wary and…

“…looked at the mother and laughed briefly. After this brief tense laugh, he paused, looked at her soberly, and then laughed again, loud and long, throwing his head back as he did so. At this point, the mother became unable to maintain an unresponsive still face.”

An experience I’m sure many a parent can relate to when – armed with a stern face – they try earnestly to tell off their child, only to be met with a cheeky grin or giggle!

The experiment has also allowed researchers to deconstruct these parent-baby social interactions into visual, auditory and tactile components. Vision and hearing, it seems, is especially important as children get older, but touch can be enough to, at least partially, lessen an infant’s anxiety when confronted with a still face.

Nevertheless, a still face is usually enough to produce the basic negative reaction in a child, even if it’s in response to their mother, father, a stranger or someone on television. Children make a distinction, however, for inanimate objects, even if they appear quite human-like, demonstrating their ability to form genuine social relationships.

This experimental set-up has also revealed possible negative consequences of a parent’s still face. According to Adamson and Frick, children actually show a more dramatic reaction to a still face than to a brief period of separation or to situations in which the parent interrupts interactions to talk to a researcher. Babies assimilate and react to a negative social cue, rather than simply becoming distressed at the lack of stimulation.

The “still face” experiment has shown its use in further understanding various developmental disorders, such as Down’s syndrome, deafness and autism, as well the effects of environmental conditions like infants exposed to cocaine prenatally or to depressed mothers.

The still face experiment has been used to ask questions about how early social and emotional engagement may affect later behaviour. The strength of an infant’s still face effect has been linked to their mother’s normal sensitivity and interactive style, and it may predict the degree of later infant attachment, depression or anxiety, and even behavioural problems.

Clearly, parents who may have a lower level of engagement, such as those experiencing postpartum depression, should not be guilt-tripped, especially as this could have an exacerbating effect. But the still face experiment has shown that simple procedures can help in these situations – depressed mothers who are encouraged to provide more touch stimulation are often able to offset the lack of visual or auditory engagement to bring about more positive social interations.

As Ed Tronick – one of the original researchers of the “still face” experiment – says on his website:

“An infant’s exposure to “good, bad, and ugly” interactions with the mother, as repeatedly communicated by her facial expressions or lack of expression (i.e., a still-face) has long-term consequences for the infant’s confidence and curiosity, or social emotional development, with which to experience and engage the world.

Though let’s not forget the role of fathers, or other partners, either.

[Thanks to mum-in-law Jenny (once again) for the video and @matthewcobb for the Adamson and Frick article]

Should babies watch TV?

This question seems to trouble many parents, and can cause a lot of guilt too.

“Will the TV numb my baby’s brain?”

“Are they destined for a sedentary life?”

“AM I CONDEMNING THEM TO LIFE AS A MINDLESS AUTOMATON?!”

This is why an interview last week with psychologist Annette Karmiloff-Smith on the BBC’s The Life Scientific caught my ear (thanks to a pointer from mum-in-law, Jenny). It’s a fascinating insight into how babies learn to learn, and how their brains develop to understand the world around them. You can listen here: The Life Scientific.

But on TV watching, Prof Karmiloff-Smith, an expert in developmental disorders, argues that if the subject matter of the programme is carefully chosen and scientifically based, then the TV can be better for a child’s learning than even a book.

This was largely in response to advice reissued by the American Academy of Pediatrics (AAP) that babies under two shouldn’t watch any TV or DVDs. There are three main concerns: poorer language skills, a negative effect on sleep, and less time spent taking part in other types of unstructured play that are critical for the proper development of mental capabilities.

This is based on a growing body of scientific research. TV/DVD watching is common: in the US at least, by two years old over 90% of children regularly watch TV, spending an average of 1-1.5 hrs a day in front of the box. Very young babies (under 1.5 years old) cannot, however, really understand TV programmes, and are instead mainly attracted by obvious changes like applause or visual surprises.

Children learn new words or actions better when an adult is teaching it to them live, rather than via a television screen, and the worry is that parents talk to their kids less when the TV is on. And a growing number of studies suggest that children who spend longer watching TV/DVDs have delayed language development, at least in the short-term, and may also develop a worse attention span.

A child’s play may also be hindered by the distraction of a TV that’s on in the background, so the AAP advise to turn it off altogether. Many parents also use TV/DVDs as a sleep aid, but there is evidence that bedtime viewing may lead to more disturbed and shorter sleep.

Karmiloff-Smith, on the other hand, argues that we live in a media saturated world and it’s unrealistic to expect parents to shut down all media use. This view has support from some of the evidence cited in AAP report itself. Despite the original recommendation in 1999 that parents should be discouraged from letting their babies watch TV/DVDs, over 90% of them in the US currently do so by the time their child is two years old. What’s more, the average age that TV is introduced is 9 months, so the advice is clearly not striking a loud enough chord.

From my experience, I can certainly appreciate this. The AAP report says that many parents use the TV so that they can have a shower or cook dinner. Absolutely! Even these seemingly mundane activities can feel like an exercise in military-like efficiency when you’re looking after a child. A 10-minute respite when they’re quiet and content gazing at a TV or prodding an iPad can be just too tempting.

It’s also interesting to consider that throughout history many new technologies have been treated with caution. Dr Vaughan Bell, a psychologist based at King’s College London, has highlighted how the printing press, popularisation of the radio, and now the Internet have been damned for ruining kids’ brains.

Karmiloff-Smith goes on to say that, rather than banning TV for babies, TV programmes just need to be made better and based on science developments. For instance, the visual system is attracted by movement, but most kids’ TV programmes have their focus on the centre of screen. Instead, objects and features that come in from the sides, move across screen and encourage the child to interact promotes the active participation that’s good for mental development. For very young babies, moving image media may even have advantages over books, which are static and whose main attraction is the rustling of the pages.

The caveat in this is that Karmiloff-Smith reveals herself to be a scientific consultant to a DVD company that is designing such programmes. This could cause suspicion of a financial conflict of interest. But her honesty and gusto make me suspect that she became a consultant so that she could promote these ideas, rather than the other way around.

She finished the interview by emphasising that parents still need to interact with their children and the TV shouldn’t be used as a babysitter. But we should think more carefully about which types of media can stimulate the visual and auditory systems, so as to help train the attention and memory systems early.

I’ve written before about the various kinds of programmes and the various contexts in which kids can watch TV, which may have different effects on child development. And some of the evidence cited in the AAP report highlights these complexities. The effects on children’s attention, for instance, seem to depend on the programme content and style, with problems seen not when the content is deemed educational but only when it’s geared towards entertainment. And when a parent watches a programme with an infant and talks them through it, the child tends to become more attentive and responsive. The AAP report also points to evidence that watching Sesame Street can have a negative effect on expressive language in children under two. But the same study showed that watching other programmes, such as the North American-based shows Dora the Explorer, Blue’s Clues, Arthur, Clifford, or Dragon Tales, was associated with greater vocabularies and higher expressive language scores. So it appears that not all ‘screen time’ is equal.

The AAP report seems to fall into the trap of treating all TV and DVD viewing as the same:

For the purposes of this policy statement, the term “media” refers to television programs, prerecorded videos, Web-based programming, and DVDs viewed on either traditional or new screen technologies.

Another major limitation of the AAP report is that all of the cited studies are, by necessity, observational. These investigations are good at highlighting whether two factors are associated with each other, but they cannot tell you whether one causes the other. As the report itself asks, are children with poor language skills simply placed in front of the TV more? Are children with shorter attention spans more attracted to screens? Are parents who are less attentive on the whole, more prone to resort to screen time? If so, then turning the TV off would not necessarily lead to more parent-child interactions.

And some results are just contradictory. One study in the US showed that when the mother’s educational status and household income were taken out of the equation, the association between TV viewing and poor language development disappeared. This appears to have been glossed over by the AAP.

So how do I answer my original question?

The AAP are right to caution against a lot of TV for under twos (over four hours a day, say), as this is when the damaging effects are really apparent. But Karmiloff-Smith is also right to say it’s unrealistic to expect no TV at all, and that the right programme in the right environment is fine and potentially beneficial.

And I’ll leave you with this quote in Time from Dr Dimitri Christakis, a paediatrician at Seattle Children’s Hospital:

Ask yourself why you’re having your baby watch TV. If you absolutely need a break to take a shower or make dinner, then the risks are quite low. But if you are doing it because you think it’s actually good for your child’s brain, then you need to rethink that, because there is no evidence of benefit and certainly a risk of harm at high viewing levels.

Is breastfeeding all it’s cracked up to be?

Zoe Williams wrote an intriguing article in The Guardian that challenged some widely held assumptions and beliefs about the benefits of breastfeeding (‘The backlash against breastfeeding’). It did, as you might imagine, generate strong reactions from those who vehemently espouse that “breast is best”. It was written on the back of a recent front cover of Time magazine that caused an even greater furore (‘Are you mom enough’), which championed a form of ‘attachment parenting’ that encouraged breastfeeding until the child is well over one year old.

I did feel that Zoe Williams’ article raised some interesting points, some of which I wanted to address here.

But I also had the strong suspicion that the claims made for [breastfeeding’s] benefits – the higher IQ, the protection against obesity, the superior bonding, the warding off of disease both now and for ever, both for baby and for mother – were mostly bogus. A lot of the reasoning seemed syllogistic (babies born into low-income families end up fatter; low-income mothers breastfeed less than high-income mothers; therefore breastfeeding prevents obesity) or frankly lame.

This relates to the concept I’ve written about before, that correlation does not imply causation. As she quotes Joan B Wolf later in the article: “Breastfeeding cannot be distinguished from the decision to breastfeed, which could represent a more comprehensive commitment to healthy living.”  

While this is true, that is not to say that the researchers who conduct these types of observational studies are not aware of this limitation. It is hard to do interventionist, controlled studies, as you would do in a lab or in randomised controlled trials to test a new medicine. Imagine randomly assigning new mothers to one of two groups – breastfeeding or formula-feeding – and getting them to stick to this regimen so that you can measure the outcomes of the children. Not likely, which is why such interventionist studies have been limited (1 & 2).

So researchers work with the tools available to them. They try to include appropriate comparator groups and make statistical adjustments to account for potential confounding variables. Not perfect by any stretch, but the best available methods.

I knew a lot of mothers who formula fed; they didn’t seem to love their babies less.

Ignoring the submission to anecdote, which is a mortal sin to evidence-based thinkers, a more worthwhile point to address is an argument I’ve often heard that goes approximately: “Well, they say breastfeeding is best, but I formula-fed and my child turned out alright”.

There are two key flaws in this reasoning. One is that by advocating breastfeeding, it is implying that formula-feeding is bad. No. It’s just there’s less chance that any outcomes associated with breastfeeding will also be seen with formula-feeding. The second misconception is that there’s a complete separation, or dichotomy, between the two groups. But here we’re comparing averages of large study groups – there will be huge amounts of variability around the averages and a lot of overlap, and only the right statistical analyses can reveal any true differences.

Put simply, there will be mothers of formula-fed babies who form strong attachments (to carry on the example in the article) and mothers of breastfed babies who do not.

By analogy, there will be some people that do all the ‘right’ things – not smoke, eat healthily, exercise, apply sun cream – who will get cancer and there will those who smoke 40-a-day and drink to excess who do not. It doesn’t disprove the link, it’s all about stacking the odds in your favour.

(I should clarify that the evidence I’ve seen for superior bonding associated with breastfeeding is somewhat weak, but I referred to it here to address a more general point about the common use anecdotal evidence).

This struck me as a bizarre place to have arrived at; where even to talk about the evidence behind the benefits of one type of infant feeding over another is heretical.

Absolutely correct. We should constantly gather and scrutinise data, and if strong enough evidence emerges that contradicts our prior assertions, then we should be prepared to change our minds. I applaud the fact that this article was written, even if there are bits I wouldn’t necessarily or wholeheartedly go along with, as we should always be ‘talking about the evidence’.

The questioning of the orthodoxy is taken as a direct attack on babies.

[Charlotte Faircloth, sociologist]: “… Everything has got very heated, and very moralised. How you feed your kids is no longer a personal decision. There’s this idea that you can breastfeed your way out of poverty, or if you don’t breastfeed your kid’s going to be fat or have a low IQ…” She pauses. “It’s all got a bit out of hand.”

Williams is right that some breastfeeding advocates are evangelical and overly ideological about breast milk, to the point that some mothers feel over-bearing pressure to breastfeed. As Charlotte Fairclough is quoted, it’s a personal decision. Fairclough also touches on my earlier point that there’s no binary distinction in the outcomes of children who are breastfed and those who are not – breastfeeding doesn’t determine the outcome but may make it more probable (and, if it does, it will certainly still only be one factor amongst many).

Williams then quotes French feminist Elisabeth Badinter:

“when it’s recommended that you breastfeed your child for one year – six months exclusively, with nothing else, day and night, on demand – there are obviously consequences for a couple.”

“There are women for whom breastfeeding is a true pleasure. It’s very good for them and it’s very good for the baby. But to breastfeed a baby if the mother herself doesn’t like it? It’s a catastrophe. The decision to breastfeed is an intimate and private decision. No one should be able to interfere.”

In my mind, this touches on something I have written about before – that to lay down a hard-and-fast prescription for parents to follow is not always straightforward or productive. A more nuanced approach is often required that takes into account the familial circumstances and considers the parents’ well-being as well. It would be no good hectoring parents to follow a particular path, if it leads to a significant worsening of their own physical or mental health, especially if the knock-on effect is a deterioration in family relationships.

It seems highly unlikely that this would allow people to be good parents nor provide a decent environment for the child (a brief look at the scientific literature suggests this assumption isn’t entirely unreasonable, e.g. thisthis and this). It also risks attaching blame to a parent for any perceived character flaw in their child, and guilt-tripping parents in this way seems a counter-productive approach.

The research about ear infections, respiratory disease and diabetes is very mixed. Neither fussiness around new foods nor constipation are classic or very salient markers of good health. The obesity studies are debatable. The weight loss of breastfeeding mothers is taken from a WHO report, based on two interventionist studies in Honduras. It’s nothing like that straightforward: it does use 500 calories a day, but if your appetite increases at the same time, it is amazing how quickly and easily you can pop 500 calories into your mouth. Meanwhile, Wolf points out, no study on maternal cancer has “distinguished the effects of breastfeeding from the behaviour of women who breastfeed”

Again, I agree, it’s not straightforward! But I would, perhaps, strike a more positive tone.

The studies aren’t perfect (Williams also quotes the American Academy of Paediatrics: ‘There are a lot of methodological problems’), but that’s no reason to just give up on evidence altogether. The best available evidence, as far as I can see, is saying that breastfeeding is likely to bring a range of benefits to the child, and possibly some to the mother. A Cochrane Review from 2009 includes many citations that support various benefits of breastfeeding, as well as a discussion of some of the uncertainties.

I also agree that the weight loss data must be taken in context, such as whether you are dealing with developed or developing countries, and some effects, such as iron status, can be achieved through supplementation. So, in some instances, there’s no need to be over-zealous about breastfeeding, as long as adequate healthcare advice is in place.

“The notion of risk [has been] transformed from a dichotomy to a continuum.” It’s no longer a case of “safe” versus “dangerous”; rather, everything carries some risk and you announce your fitness as a parent to the world by interpreting hazards in the most credulous, fervent way. The onus isn’t on the researcher to prove the point any more – the onus is on the parent, or parent-to-be, to prove that they’ll believe the researcher.

I’m not sure this is true and seems an over-generalisation. There’s a huge variety in parental attitudes and some are incredibly questioning, and whether and how this has changed in recent years is uncertain without any data. I think it misrepresents the role of a researcher, too – that the onus is on them to ‘prove a point’. Scientists don’t (or shouldn’t) undertake work to prove already held beliefs, rather they formulate hypotheses and design experiments to support or reject those theories.

There are lots of other points in and around the ones I’ve highlighted, a lot of which veer from my intention to address evidence-based decisions, but I do encourage you to read the whole article for some interesting discussion of feminism and social policy.

I’ll summarise by saying that I would still state that breastfeeding can potentially bring a range of benefits over formula-feeding, because that is where the balance of scientific evidence is, with little or no contrary evidence to dissuade me yet. And this should be reflected in the healthcare advice that is provided. I absolutely agree, though, that foisting this decision on mothers is, at best, unnecessary and, at worst, damaging. Healthcare advice must take context into account.

On a more general point, I welcome any sensible, critical look at the evidence behind claims, as Zoe Williams has done. It’s certainly made me re-evaluate – and in some instances, such as in the link to lowered risk of maternal breast cancer, made me temper – my own standpoint on the benefits of breastfeeding.

A final point, though. It was disappointing that an article that relied so heavily on rejecting or challenging some of the evidence that is used to promote the “breast is best” standpoint, did not once link to any primary research. A few quotes here and there from, no doubt, serious academics, and a link to a book, but nothing that could point the reader to the original research studies.

It is perennial complaint that evidence-based advocates level at popular journalists, so I don’t want to single out this author for special criticism. But it is something that could do with a cultural shift and, perhaps, mainstream commentators will start to follow the examples of their science colleagues.

———————-

Hat-tip to Mum-in-law, Jenny, for The Guardian article.

The influence of early eating habits in children

Our little one, who is now 10 months old, seems to have got his eating sorted after a stubborn start. We started weaning around the World Health Organization’s recommended 6-month mark, using a mix of spoon feeding and baby-led weaning (more on that in later post). Since then, it has seemed apparent that some things have gone down better than others: scrambled eggs, yoghurt, cheese, toast, chicken, bananas and strawberries were all early hits, while broccoli, tomatoes and beef were swiftly rejected.

He seems to have developed an appetite for some foods after a unsure start, such as cucumber, carrot and apple. And this brought to mind a Naked Scientists podcast from a few months ago, which featured an interview with Marion Hetherington, Professor of Biopsychology at the University of Leeds, on children’s appetite and eating behaviour.

The full transcript is available here and the audio is available here. I’ve made a few summary points below, but do check out the full interview.

  • A developing foetus can encounter tastes and odours derived from the mother’s diet and toxins from the environment, and this may affect later food preference.
  • Babies fed with breast milk are exposed to a greater variety of flavours than are formula-fed babies, and this can mean they are more willing to try new tastes.
  • Babies are primed to accept sweet tastes from birth, whereas bitter tastes are rejected. This means that we have to learn to like bitter foods but not sugary foods.
  • Parents may need to try their baby 8-10 times with a new flavour before the child will accept it, so parents shouldn’t give up after the usual 2-3 times. Also, there may be a sensitive period between 6-9 months in which to introduce new flavours and textures, after which it becomes harder for the child to accept a new food.
  • If a child of school age is fussy about trying new foods, then using rewards and social praise is an effective way of persuading them to test new tastes.
  • Setting healthy eating preferences early on is best to keep healthy eating going into childhood. Even if eating habits go awry in teenage years, many return to their early healthy eating habits as adults.

I thought this raised some interesting points, such as the persistance needed to introduce new tastes during a sensitive time window, and was worth highlighting.

It’d be interesting to know how these environmental factors interact with genetically influenced preferences, such as whether early exposure to broccoli, sprouts or cabbage can moderate the repulsion certain people have towards a compound in those foods. It has been suggested that ageing, smoking or illness may modify this genetically based food preference, and so it would be intriguing to know whether child eating behaviour did so too.

Demanding babies and fraught mothers

There was quite a bit of coverage at the end last week about a report published by Essex and Oxford-based researchers that looked at the effects of on-demand feeding versus scheduled feeding. The researchers analysed just over 10,000 thousand babies born in the 1990s and checked whether babies fed in a particular way at 8 weeks and 33 months achieved better academic results later in their lives and whether the well-being of the mothers was affected.

The authors of the study reported an association between being fed on-demand as a baby and higher IQ scores at 8 years and better SATs exam scores at 5, 7, 11 and 14 years. This held true for breastfed and bottle-fed babies. Another effect they uncovered was that mothers who fed on-demand reported lower confidence, higher fretfulness and worse sleep patterns.

Photo by Anton Nossik*

Now I’ve mentioned quite a few times the mantra that “correlation does not imply causation”, and so my immediate reaction to seeing this in The Guardian was ‘here we go again’. Journalists often overlook the limitations of correlative studies in favour of neat and tidy story – after all, “this behaviour causes this effect” has a bit more punch than “this behaviour is associated with this outcome, but it may be acting through a third or multiple independent variable(s)”.

For an entertaining and revealing example of this issue, I would recommend reading stand-up mathematician Matt Parker’s ‘mobile phone masts cause increase in birth rates’ hoax story.

My first thought when my wife told me about this story was that, rather than on-demand feeding directly causing the higher IQ scores, it could equally be that a third factor was at play. As a speculative example, it could be that an attentive personality primes a mother to feed on-demand and also, independently, to spend more time with their child on educational development. This is an important distinction because it would mean that mothers wouldn’t be able to improve their child’s academic chances by feeding on-demand, rather they would have to pay more attention to educational development.

The authors were well aware of possible confounders and tried to take into account other differences between the groups to narrow down the possibilities as much as possible. This involved adjusting for family income, the education level of the parents, different parenting styles, the age and sex of children, and general maternal health. After all this, there was still a significant difference – children who were fed on-demand as babies had, on average, IQ scores 4 points better than children who were fed to a schedule.

This study has an advantage over many other correlative studies in that a third group presented itself – mothers who wanted to feed to a schedule but were unable to and so fed on-demand, i.e. they wanted to be in one group (scheduled feeding) but ended up as if they were in the other group (on-demand feeding). Crucially, the children in this third group achieved the same elevated academic achievement as seen in the other on-demand group.

Photo by Tom Carmony**

This meant that the authors were able to suggest that the improved academic outcomes weren’t due to having the type of mother who wishes to feed to a schedule, but that they were due to the actual act of being fed on-demand. This relies on an assumption that the mothers in the scheduled feeding group and the attempted scheduled feeding group had similar characteristics, and would therefore have similar approaches in other ways that may affect educational development. This may not be entirely true as other, more subtle differences could exist between these groups, but it’s a tantalising result that merits further investigation. I guess measuring the amount of time spent with the child on learning and development would be something at which to look.

There will still be other factors at play and it is still essentially a correlation, but it starts to narrow down the possibilites. The authors themselves admit the limitations in their study, with the lead author Dr Maria Iacovou telling Science Daily:

“At this stage, we must be very cautious about claiming a causal link between feeding patterns and IQ. We cannot definitively say why these differences occur, although we do have a range of hypotheses. This is the first study to explore this area and more research is needed to understand the processes involved.”

Dr Iacovou was also fairly even-handed on Channel 4 news, rightly highlighting that we still don’t know the mechanism for the observed effects and this is really the first step in establishing a causal relationship.

The final thing to note about the study, is that it was gratifying that the researchers looked at both sides of the issue – the outcomes for the baby (IQ, academic achievement) and the mother (well-being indicators). I’ve written before about the importance of looking at all knock-on effects, as it can be counter-productive to focus solely on the baby if it means a serious detrimental effect on the mother’s mental health.

If on-demand feeding really does drive academic development, then implementing a healthcare strategy to encourage this must take into account the negative impact this may have on the mother and include an appropriate support mechanism. Otherwise, the effectiveness of the intervention will be limited, as mothers will be more likely to give up in favour of a reassuring routine.

As Dr Iacovou said, “mothers are people too”.

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Hat-tip to mum-in-law Jenny who sent me this story.

*CC licence: http://creativecommons.org/licenses/by/3.0/deed.en

**CC licence: http://creativecommons.org/licenses/by-nc-nd/2.0/deed.en_GB

On the social environment

I was brought to thinking about child development and the influence of early parental nurturing after watching a lively exchange on BBC’s Newsnight between the clinical psychologist, Oliver James, and Dr Ellie Lee, a lecturer in social policy at the University of Kent.*

From what I could see, the intense antagonism (aside from James’ unwavering dogmatism) was partly the result of a difference between a purely clinical look at child development, by which controlled scientific studies are held up to encourage the need for early intervention, and the sociological implementation of these ideas, which can introduce many variables to successful intervention.

For instance, showing that supportive parenting behaviours can lead to improved mental and language abilities in infants is one thing (as James would point out), but how you successfully communicate that to parents and change behaviour, is another (as Lee might counter). To lay down a hard-and-fast prescription for parents to follow, without layering burden upon burden, is not always straightforward. A more nuanced approach is required, as appreciated in the Early Intervention report featured in the Newsnight item.

Oliver James, in particular, seems very disposed to attach blame to a parent for any perceived character flaw in their child, and guilt-tripping parents in this way seems an overly blunt approach. And this is the point that Dr Lee may have wished to explain more explicitly.

It seems to me, albeit speculatively, that the parent’s well-being is an important consideration when encouraging them to follow particular regimens. The current consensus of the scientific community may be that a child should be doing X, Y and Z, but it may also be the case that to achieve this, one or both of the parents would end up dangerously sleep deprived, mentally exhausted and with a strain on their relationship. This would be differentially affected by a person’s physiology, underlying immunity, predisposition to mental illness, and so on. It would also depend fairly heavily on a person’s life – their age, whether they’re a single parent, in proximity to close family, in a high pressured job, etc. All of these considerations temper any absolute assertion of an intervention based on clinical data.

The field of psychosocial research, which seeks to understand the interplay between one’s psychology and their social environment, is an important factor to consider when establishing any health initiative. It would be great to see whether there is any direct evidence related to this in the context of early intervention programmes for parents. A recent special issue in the journal Science, lays out some of the issues facing educational intervention initiatives, including the obstacles faced when moving from scientific research to public policy. The need for a holistic approach is summarised in the introduction:

Early childhood education remains peppered with both opportunities and debate. Continued progress will require new research that bridges traditional disciplines of neuroscience, psychology, sociology, economics, public policy, health, and education.

So whilst the clinical research may show that a particular intervention leads to the absolute best outcomes, it may be that a parent ends up finding a middle ground that still provides a beneficial environment for their child, but also a satisfactory outcome for themselves (a sort of cost-benefit assessment, if you like). It would be no good hectoring parents into following a specific course of action, with no amount of flexibility, if it leads to a significant worsening of their own physical or mental health, especially if the knock-on effect is a deterioration in family relationships. It seems highly unlikely that this would allow people to be good parents nor provide a decent environment for the child (a brief look at the scientific literature suggests this assumption isn’t entirely unreasonable, e.g. this, this and this).

I should emphasise that I do not wish to appear as though I am justifying or accepting of ‘bad behaviour’ of parents. There are clearly things we should all strive to do, things that are a struggle, and this will involve a series of adaptations, compromises and sacrifices.

Why, say, do one in five British adults smoke when we know categorically that is causes lung cancer, heart disease and increased risk of stroke? Worse, why do so many adults still smoke in the presence of children or during pregnancy, when passive smoking can cause the same health problems in children (and more) and parental smoking increases the chances that a child will smoke as an adult? A look at how mothers from disadvantaged backgrounds respond to tobacco control initiatives gives some clues – in short, increasing stigmatisation can be counter-productive.

I would like to think, though, that most, if not all, parents are happy to put their very best efforts in and would never be wilfully neglectful. But the point which seems to emerge is that the results of clinical research should be considered against a backdrop of social and population variances. In the case of early intervention, labelling a child as ‘at risk’ or categorically predicting their development, could be helpful in targeting the right guidance and support to the right people, but should not lead to undue and counter-productive stigmatisation.

So, appreciating that each baby, each parent, each family’s circumstance is different, is very valuable. It is critical, as always, to be guided by the scientific evidence available and make this the basis of any initiative to improve child development, but it may not be possible to then arrive at a ‘one-size-fits-all’ formula, a point similar to that made by Dr Luisa Dillner regarding sleep routine.

In short, it’s complicated. Plus ça change…

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* Better quality video embedded (05/10/2011) – thanks to Denys Andrianjafy.