Photo by Google DeepMind on Unsplash There are countless approaches to try to explain why people think and behave in the ways that they do, and like many Inspire the Mind readers, I have always been interested in this question. As a teenager, I had heard about the ‘nature vs nurture’ debate, where scientists disagree over how much our traits and behaviours are determined by our genes, and how much they are shaped by the environment around us. Of course, the general answer tends to be: it’s a bit of both. But one Thursday morning, sitting in my A level biology class, I learned something that blew my mind. Not only can nature and nurture interact, but how our DNA works can actually be changed as a result of our experiences, via a very clever process called epigenetic modification. This idea fascinated me (and still does!) and discovering it is partly what confirmed to me that I wanted to study psychology; so here I am, having finished my Bachelor’s degree at Oxford University, now doing a Master’s degree in Psychology and Neuroscience of Mind Body Interface  at King’s College London.   What is Epigenetics? This can be a complicated topic, so let’s start with a few definitions. DNA (deoxyribonucleic acid) is the “ molecule that carries genetic information for the development and functioning of an organism ”, whilst a gene  is a section of DNA that provides specific instructions , for example about how to build a particular protein. The field of research that investigates how our behaviours and environment can affect the way our genes work is called epigenetics . Taking a closer look at this word, we can see that ‘epi-’ comes from Greek and means ‘upon’ or ‘near’, whilst ‘genetics’ of course refers to the study of DNA and genes, and how these are passed down to offspring. This breakdown provides a clue as to what we mean when discussing epigenetics: within a cell, our DNA interacts with smaller chemicals that are ‘upon’ or ‘near’ the DNA itself. It is these smaller chemicals that are key for understanding gene-environment interactions . How does it work? So what is actually going on? What do we mean when we say that environmental factors are changing the way our DNA is working? Let me be clear, the content of the DNA itself is not being altered here; the sequence of units that make up our strands of DNA stays the same. (Note: When this sequence is changed, through damage or random error, it is not an epigenetic process but a genetic mutation , and these changes tend to be permanent). In epigenetic modification, it is the (generally reversible) labelling of the DNA that is altered, which determines whether genes are switched 'on' or 'off' Photo by Yves Cedriv Schulze on Unsplash Let’s say that our DNA is an instruction manual, and the genes that it is made up of are paragraphs detailing each of the many things that the cell could potentially build. All of our cells have the same whole instruction manual, but they only need to pay attention to the paragraphs that are relevant to their particular function. For example, cells in the pancreas may need to read the paragraph on how to build the protein insulin, but cells in the skin can (and should) ignore this paragraph, as producing insulin is not their job. The way that these cells know which paragraphs to read, and which to ignore, is through a labelling process. Essentially, an instruction paragraph (i.e. a gene) can be labelled with a sticky marker that indicates whether it should be read, and this helps different cells to perform their different functions. There are a number of ways that genes can be labelled. One way is by adding a chemical called a methyl group, a process which is called DNA methylation  (or demethylation when a methyl group is removed). This type of label essentially tells the cell’s machinery to ignore the methylated gene, i.e. to stop reading the instructions for the particular protein which that gene is responsible for building, and therefore less of that protein gets produced. Photo by Chiara F on Unsplash What environmental factors can affect this process? Our epigenome – the collection of chemical labels determining how our genes are processed – changes massively through adolescence and across our lifespan  as a feature of normal ageing. But it can also be affected by exposure to things in our environment both in the womb and throughout life. This is a huge topic, and these environmental influences span from nutrition and chemical exposure to mental illness, stress and many others. For example, offspring of mothers who were subjected to famine during their pregnancy  show epigenetic changes at several genes with many potential health implications. One of the most affected genes, IL10 (interleukin-10), has been linked to schizophrenia risk , which is consistent with the finding of significantly higher rates of schizophrenia in children conceived at the height of the Dutch 1944/1945 famine. Pre-natal exposure to cigarette smoke has also been linked to epigenetic changes: adolescents whose mothers smoked during pregnancy who had more DNA methylation  at a section of DNA that is part of the BDNF gene (brain-derived neurotrophic factor gene). This is important as epigenetic changes to this gene are proposed as a potential biomarker for Major Depressive Disorder (MDD) . Another well-studied example of how a foetus’ environment in pregnancy can alter their epigenome relates to maternal mental health during pregnancy. Infants of depressed or anxious mothers reliably show epigenetic changes in genes that are important for dealing with stress , neurotransmission  and neuroplasticity , thereby increasing vulnerability to psychopathology. Photo by Omurden Cengiz on Unsplash However, even in the absence of a mental health disorder, our mood and stress levels can shape our epigenome. One example of this relates to the neurotransmitter serotonin, which is implicated in depression. It has been long established that variations in the serotonin transporter gene can make some people more vulnerable to developing depression  following stressful life events. More recent research recognises the crucial role of epigenetic mechanisms (e.g. methylation of the serotonin transporter gene ) in this process. Similarly, some researchers have found that chronic stress is linked to epigenetic changes that reduce the expression of the BDNF gene (mentioned above as being associated with depression risk and sensitive to tobacco smoke, among other environmental factors). This stress-related epigenetic down-regulation of the BDNF gene can persist well into adulthood . However these changes are not necessarily permanent, as shown by the fact that antidepressant medications can act via epigenetic mechanisms to re-establish normal BDNF expression levels following chronic stress. This last point helps to demonstrate why understanding these relationships between our environment, genetics and mental health is so key: these processes can be modifiable and may offer promising targets for therapeutic approaches. However, it is important to emphasise that it is not as simple as identifying and targeting any single gene, epigenetic mechanism, or environmental factor; the interactions between our biology, psychology and the world around us are incredibly complex. Nonetheless, investigating epigenetic mechanisms is one way to get a deeper understanding of how it all ties together to make us who we are.

Learning what the Mother and Baby Unit is like and how do occupational therapists work with mothers and their babies Welcome to the fourth week of our Maternal Mental Health series. This week I wanted to bring you the perspective of professionals in the community that help mothers that are struggling with their mental health. We often think of GPs, psychologists or psychiatrists, but other professionals can complement their work and, as a team, bring mothers back to health and wellbeing. Jenny Shaieb is a senior occupational therapist at the Bethlem Royal Hospital Mother and Baby Unit (MBU). In this inpatient NHS ward, mothers with severe mental illness and their babies are typically admitted together, to maintain the important contact between them even when the mother is not well. I have spent some time as a researcher at the MBU; it is a tranquil one-story building in a very leafy hospital campus, with a nursery, a community kitchen, activity rooms and private rooms for each mother and her baby — very different from what someone might expect from a psychiatric ward. Photo by Kelly Sikkema on Unsplash Can you tell me about your professional journey and why you became an Occupational Therapist (OT)? I left school at 17 and worked as a chef for a while. In my mid-twenties, I went back to college to do my ‘A’ levels and did human biology, fine art and chemistry. My mum was an OT, but she hadn’t returned to work by the time I left home, so I wasn’t aware of what she did. After I spent a day with her work (she was a community-based physical OT), I thought, “yes, this is interesting!”. I wanted my future career to combine arts, creativity and human biology and to have some intrinsic value. I got into OT college and qualified. OTs are all dual-trained, and after my first placement in a community mental health team in Camberwell, I knew I wanted to work in mental health. I started working at the Maudsley in a continuing care team; after a few years, I went to work in the rehabilitation ward. I’d always been interested in the challenges for women with mental health issues and how that affects the children and the rest of the family, so when a job came up at the MBU, I was fortunate enough to get it and have been here for the past 28 years. OTs are trained to use activities to assess and treat people. We look at the person’s usual roles in life, how these may have changed and how they live their day-to-day lives. We look at this from mental health and physical perspective. We also do much hands-on work with people. If you speak to OTs, you’ll often find that we are people who do activities ourselves, so we ‘get’ the importance of activities for balance and satisfaction in life. We are trained in adapting activities and environments so that people can do the activities they want and need to do; working hand-in-hand with the person we support is essential. What kind of activities do you do with the mothers at the MBU? We do baking, cooking meals, running, cycling, creative writing, maternal journaling, and gardening, among other activities. We also use the OT Dept for pottery, textiles, woodwork, drama therapy, music therapy, and other creative activities, as the OT Dept has specialist instructors who can teach these skills. We also use the OT department’s organic kitchen garden, and we have gardens on the ward where we grow produce and spend time outside. We also do 1-to-1 sessions with patients, and home visits (for women that need rehousing or need the situation at home requires assessing). We also go out to the shops and on buses, with women and their babies, usually to improve confidence in taking babies out. Photo by Sebastian Pandelache on Unsplash We involve the babies as much as possible; we are an MBU and getting used to caring for a baby whilst also doing an activity is an essential skill for a parent. We also recognise and promote the importance of women having some ‘me time’. The OT department offers good opportunities for this. Being away from the baby for some periods of time can reinforce to a mother that she is still an individual and that however much she loves her baby, she will need a bit of her own space at times. A structure is helpful for most people, but within that scaffolding, there needs to be a level of flexibility. Hence, we adapt daily activities to the people on the ward whilst also keeping to a general routine. We are a culturally diverse ward, and activities can help make sure that women whose first language is not English feel and are included in what is going on at the ward (we do have regular interpreters as well, though). For all the women on the ward, sharing, teaching and learning about other people’s traditions, foods, art and craftwork can be powerful ways of maintaining and reinforcing the individual’s sense of pride in themselves and their identity. How do you feel the OT programme impacts the treatment of severe mental illness? We meet people for a detailed initial assessment (if the person is well enough to do this). We find out from the person what they feel they need, what things they are worried about or are not confident in, and what they can do. We offer them a structured program of activities that they can use to help reduce the symptoms that they are experiencing; this will be with a level of support that is useful at that point. We always support them, 1-to-1, if they need it. OT activities are graded, and as someone gradually recovers, they will likely need less support and become more independent. People often talk about not being able to realise they are recovering but having concrete evidence of the progress they have made in activities can help the person realise that things are improving. Photo by Valentina Conde on Unsplash Do you have any stories of success stories from previous patients that you would like to share? We had someone who was very confused due to her illness, and she felt she couldn’t concentrate and complete a task. However, she had always been an excellent cook. When this lady cooked on the ward, she regained some confidence and improved her sense of capability; her self-confidence also benefitted from the positive remarks people made when they ate the food she shared with them. We’ve had people experiencing psychosis, and the simple act of watering the garden and talking about the plants gave them a moment of calm in the storm. A while back, we had a lady who had been at the MBU with her first baby and came back with her second. She had been terrified of going to the shops with her baby during her first admission. Together we created a program to overcome this challenge, and the practical side of applying the program gave her evidence that she could do it. When she returned with her second baby, even though she was unwell, going to the shops was not such a source of anxiety for her. Photo by Levi Guzman on Unsplash Thank you for sharing so much with us, Jenny. Is there anything else you would like our readers to know? OTs help people manage the stresses in life and help them find balance and satisfaction in day-to-day living. Looking at how you can do things that fulfil you as a person can improve your perspective on how things are currently and how they may be in the future; this can impact your relationship, baby, family and community. To access the support of a perinatal OT, please talk to your GP or contact Community Mental Health and/or Perinatal Services directly.

Welcome to the fourth week of our Maternal Mental Health series. This week I wanted to bring you the perspective of professionals in the community that help mothers that are struggling with their mental health. In this blog, we speak to Dr Gauri Seth. Dr Gauri is the founder of Brain-Based Connection®, and in the blog, we talk about the work she does with parents to help them strengthen their relationships with their children. Photo by Christina @ wocintechchat.com on Unsplash Tell me more about yourself, your background, and how you’ve come to do this work? My name is Gauri Seth, I am British-born, and my parents are from North India. I studied Medicine in Bristol and have a Bioethics degree in medical law, ethics and philosophy. Along with my clinical work, I did a lot of research. As an integrated academic trainee, I completed my Psychiatry training at the Institute of Psychiatry, Psychology & Neuroscience. I recently sat my final postgraduate exam and am now a member of the Royal College of Psychiatrists. I’ve now stepped out of my clinical training temporarily. Due to the pandemic and childcare responsibilities with three young children, I decided it was time to step out for a short while. I then discovered the world of coaching and started a coaching practice, developing my work as a connection coach. What is a Connection Coach? I should start by talking about my experience working 1-to-1. I have worked in psychiatry and psychotherapy, which is different from being a coach. Coaching focuses on empowering a client to develop strategies from within, therefore requiring an element of baseline resilience. For this reason, my coaching work is not designed to replace therapy or psychiatry support, and in fact, I work with those who are clinically unwell only once they are stable and able to work with me in a solution focussed way to move towards their goals. Coaching provides a confidential, safe space for individuals to talk. As individuals, clients think about goals; coaches are like ‘mirrors’ for the client, and show the client where they are now in relation to their goals. It is a very proactive method that does not focus on the past (like psychotherapy usually does). I am interested in assisting people in connecting with themselves, so they can connect with others by giving them tools they have to keep in their metaphorical toolbox. While coaching has various specialist areas of focus, to my knowledge, ‘Connection Coaching’ for parents is a novel space within coaching. Photo by Tanaphong Toochinda on Unsplash What are the most important “tools” mothers (and the family unit!) should have in the metaphorical toolbox you speak of in the postnatal period? Parenting can be a very self-sacrificing period of life. Parents (mothers and family) need to remember their self-care, try not to strive for perfection, and master the art of flexibility. What do I mean by the art of flexibility? Essentially, many parents want a routine, which can be helpful. At the same time, children are unpredictable (even those with a routine!), and if parents can be flexible when necessary, that can help them deal with the unexpected. Switching perspectives is essential, looking at the world from the child’s perspective. A big tool is also to remember that these are transient stages of life -parenting is the hardest thing I’ve ever done! — but these difficult phases do pass (for example, behaviour issues, and sleeping deprivation). Be patient and communicate openly with the family unit. The power of a tribe (bringing up children with connected caregivers) and accepting/asking for help is so important. Asking for help might be meeting with other parents with children the same age, or the extended family. To sum up, some of the most important tools would be: Be kind to yourself, and make sure you practice self-care Try to master the art of flexibility Understand that it’s okay not to be perfect Understand your child’s perspective Communicate as a family Accept help, and know that it’s okay to ask for help Remember that this is a transient phase of life. What are some of the biggest challenges concerning the mother-child connection when working with mums postpartum? Many themes re-occur. Parents’ state of mind is so important to connect with anybody. Often parents feel guilty; it is very easy to judge themselves or their child — which in turn gets in the way of connection with themselves and the child. I often see parents wanting to be perfect. Sometimes, people who strive for perfection and may in fact be very successful professionally, face specific challenges when they enter the world of parenting — and the drive for perfectionism can get in the way of being consciously connected. Photo by Jordan Whitt on Unsplash How could your work complement the work of someone being followed by an NHS psychiatrist or any other mental health service? As long as it’s very clear that the care that I will provide is not clinical and they are supported in the clinical space by a qualified clinical professional, connection coaching can provide people with holistic support that helps with maintenance work after the clinical work is done. Coaching can be used when someone is well but would like longer-term support for future planning and goals and even prevent relapse into old patterns that do not support their health. The focus is on the quality of interpersonal relationships, which improves the parent-child relationship and impacts the well-being of parents and children. Have you seen changes in the parent-child relationship during the COVID-19 pandemic? The negatives have been stressed in the media enough; I would like to give you a positive perspective. There were some positives of the pandemic on the parent-child relationship. As the pandemic forced families to re-calibrate relationships, some people now have a residual connection forged during the pandemic. There is more of a tribe and more quality time spent in the nuclear and sometimes extended family, which has many long-term benefits for the well-being of individuals and families. Do you have any “success stories” from people you’ve worked with in the past that you can share with us? There was a family I worked with the parents; their child was going through the CAMHS (Child and Adolescent Mental Health Services) pathway (possible attention deficit hyperactivity disorder, ADHD, diagnosis). They got the diagnosis while they were under my coaching. I was working with the parents to help them remain connected with the child; they felt they were being pushed away. With the related parenting techniques, I helped them identify a less judgmental perspective on the relationship and optimise communication with the child. When they worked on that connection, it positively impacted the child’s behaviours and the whole family dynamic. I explained some of the science to them and helped them understand emotional regulation. They also realised the way they were parented as children (transgenerational parenting) and how that influenced how they were parenting their children. In a different case, with a toddler, the parents struggled with tantrums and entitled behaviour — this impacted the parents’ state of mind and was exhausting. They were concerned they were raising a child that would not be compassionate and wouldn’t be able to relate to others. I explained brain development to them, and introduced the concept of neuroplasticity and stages of child development (the world is about them at that stage of development). Parents can be non-judgmental and assist with developing empathy and compassion through things like storytelling, which they apply to their children. The parents were judging themselves, but by helping them recognise how these behaviours of the child are developmentally normal and that we’re not perfect parents, they improved the relationship. Photo by Everton Vila on Unsplash Closing remarks The work that Dr Gauri does on a daily basis is powerful and so important. She highlighted the most important tools parents should have in the perinatal period, which can go a long way when focusing on deepening the connection as a family unit. While the pandemic has resulted in changes in familial relationships, Dr Gauri highlighted a positive change, i.e., it allowed families to re-calibrate their relationships and spend more valuable time with one another. Her success stories with families she worked with portrayed how meaningful fostering connection is and showed us real success stories of parent-child connection coaching. DISCLAIMER: Any information or advice Dr Gauri gives is purely based on her own experience. Comments made are as a coach, this is not medical or psychiatry advice. There is no guarantee as there are many variables that will impact outcomes. Everything stated should be taken as an opinion.

This is the fifth week of our Maternal Mental Health series, which is dedicated to postnatal post-traumatic stress disorder (PTSD). We are publishing two blogs: one by Becky Fisher, sharing her personal experience with postnatal PTSD, and another one by Professor Colin Martin focusing on describing the clinical and scientific perspective of postnatal PTSD. I knew my life would change that week; I was about to become a mum, but I had no idea that the next few days would also take me on a path that I never expected. I’m Becky, mum to two amazing boys. I suffered complications from my first birth and following my recovery, I want to share my story of living with postnatal post-traumatic stress disorder (PTSD), for anyone going through their own recovery journey to know they are not alone, and to help raise awareness of the effects a traumatic birth can have. My birth trauma was 5 years ago, and although I can now say I am in a good place, it didn’t start off that way. Let me take you back to the beginning. My son was born by emergency caesarean section, I had to be put under general anaesthetic so my husband had to leave the room and the last thing I remember was a midwife holding my hand and looking at the hospital light above my head. The next thing I knew of was waking up in the recovery room and being told I had a baby boy. What I would later learn was that he had been born blue in colour and not breathing. A neonatal crash call was made and after a day of intensive care he was on the Special Care Baby Unit where he was treated for sepsis. I was back on the labour ward when I started having breathing difficulties, my oxygen levels were dropping and I was struggling to breath. I was scared of being left alone and had this overwhelming feeling that if I closed my eyes, I wouldn’t open them again. I thought I was going to die. I too was diagnosed and treated for sepsis, and when we were both well enough, we were discharged from the hospital. Image by Milan Popovic on Unsplash Living under a cloud Initially, I had no idea I had any lasting effects from the birth. I was a new mum, and I was learning how to look after my baby. I didn’t know what feelings normal ‘new mum’ feelings were, and I was just getting used to our new family life. That was when the flashbacks started, most of the time they were at night,I would lay down to go to sleep but as soon as I closed my eyes I was back in the hospital room struggling to breath and it felt just as real as when I had been in hospital, even now as I write this I can picture all the details of that room, like its imprinted on my brain. Sometimes there was a trigger that set them off, something as simple as my husband putting the baby down to sleep would take me back to being on the ward and hearing him cry from the special care baby unit and not being with him. It felt like I was re-living the moments over and over. At other times they just seemed to come from nowhere and I didn’t feel like I had any control over them. I just thought, well that must be normal after a difficult birth and tried to ignore the feelings hoping they would go away. I found myself on high alert all the time. I remember a time that my husband and I were walking through town, and even though we were completely safe, I had this intense feeling that we were going to be attacked and that I would have died. It didn’t seem to matter how hard I tried to ignore the feelings they would rise back to the surface, I recall another time where I was out with friends, one of which had just recently had a baby and another friend asked her what it had been like at the moment of the birth. After she had answered the question was put to me which took me by surprise. I didn’t know how to answer, we hadn’t been there for the birth of our baby, my body froze and instead of answering I just got up and left the table. All of those feelings were back, so I did what I thought I needed to do and pushed them away, went back to the table and went on with the rest of the evening. It was a really difficult time, and although I was very lucky to have a wonderful baby boy and was surrounded by loving and supportive family and friends, it was also a lonely place because I didn’t understand why I felt the way I did, and I didn’t have anyone that knew what I was going through. Image by Quang Nguyen Vinh on Pexels Road to recovery As time passed, I knew something wasn’t right — I was still having a difficult time with anxiety and flashbacks, so I started trying lots of different things like grounding techniques, mindfulness and exercise, in the hope that they would make me feel like me again. They did start to improve my anxiety, and at points I felt like I was making some progress, but before I knew it, the flashbacks were back and I was right back at the beginning. At this point a year and a half had passed since my birth trauma and deep down I knew that what I was doing was not enough, but I felt lost and didn’t know what else to do. Then I remembered a leaflet I had been given about our local NHS Talking Therapy Service . I opened and closed the website so many times before I plucked up the courage to send a referral in. It had been nearly 2 years when I was diagnosed with postnatal post-traumatic stress disorder (PTSD) and started the Cognitive Behavioural Therapy (CBT) . It was tough because I had spent all this time trying to push my feelings away, thinking I was helping myself and now I had to bring them all back to the surface. During one of my sessions, it felt like a weight had been lifted and I hadn’t realised the heaviness of living with PTSD until that point. I can still picture myself sitting with the therapist and finally feeling like the trauma was actually a past event, my body was no longer stuck in that moment. Towards the end of my recovery journey, I came across a charity called The Birth Trauma Association and found a community of people who had all suffered birth trauma supporting each other through difficult times. The information I found through the charity really helped me to understand what I had been experiencing and that I wasn’t alone. Image by Joábel Pires on Pexels One step at a time I spent a lot of time searching and trying to make sense of why I felt the way I did, and if that is you now, reading this, I want you to know that it does get easier, and you are not alone. Give yourself time, you’re healing while taking care of your baby and that takes strength, so be proud of yourself. It’s fair to say I’m not the same person anymore, trauma changes you, but so does the healing. I found a new version of myself, a stronger more confident me. The birth trauma will always be there, it’s a part of me, but it no longer has a hold over me.

This is the fifth week of our Maternal Mental Health series, which is dedicated to postnatal post-traumatic stress disorder (PTSD). We are publishing two blogs: one by Becky Fisher, sharing her personal experience with postnatal PTSD, and another one by Professor Colin Martin focusing on describing the clinical and scientific perspective of postnatal PTSD. Photo by Devon Divine on Unsplash Becky’s account of her experience of postpartum post-traumatic stress disorder (PP-PTSD) is shared and conveyed with sincerity, honesty, bravery and with a fundamental insight that many, even seasoned, practitioners find challenging to grasp. This should not though, be a surprise, neither is it a criticism. The presentation of mental health issues in the postnatal period and indeed, over the perinatal period more generally, raises important theoretical and clinical questions about the cause, identification and treatment of mental health problems during a period and context (childbirth) almost universally perceived to be associated with excitement and optimism. However, the reality, as elegantly expressed within Becky’s account , may be altogether different to the widely believed ideal. Certainly, many of the symptoms of PTSD will cause considerable distress and within the context of the postnatal period, additional burden above and beyond that of caring for a new baby. Symptoms of PTSD classically include re-experiencing the traumatic event, through for example ‘flashbacks’ or nightmares, and using strategies to avoid things or circumstances that may remind of the traumatic event. In addition, hyperarousal is frequent, typically exemplified by high anxiety and difficulty in relaxing, and by sleep problems. There are a variety of other symptoms too associated with PTSD. The very positive news is that PTSD is very effectively treated by cognitive behavioural therapy (CBT) , a ‘talking’ therapy, as detailed by Becky. Having the opportunity to do this blog allows me the rare chance to express some views and indeed, even express an opinion, on issues within the perinatal mental health area which are both vexing and sometimes uncomfortable, simply because they sound straightforward to understand and explain but in reality, they are perplexing. Photo by Anthony Tran on Unsplash Perinatal mental health problems are not uncommon and indeed vary widely both in terms of presentation (for example, anxiety, depression) and severity. Mental health problems specific to the period following birth have long been accepted as both a potential issue of concern and moreover, imbued with characteristics of the presentation making them unique in cause, symptom profile and course, compared to similar conditions occurring outside the postnatal period. The most well-established in the clinical literature is postnatal depression ( PND ) , occurring in 12–15% of women postpartum. More recently recognised mental health conditions identified within the perinatal period include tokophobia (fear of childbirth) and PP-PTSD. Interestingly, though more recently recognised, PP-PTSD shares several commonalities in terms of accurately and conceptually defining what the phenomenon is. This has implications for the provision of evidence-based treatment interventions, since these should be based on a coherent model of aetiology (causation). Photo by Greg Rosenke on Unsplash Let me explain. PND remains, despite broad clinical awareness, an enigmatic presentation. There is still no agreed consensus on whether PND is ‘normal’ depression occurring postnatally or a special type of depression specific to the perinatal period. This is not a subtle distinction since the implications in favour of either perspective may influence thinking regarding the most appropriate interventions. One of the most inconvenient questions a clinical researcher may be asked if giving a talk on PND is, why are the rates of PND similar to general population rates of depression? Common sense might dictate that they might be higher if specific to the postpartum period and moreover, if we only screen postnatally, could we actually simply be identifying, in some instances at least, pre-existing depression? It has further been observed that screen positive depression rates during pregnancy are similar to those observed postnatally in some studies. Interestingly, this conundrum also appears salient to PP-PTSD. Irrespective of attitudes, opinions and beliefs about the cause, course and outcome following the onset of PP-PTSD, it has also been observed that PP-PTSD rates are not hugely dissimilar to those observed in the general population. Thus, it is not conclusively known whether PP-PTSD is a specific form of PTSD unique to the postnatal period or whether, in some instances, the individual may have pre-existing PTSD, which is identified through opportunistic screening postpartum. The symptoms described by Becky are undoubtedly those of PTSD and within the narrative clearly related to the causal event/s occurring during and immediately after childbirth. However, consider the case of a woman with previously undiagnosed but pre-existing PTSD screening positive postpartum. In that event, might the assertion be to associate the diagnosis with the most obvious event (childbirth), contextualised within the screening protocol (screening for PP-PTSD)? Moreover, what of the situation where there may be pre-existing PTSD and then PP-PTSD, could this lead to additive effects? The path of evidence-based and effective interventions in relation to the occurrence of perinatal mental health problems is firstly accurate identification. However, we can see, that in relation to PP-PTSD this is by no means a simple undertaking, particularly in terms of differentiating which type of PTSD it may be (childbirth-specific or not). Photo by Robert Anasche on Unsplash Though it may seem fundamental, many studies examining PP-PTSD do not differentiate in terms of screening methodology used between childbirth-specific PTSD and PTSD related to other factors. A large study by Harrison and colleagues (2021) with 16,000 postpartum women recruited in England recently published striking findings related to this issue looking at post-traumatic stress (PTS) using a questionnaire-based PTSD screening tool. Harrison et al. (2021) found a fundamentally different profile of predictors of childbirth-related PTS compared to PTS related to non-childbirth-related factors. They found that those who reported childbirth-related PTS were significantly more likely to report re-experiencing symptoms of PTSD than those who reported PTS related to other factors. Indeed, the ‘smoking gun’ highlighted within the Harrison et al. (2021) study was the observation that PTS occurring during the postpartum period was not only common but often not related to childbirth but to other factors. Importantly, the small number of factors found to be associated with both were anxiety during pregnancy, health problems specifically related to pregnancy, and lower birth satisfaction. Photo by Aditya Romansa on Unsplash Taking this final point and under this rubric, addressing issues of antenatal anxiety, health problems during pregnancy and improving the birth experience and thus birth satisfaction may be highly beneficial in mitigating against the occurrence and severity of PP-PTSD symptoms. In fact, two of these factors precede the birth by a considerable period and strategies to improve the birth experience may be considered in many respects prior to birth also. Within the clinical research field, we clearly, need to understand PP-PTSD to a significantly greater degree than we do to date, through a process of systematic research, with the goal of improving the experience of women following birth, through the prevention (where possible), identification, treatment and enhancing recovery. Work continues apace, for example, the global International Survey of Childbirth-related Trauma (INTERSECT) study , however more can, could and should be done to improve outcomes for women at risk or, or experiencing PP-PTSD.

This is the last blog of our Maternal Mental Health series. For the last six weeks, dear reader, we have discussed the often misrepresented, largely misunderstood world of maternal mental illness. We have published stories from lived experience perspectives and given you the researcher or clinician’s perspective on the topics of perinatal OCD, postpartum psychosis, clinical and community mental health support, and childbirth-related post-traumatic stress disorder, and we will now close with a final interview led by Dr Jodi Pawluski . We hope that this series brings you a greater insight into maternal mental illness and demystifies its prevalence, symptoms, experiences and outcomes for mothers and their families. I recently sat down with Emma Jane Unsworth , a bestselling author and mom of two, to talk about her memoir After the Storm: Postnatal Depression and the Utter Weirdness of New Motherhood (a must-read!), the stigma around maternal mental illness and ways to protect maternal health. (You can listen to our full conversation on my podcast Mommy Brain Revisited #34 ). I’m a neuroscientist, therapist and author who focuses on understanding how the brain changes with the transition to motherhood and perinatal mental illness. I first met Emma when she was writing her memoir After the Storm as she was interested in how the brain changes with motherhood , and we’ve kept in touch ever since. Photo by Abigail Keenan on Unsplash After the Storm Before we get into Emma’s experience overcoming postnatal depression , let’s touch a bit on why she wrote her memoir. “After I had him (her son),” Unsworth says, “I started to feel very unlike myself…. I was furious all the time and at the world. Combined with that rage was an undeniable pressure to be enjoying myself, be grateful, to be doing my job…I wasn’t well, I was ashamed, and to be all these things and not have sleep was too much.” It took months for Emma to reach out for help, but she did. One of the turning points in her recovery process was when her therapist “thought that everything I was describing sounded like a very reasonable response to the pressures of motherhood in the western world. The fact that she could call it reasonable felt so freeing for me and helped me to be kind to myself”. Photo by Christina @ wocintechchat.com on Unsplash Unsworth also wanted to help other women. “No one was talking about this [postnatal depression]. I felt I couldn’t find anything in books that was from a personal point of view, so I thought I want to put something out there about what I’ve been through and what often happens in the early months of motherhood — hard, lonely, dark months — but also make it a resource”. She wrote a piece in the Guardian that went viral, and her book After the Storm followed. Today, two years after we first met, Unsworth has given birth to her second child without even a “whiff” of postnatal depression. The question is, how? How did she prepare and protect her mental health? Birth Choices Emma describes a “horrific birth experience” with her first child, which contributed to postnatal depression , so for her second birth, she planned a caesarean delivery (c-section). “There is no easy way to get a baby out of your body” she says, but she wanted to have some control over the situation. We know that the realities (and often trauma) of birth are important players in maternal mental health, so preparing for birth is an important step. However, it is important to know that birth is often unpredictable. Photo by Krista Mangulsone on Unsplash Sleep is Medicine The lack of sleep “destroys you and destroys your relationship…. it was awful… sleep deprivation was such a big part of my illness that I didn’t want to have that happen again”, Unsworth says. Unsworth saved up and hired a night nanny to ensure that her sleep was protected in the early months postpartum with her second child. We often underestimate the importance of sleep for perinatal mental health , but “You need someone helping you at nighttime so you can recover from this massive thing your body and brain have done.” Definitely. Reconnecting as a Couple Another factor that Unsworth focused on was her relationship with her husband. Emma noted that with their first postnatal experience, “a lot had been destroyed [in their relationship], so we had work to do”. She and her husband went to couples counselling online and were able to talk through their experiences of the birth and postnatal depression, reconnect and communicate, and remember that there was “so much joy as well”. The warped reality of motherhood In her book Unsworth writes that becoming a mom “can’t be this hard or people wouldn’t do it”, but the reality is we don’t talk about how life-changing motherhood can be — the good and the bad — and the fact that it’s not a one person job. Taking care of a baby is a “three-man job”, Emma says (100% yes!) with, ideally, someone cleaning up, someone prepping for the next shift, and someone caring for the baby. Thinking about motherhood this way is key. It’s not a lone venture. It’s something that takes a community - a community that can take many forms. Maybe the community is full of family or friends, maybe it involves paid support, or maybe the Sunday night food delivery person is a member. The point is maternal mental illness happens, but perhaps it would happen less if we talked more about motherhood and how important it is to support new mothers and parents. Photo by Markus Winkler on Unsplash InSPIre the Mind would like to thank Dr Jodi Pawluski and our previous assistant editor Melissa Bujtor for their initiative to demystify severe maternal mental illness and for envisioning this series. If you or someone you know is struggling with a maternal mental illness it’s important to your healthcare provider. For more resources see PANDAS Foundation UK or Postpartum Support International . To learn more about maternal mental illness check out the Maternal Mental Illness Series at InSPIre the Mind and other blogs on maternal bonding , Black maternal health inequality , and journalling for mothers , among others .

Trigger warning:  This article contains mentions of eating disorders which some readers may find distressing. The impact of eating disorders on oral health is well documented, yet it remains an overlooked consequence of these complex mental health conditions. Research consistently shows that individuals with eating disorders often experience significantly poorer oral health than the general population, with an increased risk of dental erosion, tooth decay, gum problems, and dry mouth. Dentists are frequently among the first healthcare professionals to notice physical signs of underlying eating disorders, sometimes even before a patient feels able to disclose their struggles.   As a newly qualified dentist, my clinical experiences have highlighted how eating disorders can significantly affect oral health, prompting me to explore these often under-recognised consequences in greater depth. Image Source: Annie Spratt on Unsplash What Are Eating Disorders? Eating disorders are psychiatric conditions characterised by abnormal eating behaviours and distorted relationships with food. Bulimia nervosa and anorexia nervosa are among the most recognised eating disorders and affect millions of individuals in the UK.   Bulimia nervosa is characterised by cycles of binge eating followed by compensatory behaviours aimed at preventing weight gain, such as self-induced vomiting, abuse of laxatives or diuretics, or fasting. In contrast, anorexia nervosa is defined by persistent restriction of food intake, resulting in significantly low body weight. While traditionally defined by restriction, some individuals with anorexia nervosa may also engage in purging behaviours such as self-stimulated vomiting .   Although these conditions differ in presentation, they both have serious and sometimes overlapping effects on oral health.   Tooth-wear and Acid Erosion One of the most characteristic oral manifestations of eating disorders, particularly in individuals who self-induce vomiting, is dental erosion. Repeated exposure of the teeth to stomach acid gradually erodes enamel (the protective outer layer of the teeth), particularly on the inner surfaces of the upper teeth. This erosion pattern often reflects the path stomach acid takes during vomiting episodes.   As enamel erodes the underlying dentine becomes exposed, resulting in dental hypersensitivities, for example to cold drinks and air. Teeth may also become discoloured, become more fragile and be prone to chipping and structural damage, all of which can negatively affect oral health–related quality of life.   While tooth-wear is more common in bulimia, with individuals being up to four times more likely to show these changes, this pattern is also seen in patients with anorexia nervosa, particularly in those who engage in purging behaviours.   It is important to note that while these dental changes are indicative of eating disorders and should be dealt with accordingly, similar patterns can occur in other conditions, such as acid reflux. Therefore, while dental changes are helpful, dentists should not solely assume someone has an eating disorder based on one appointment, and further sensitive conversations are needed in order to provide support to individuals. Image Source: Shedrack Salami on Unsplash Additional Oral Effects Purging behaviours can also cause trauma to the soft tissue in the mouth due to repeated stimulation of the gag reflex.  Dentists can often recognise this as bruising or injury to the palate (roof of the mouth) during dental check-ups.   In addition, patterns of binge eating which typically involve high-sugar foods can increase the risk of tooth decay. When combined with the acidic environment created by vomiting it can create a particularly harmful environment for teeth. This is because vomiting temporarily lowers the oral pH accelerating the early stages of tooth decay called demineralisation and subsequent erosion. Moreover, mental health challenges associated with eating disorders, such as depression and anxiety, can also impact oral hygiene. Low mood, fatigue, fear of judgement, and diminished motivation can sometimes make daily self-care, including brushing and dental visits, feel overwhelming, which can increase the number of visible dental changes. As oral health deteriorates, individuals may experience feelings of shame which reinforces the secrecy of their eating disorder. The cognitive-interpersonal model of anorexia nervosa highlights these psychological symptoms and demonstrates how low self-esteem, social comparison, and emotional regulation difficulties can perpetuate the illness.   During my early experiences as a dentist I have encountered patients who have confided in me about their history of disordered eating, which has allowed me to recognise the importance of establishing rapport and building trust with patients to help them feel comfortable enough to disclose such information.   It is therefore important for different healthcare professionals to treat patients on an individual basis to help them feel more confident in various areas where they may be struggling.   The Role of Medications While behaviours of disordered eating play a large role in dental hygiene, many individuals are prescribed antidepressant medication, particularly selective serotonin reuptake inhibitors (SSRIs). A common side effect of these medications is dry mouth.   Saliva plays a vital role in protecting oral health by neutralising acids, aiding in remineralisation, and controlling bacterial growth. Reduced saliva flow makes it harder for the mouth to repair early damage, increasing vulnerability to tooth decay and infection.   Dry mouth symptoms are often addressed with advice such as regularly sipping water throughout the day, using saliva substitutes such as over-the-counter gels, or using sugar-free chewing gum to stimulate salivary production. However, this issue is often compounded by malnutrition and dehydration , which can further decrease salivary production, exacerbate the effects of medication, and weaken the body’s natural defence system. As a result, the mouth becomes more vulnerable to disease and it becomes harder for the body to fight oral infections and heal. Image Source: Oscar Ochoa on Unsplash How Dentists Can Support Patients Dentists play a vital role in identifying and supporting individuals who may be struggling with eating disorders. A key first step is understanding a patient’s current oral hygiene routine and providing individualised advice to help improve it.   For patients who purge, practical guidance can help minimise damage. For example, brushing teeth immediately after vomiting should be avoided for at least sixty minutes after vomiting so as not to agitate the stomach acids on their teeth. Instead they could rinse thoroughly with water which may help prevent further erosion to their teeth. Dentists could also prescribe high-fluoride toothpaste to help protect teeth against decay. In addition to daily advice, dentists should make appointments every 3-6 months to monitor any erosive tooth wear .   It may be useful for dentists to start by educating the patient on oral hygiene and the effects of neglecting self-care. This can be done in the same way psychoeducation is used in psychiatric and psychological practices when explaining a diagnosis to the patient.   A Holistic Approach to Care While dentists and medical doctors may seem to be a world away, oral health does not exist in isolation from mental health.   Eating disorders can have profound effects on individuals as they may report reduced quality of life due to tooth pain, functional impairment from erosion or decay, and dissatisfaction with their dental appearance. This can impact them psychosocially as these dental changes may affect their eating, speaking, and smiling, and for individuals already struggling with body image, these changes in dental appearance and possibly smile dissatisfaction may further impact their self-esteem and social confidence .   Patient readiness and shared decision-making must be at the forefront of prevention and management strategies, ensuring that oral health advice is delivered in a supportive, realistic, and patient-centred manner. This highlights how vital it is for psychiatry and mental health professionals to be aware of the dental effects of eating disorders, and even mood disorders such as depression, to promote oral health.

Play is a very serious activity for children, and is, as the Italian physician and educator, Maria Montessori, said, the work of the child.   The role of play in infant development   Play is fundamental for child development and has been recognized to be a right of every child by the United Nations High Commission for Human Rights.   Picture on Pexels by Tatiana Syrikova Play is indeed learning, as it’s how children experience, discover and get to know the environment. Play helps promote healthy cognitive, physical and social-emotional development and wellbeing.   Through play, children learn many abilities, including motor skills, cognitive abilities, language and socialization skills, self-confidence and abilities to successfully manage stress. They also learn to use their creativity and imagination, to care for others and the environment, to communicate, and to solve problems.   During play, children are also able to experience emotions, frustrations and conflicts in a “protected context”. This means that intense emotions become more manageable, as they are put outside and are recreated through playing life scenarios appropriate for the child’s age. In this way, children learn about their own, and others’ emotions and how to regulate them. As previously mentioned, when a baby is born their brain is very immature   and the first experiences are critical for their development . In the first years, experiences are taken in and guide the development of specific connections between neurons in the brain . Therefore, the brain creates individual pathways of connections based on experiences. For example, a parental caring response to the baby helps build emotional connections which create the basis for future healthy relationships. Similarly, talking, reading and playing with caregivers help children strengthen language and cognitive connections. Although every baby is born with a genetic makeup, lots of their development is determined by the specific environmental experiences that infants have, particularly during the first years of life.   Nowadays, for parents who are constantly trying to balance work and home life, with limited support available and constant time pressure, it’s often hard to find time to play with their children. However, this is very important, not only because it helps master infants’ fundamental skills but also because it promotes the parent-infant relationship. The different developmental stages of play Infants play from birth and play evolves with their development. As we discussed in a previous article , new-borns already have many competencies for interaction. In the first 6 months of life, play is mainly represented by the face-to-face interaction with the caregiver in a dance of movements, touch, sights, sounds and words. Often, from the very beginning, there is a general impatience in wanting to give toys to babies, but these are not necessary at this initial stage. At 3-4 months there is an emerging interest in objects, which gradually babies will be able to touch, grasp and then put in their mouth. Babies also start playing with their bodies and those of others (e.g., touching, pulling hair, putting hands and feet to mouth) as this is their first channel to get to know the world around them. After 6 months, there is further opening to the environment, with a greater interest in the exploration of objects. Interactions with the caregivers also become more complex conversations with alternations of turns and, with time, objects also incorporated in the interaction, so that the interest in the world becomes shared. The first real games also emerge, such as peek-a-boo, which also help to start processing and tolerating the separation from the mother who sometimes goes away but then comes back. This stage of play in the first 12 months is often called exploratory  or sensorimotor play. Picture on Freepik  Between 12 and 18 months, functional or relational  play emerges. At this stage, toddlers are starting to learn concepts such as cause-effect, and can use objects according to their function. Therefore, play involves filling, turning and manipulating objects to understand for example how they can twist or make noise.   Picture on Pexels by Karolina Grabowska Then, gradually functional play becomes more complex and becomes proto-symbolic play. Infants receive care from their caregivers and reproduce these actions first with themselves (at around 15 months) and then with objects, such as dolls and animals (at around 18 months). Examples include caring for a bear or dressing up a doll.   At around 24 months toddlers start to engage in pretend  or symbolic  play, which means play becomes more abstract and an object can now be used not only with its real function and characteristics, but also to represent something else: a block can become a phone, a stick a hair comb, a piece of wood an aeroplane. This play will gradually become more complex and articulated over the years.   Between 2 and 3 years, play becomes more imaginative and children start combining different actions to perform new and original play scenarios, which gradually become more complex. At the beginning, children start acting everyday life scenarios (feed a doll, then change her nappy and clothes and then put her to bed); later on, scenarios become more abstract and imaginative. Furthermore, at this stage, play starts becoming less solitary and children start the first play interactions. From 3/4 years, there is the emergence of group play and group games with rules. Play: Which and how many toys   Picture on Pexels by Olya Harytovich Children need to get in touch with objects; however, these don’t have to be expensive toys. Indeed, particularly in the first stages, anything that can be found at home, as long as it’s safe, can be something unique to explore and play with. With time, when different toys and materials appear in the house, it’s important that the space is organized in a way that these are all easily seen and reachable by the child. In this way children can freely choose what to take and do, without having to always compel to a choice made by someone else. This helps them master their abilities and build confidence in themselves.   However, as a rule, it’s always best to give only a few toys to not overstimulate children. With fewer toys available children play for longer and in more various and creative ways.  In short, fewer toys promote sustained play, concentration and creativity. On the contrary, too many toys make it hard to concentrate, facilitate distraction, and inhibit the development of creativity and of cognitive abilities. To this end, a useful piece of advice is to do cyclic rotations of toys. This means that different toys are left around while others are temporarily hidden.   Connected to this, is the fundamental importance of not filling every single minute of children’s lives. Unfortunately, recently there has been a marked reduction of free exploratory playtime for children , as a consequence of a generally hurried lifestyle, changes in family structure and increased focus on school performance and enrichment activities. We should not fill every single minute of children’s lives. Children don’t need to have a busy agenda of activities and events; they need space to play freely, experience and get to know the environment. So, we shouldn’t worry about the fact that children may get bored, because it’s, indeed, in this empty space that creativity and cognitive processes are promoted. Furthermore, we need to be careful as this busy lifestyle can be a source of stress for children, which can also contribute to anxiety and depression.   Furthermore, screen time should be limited. In particular, the World Health Organisation (WHO)  recommends  no screen time for children under 2 and no more than one hour a day for children aged 2 to 4. This is because, it’s fundamental for little children to get in direct contact with reality with all different senses to get to know the world and themselves.   Some useful advice Here are some advice   on how you can support play and your child through development: Talk and read to your baby from birth, and even during pregnancy. This will support your baby’s cognitive and language development as well as your relationship with them. Remember to respect turns and pauses to give the baby a chance to respond. Involve the baby in day-to-day activities : describe what you are doing, nominate objects, talk to your baby! Provide new materials and experiences  that are suitable for the child’s age and can master new and different skills. These don’t need to be expensive. Allow time for free-play  to learn and develop creativity. Children who are hurried from one activity to another don’t have time to focus, find new solutions and be creative. Don’t overwhelm the child with toys : less is best at each developmental stage. With fewer toys, children are more able to concentrate and are prompted to develop new skills and their imagination. Support play but give the child time to explore independently :  you can encourage play, make suggestions of what can be done and participate, but it is also important for the child to explore independently.

From maternal childhood maltreatment to children’s emotional-behavioural problems: what can be done to break the link I have written this piece together with Xuemei Ma, a PhD student at King's College London who, like me, is particularly interested in the relationship between early life adversity and child mental health. We recently investigated this topic   in a systematic review . Picture from American Academy of Pediatrics Childhood adversity: effects on physical and mental health during lifetime Childhood maltreatment, defined as exposure to sex ual, physical, emotional abuse or neglect (i.e., unwanted sexual experiences, physical punishment, experiences of rejection, criticism and lack of care for the child’s needs) before 18 years of age , is a serious public health issue. Every year, millions of children suffer from abuse and neglect , with a worldwide prevalence ranging between 12.7% and 26.7% .  This prevalence is an underestimation , as many cases are not reported, particularly those of emotional abuse and neglect, which often don’t come to clinical attention but can equally have devastating consequences on the child’s well-being.   Childhood maltreatment increases the risk of developing psychiatric disorders , such as depression, anxiety, bipolar disorder, substance abuse, psychosis and personality disorders. It has also been associated with an earlier age at onset of these mental health problems, and with a more severe clinical presentation (e.g., more frequent episodes and severe symptoms, increased risk for suicide attempts, more hospitalizations and multiple disorders in the same individual, less response to treatment). Childhood maltreatment is also associated with an increased risk of developing medical disorders  such as coronary artery disease, cerebrovascular disease, type 2 diabetes, asthma and cancer, and with a generally significant reduction in life expectancy.   Biological mechanisms are involved in this increased vulnerability. These include: increased inflammation in the body (i.e., increased activation of the immune system, the system that fights against infections); alterations in the functioning of the hypothalamic-pituitary-adrenal (HPA) axis, the system that gets activated in case of stress, and consequently higher levels of cortisol, the hormone released during stressful situations; genetic and epigenetic processes (i.e., modifications in the expression of DNA following environmental experiences); and changes in brain function and structure. Childhood adversity: effects through generations Childhood maltreatment can also have negative effects across generations. Women who experienced maltreatment in childhood are more likely to have children who also experience adversity   (often not by their mothers but by other adults inside or outside the family or by peers)   as well as emotional and behavioural problems. Picture by Omurden Cengiz on Unsplash The mechanisms through which maternal traumatic experiences can pass across generations are multiple, and these may start during pregnancy or even before, through changes in the uterine environment and in the expression of DNA. Many psychological factors are also involved; for example, women who experienced childhood maltreatment can have more difficulties in bonding  and interacting with their children .   Despite this evidence, it is also true that the majority of mothers who have experienced childhood maltreatment go on to have healthy children who do not experience stress, maltreatment, or mental health problems. It is therefore important to understand how maternal adversity and child outcomes are linked, to identify which factors could be targeted in preventive interventions.  Potential important factors involved in the transmission of childhood maltreatment As mentioned above, we recently investigated , in a systematic review , which factors are important in the relationship between maternal experience of childhood maltreatment and less optimal emotional and behavioural development in their children. Designed by Freepik Maternal depression , occurring in the child’s first three years of life, plays a key role in whether a mother’s childhood maltreatment can impact her children’s emotional-behavioural development. Women who experienced childhood maltreatment are indeed at an increased risk of antenatal and postnatal depression , and this depression, in turn, increases the risk of offspring being exposed themselves to childhood adversity as well as developing emotional and behavioural problems during childhood  and adolescence . This provides a vehicle for the intergenerational transmission of childhood maltreatment, suggesting that the perinatal period is an optimum time to provide interventions to improve women’s mental health and protect their children as well.   Maternal insecure attachment is another important linking factor . An insecure attachment develops when a child feels that the caregiver is not reliably available or responsive . The style of attachment developed in childhood has a lasting impact on how individuals build relationships in adulthood, including with their children. Mothers with a history of childhood maltreatment are at increased risk of developing avoidant attachment (one type of insecure attachment),  which is then linked to an increased risk for the children to develop insecure attachment themselves, leading to more emotional and behavioural problems . Conversely, a more secure maternal attachment can lower the risk of emotional and behavioural problems in children . Therefore, working with women to improve the relationship with their infants should be a key focus of intervention, to minimise the potential negative effects of maternal childhood maltreatment on their children. Parenting styles also play an important role. Maternal childhood adversity is associated with an increased risk of less optimal parenting practices, such as the use of hostile parenting and harsh discipline, which further increase the risk of aggressive behaviours in their children.   On the contrary, positive parenting styles such as highly sensitive parenting  (parenting behaviours that are child-centered, engaged, warm, and stimulating) could promote children’s mental well-being. It is therefore important to increase awareness of the importance of positive parenting for child behaviour and mental health. Notedly, the effect of parenting practices on children's behaviour may be more pronounced in girls compared with boys.   Other factors need to be further investigated. For example, emerging research  has shown that maternal nutrition can impact offspring’s mental health. Maternal poor nutrition during pregnancy (such as inadequate intake of energy, protein, essential fatty acids, and various key micronutrients) can have negative effects on the offspring ’s mental health. A lower adherence to a healthy diet  during pregnancy has been related to higher levels of inattentive and aggressive behaviours in the offspring during childhood. This suggests that nutrition-based interventions in pregnant women could mitigate the potential negative consequences in children.   Additionally, children’s healthy diet during early life may also reduce the likelihood of developing a mental illness. In early childhood, an increased intake of unhealthy foods (such as chips, sweetened desserts and beverages), and a lower intake of nutrient-rich foods (such as vegetables, fruit, egg, and fish products), increase the risk of developing mental health problems . Therefore, targeting a child’s diet might be another way to break the transmission of maternal childhood maltreatment on child’s mental health .   Fathers play a key role in the family environment, from the very beginning. For example, low partner support is a strong risk factor for both antenatal  and postnatal depression, which can further increase the risk of mental health problems in children of mothers with a history of childhood maltreatment. Additionally, fathers also have a significant influence on children’s development. For example, father’s language input promotes child’s expressive language at age 3; and a father’s emotionally responsive parenting style can lower the risk of depressive symptoms  in pre-adolescence. Additionally, a positive father-child relationship reduces the risk of  engaging in delinquent behaviours and substance use in adolescence, with a stronger effect seen in boys. Thus, improving fathers’ mental health and their relationship with their children could also have a protective effect on child’s mental health   In conclusion,   working on these factors (maternal perinatal mental health and style of attachment, parenting practises, diet and father’s involvement) with targeted interventions could help minimise the potential negative impact of maternal childhood maltreatment on children's mental well-being, helping them pursue a more positive life trajectory.

A few months ago, while walking home, I heard a child screaming about not wanting to leave the playground. The parents were also shouting, “Stop crying… we won’t go the playground anymore… if you don’t stop crying we will leave you here.” The child, around 3 years old, was exhausted. When he heard his parents threatening him, he started screaming even more until, eventually, he stopped crying and went back on his bike to go home. What happened? A child, most likely exhausted by the day and the emotions he was experiencing, was having what is commonly referred to as a "tantrum". I don’t particularly like this term, I prefer to refer to these episodes as episodes of emotional dysregulation . Emotional Dysregulation: A child acting their age When a little child is experiencing intense emotions such as anger, frustration, boredom, or feels overwhelmed, they won’t be able to put those emotions and needs into words, as their brain is still very immature. They are still learning about emotions: what they are, how to name them, and how to regulate them. Therefore, infants and toddlers communicate with their behaviours, and these behaviours are often misinterpreted as misbehaviours  that must be corrected. Clear examples of these "misbehaviours" include crying, hitting, biting, screaming, whining, throwing things on the floor, disorganized behaviours, and "general tantrums". Tiredness, overstimulation, hunger and stress increase the probability of these behaviours. Picture by Nathan Dumlao on Unsplash A child who is expressing these behaviours is not misbehaving. They are just saying: "I am tired, I am experiencing intense emotions which I don’t know anything about and cannot handle. I need your help to get through these emotions, without ignoring them. I need your help to feel better". Being a little child is hard work. The inability to communicate properly creates frustration. Also, they haven’t developed compassion yet, so they don’t understand the consequences of their behaviours, lack impulse control, and struggle to accept a “no”. They need understanding, attention, and love, although their behaviour may communicate the opposite and may be difficult to tolerate. These episodes are developmentally normal for infants and toddlers, who are not mini adults but just children with brains at the early stages of development. Indeed, these episodes typically begin between 12 and 18 months, peak at around 2 years of age, and then gradually disappear between 4 and 5 years. Indeed, as the children’s vocabulary increases, they are better able to put their emotions into words, reducing the occurrence of emotional dysregulation episodes and "misbehaviours". The work of the caregiver: The constant process of co-regulation The work of the sensitive caregiver is not to suppress the behaviour but to try and understand what the child is saying, and help them regulate the intense emotions they are experiencing and put them into words.   We have talked about emotional regulation in a previous blog.   Emotional regulation is the ability to regulate internal emotions, i.e., the ability to calm down, reduce the intensity of our feelings and control our behaviour, so we can respond most optimally to the stimuli. It does not mean repressing emotions, but modulating internal states and reactions. This is a crucial competence for our well-being as it helps us understand our emotions and those of others, successfully managing stressful situations and remaining resilient.   If we think that emotional regulation can sometimes be difficult even for adults, this can be almost impossible for young children.   Young children rely on their caregivers to help them with their emotional regulation, as their brain is still very immature. The prefrontal cortex, which is a key area involved in emotion regulation,  is one of the last parts of the brain to develop . For this reason, they need someone else to help them regulate their internal states and emotions, so they feel calm again, in a process called hetero-regulation  or co-regulation .   Co-regulation is difficult and tiring work for the caregivers, as they need to regulate their own emotions first, to be able to regulate the child’s emotions. This means: first controlling negative emotions that may arise from the episode (e.g., anger, frustration) and impulsive behaviours that may come out (e.g., wanting to tell the child off to correct the unwanted behaviour, or sometimes wanting to shout or punish the child); then focusing on calming the child. However, this work is extremely important as little children learn self-regulation with time, through the repeated experience of co-regulation with the caregivers in the first years of life. In this way, with time and brain maturity, children learn to eventually control their emotions and behaviour  independently (i.e., self-regulation). Children learn from us; they absorb our emotions and how we cope with difficult situations and then imitate our behaviours. This is why it is fundamental to work on our self-regulation first and model positive reactions to stressful situations to the children. Picture by Jordan Whitt on Unsplash What to do and not do during episodes of emotional dysregulation For babies, physical contact is the strongest way to regulate emotions. Later on, words can also be introduced to help regulate children’s internal states.   As parents, we need to learn about staying in the emotion, without judging it as good or bad or wanting to stop it. This is not an innate competence but something that needs practice.   This is even more difficult if we are tired, going through stressful situations, lack a support network, or have grown up with the idea that these episodes need to be corrected.   When an episode of emotional dysregulation occurs, it is important to:   Stay calm (regulate your emotions first), ignore other people around you, and share your calm. As stated by Knost, "When little people are overwhelmed by big emotions, it is our job to share our calm, not join their chaos". Be present Maintain eye-contact Start with non-verbal communication : stay close to the child, go down at their level and, if possible, offer some contact, for example, a touch or a hug. This will start calming them down. Then, talk to them to  understand , validate  and regulate the emotion . Communicating to your child that you understand and accept their frustration, will help them understand that their emotions are important. Consider this as an example: "I can see you are angry (recognition of the emotion), as you wanted to jump from that stone (recognition of the origin of the emotion). I understand it and it is ok to feel angry about it (validating the emotion). I know it is exciting to do new things (recognition that what the child feels is legitimate), but you could fall if you jumped on your own, we can do it together (there is a solution)". Validating the emotion and how the child feels is crucial. This does not mean that we need to accept "unwanted" behaviours and not set boundaries. Assertive communication is important: "I know you are sad (recognition of the emotion) as you wanted an ice cream for breakfast (recognition of the origin of the emotion). It is ok to feel sad (validation) but you cannot hit mommy (set boundaries)". It is essential to show love towards the child, but not accept the behaviour. It is also crucial to try and put emotions in words, as this helps the child to build skills for later.   On the contrary, these things should be avoided: Angry comments, shouting and punishment (e.g., because you are behaving badly, you are not going to the park anymore/ you won’t have this thing that you like for dinner) Invalidating the emotion  (e.g., stop crying, crying is useless; what you are doing does not make sense; you have got nothing to cry about, you are fine) Judging the child for the behaviour (e.g., you are a spoilt/naughty child, you are acting like a baby) Lectures/logical explanations  (e.g., you are old enough to behave properly, there is no reason to cry for such a stupid thing). Time out  (e.g., now you are going to your room to reflect on what you have done) Return the behaviour (e.g., hit back). This will create confusion on whether that behaviour is acceptable   All these strategies can prolong a tantrum without resolving it while also communicating to the child that their emotions are not right, in turn impeding their healthy emotional development. These episodes   of emotional dysregulation are not indicators that the child is misbehaving or is "spoilt", but just how little children communicate their intense emotions. The role of the caregiver is to help the child calm down and put their emotions into words. Next time someone scolds you for not telling off your child during a tantrum, rest assured that you are doing the right thing.

Image Source: Total Shape on Pexels Food and nutrition are rarely thought of as an approach to improve symptoms of neurological disorders, yet for some people with epilepsy, changing what they eat can significantly reduce seizures. Epilepsy is a neurological disorder that causes recurrent and unprovoked seizures due to abnormal electrical activity in the brain. It affects approximately 70 million people worldwide . The most common treatment for epilepsy is anti-seizure medication, and for many people this treatment is effective. However, one third of people have drug resistant epilepsy where medication does not successfully control their seizures. In these cases, doctors may recommend alternative treatments, such as the ketogenic diet. As a master’s degree student on a Psychology and Neuroscience of Mind-Body-Interface course, I’m particularly interested in how metabolic interventions such as dietary therapies can influence neurological conditions like epilepsy, and how these treatments can be realistically implemented in everyday life. Today is epilepsy awareness day, a day dedicated to raising awareness and understanding of epilepsy and I wanted to highlight an alternative treatment that could be useful for people with drug resistant epilepsy.   What Is The Ketogenic Diet and How Does It Help People With Epilepsy? One of the most established dietary approaches for managing epilepsy is the ketogenic diet. The diet involves eating foods that are high in fat, moderate in protein and low in carbohydrates. Meals are likely to include eggs, cheese, meats, fish, oil, avocado, and nuts. Foods such bread, pasta, potatoes, rice or sugary snacks are limited. When the body receives very little carbohydrates, it begins to burn fat for energy instead, which creates a molecule called ketones. In the 1920s , the diet was first introduced as a treatment for epilepsy after research showed that fasting suppressed seizures and the ketogenic diet could create similar effects in the body. Image Source: mali maeder on Pexels The ketogenic diet is effective especially for treating children with drug resistant epilepsy, with studies showing that they are 6 times more likely to achieve a 50% or more reduction in seizures and 3 times more likely to become seizure free compared with those who receive standard treatment. Adults are less likely to become seizures free than children, but are still 5 times more likely to have a 50% or more reduction in seizures. There are also other benefits to the ketogenic diet: people often report feeling more alert, aware and responsive , and families of children who receive the treatment report improvements in behaviour, awareness, learning ability and development.   How Does It Work? Researchers are still working to fully understand exactly how the ketogenic diet improves epilepsy symptoms, but there are several theories about how altering the brain’s energy supply might stabilise brain activity. For example, the ketogenic diet may help to: Correct neurochemical imbalances in the brain Reduce excessive brain activity that can lead to seizures Improve the quality of deep sleep, as a lack of sleep is a known trigger for seizures Improves gut health by changing the balance of ‘good’ and ‘bad’ bacteria in the intestinal system, which may help to stabilise brain activity and reduce the chance of having a seizure The diet produces molecules called ketones which may help to calm down activity in the brain and produce a similar effect to anti-seizure medication The diet might help the cells in the brain become more efficient at producing energy which may help to prevent seizures The Practical Challenges of The Ketogenic Diet While the science behind the ketogenic diet is positive, following the diet in everyday life can be challenging. The ketogenic diet is not simply a change in eating habits; it’s a highly structured medical treatment. When you first get prescribed the ketogenic as a treatment it needs to be formulated by a professional based on your age, activity level, and growth for children to make sure that it is safe and nutritionally adequate. When you are on the diet you must follow a strict macronutrients ratio, carefully plan meals and in some cases weighing your food. Alongside maintaining the diet, you need to keep track of your blood ketone and glucose levels in addition to regular check ins with dieticians and doctors. After two years , the effects of the diet will be evaluated, and a decision will be made whether you should continue or stop the diet. For families and patients managing epilepsy, maintaining such a regimented diet can be demanding and time consuming. Everyday situations such as eating out, school lunches or social events can become complicated when you are no longer allowed to eat common food. While many people experience meaningful reductions in seizures, the level of organisation and commitment required, can make the diet difficult to sustain for a long time. Image Source: i-SENS, USA on Pexels Beyond the practical challenges of maintaining the ketogenic diet, social and economic factors also influence who has access to this treatment. The ketogenic diet relies heavily on high fat ingredients such as dairy products, oils, nuts, and specialised low-carbohydrate alternatives, which can often be more expensive than a regular diet. For people already experiencing financial pressures, maintaining these dietary requirements on a daily basis may not be possible. The ongoing cost of living crisis in the UK has intensified this issue, as rising food prices have increased food poverty and affected people’s food choices. Time and knowledge also play an important role. Preparing ketogenic meals requires careful planning, nutritional understanding, and consistent monitoring of ingredients. For households balancing work, childcare and other responsibilities, maintaining such consistency can be extremely difficult. Access to the specialist professionals and epilepsy clinics needed to use the ketogenic diet safely can be difficult, particularly for people living in areas with limited healthcare services. What’s Next? Researchers and clinicians are increasingly exploring ways to make ketogenic therapies more accessible and easier to maintain. In the UK, some people with drug resistant epilepsy can receive ketogenic diet treatment through the NHS, where a dietitian will help them to safely implement and monitor the diet. At the same time, new approaches are being developed, one example is K.Vita supplements , which are designed to raise ketone levels without requiring a highly restrictive diet. Researchers are also investigating modified versions of the ketogenic diet that are less restrictive which may be easier for patients and families to sustain. While these developments are promising they do not remove all barriers but are a positive step forward to making the treatment more accessible for everyone. Conclusion For some people with epilepsy, the ketogenic diet can significantly reduce seizures and improve quality of life. However, ketogenic therapy also highlights a broader challenge in medicine: treatments must not only be effective, but also realistic for the people who need them. As research into metabolic therapies continues to develop, ensuring that treatments are accessible is an essential part of improving care for people living with epilepsy.

Image Source: Yan Krukau on Pexels Editor's Note: The writer has received permission to name all individuals mentioned in this piece. Of the nearly 50 years that I’ve been alive, I’ve been different people for varying lengths of time. I was a naturalist-in-waiting for a few years before I turned 10. I was a mostly reluctant student for around 20 years and a (failed) bassist for most of my youth. I’ve been a writer for nearly 25 years now. Since last year, I’ve been a fiancé. But, of all the different people I have been across my life, there is one I have never stopped being – a stammerer. My parents told me that I began stammering as I started speaking. What they didn’t tell me, until I was much older, was that they took toddler me to a few doctors to understand exactly why I was doing it. The first was a paediatrician whom I clearly remember. They took me to her when I was around 3 and had started speaking in sentences. That is when my parents realised that my pauses, gaps, and repetitions were not just the expected struggles of a toddler learning to speak. Dr Parekh, as Dad recounts, smiled at me, turned to them and told them something that would form the bedrock of how they approached my stammering and, in turn, became the main reason I didn’t grow up with the traumas that stammers often endure (more on that later). She told them the best way to handle this would be to not handle it. Just let him speak, she told them, and don’t ever correct him or finish his sentences. Let him grow up unburdened with the confusion of whether he’s speaking ‘wrong’, Dr Parekh told my two new parents in their mid-20s in the fairly unsensitised social landscape of late 1970s India. Image Source: RDNE Stock project on Pexels That said, my parents not only heeded her advice but also adopted it as the foundation for raising their firstborn, which I believe is the main reason I’ve grown up unencumbered by the embarrassment and shame that shapes the lives of most other stammerers I’ve met. How? Because, unlike most stammerers I’ve met, I did not grow up thinking I spoke wrongly. I just spoke. I’ve seen so many parents flinch when their child stammers, especially in public. But mine? They just waited for me to finish, however long it took. And while the outside world was often cruel and made me feel like I stuck out, I came home to an environment where I wasn’t different. Here, I fit right in.  Two decades later, I was preparing to join the workforce. It was then, for the first time in my life, that I felt insecure about my stammer. Stammering while speaking in a classroom was one thing, but to stammer while presenting in a boardroom filled me with dread. I spoke with my cousin Aayesha, an audiologist, and she set up an appointment with Maya Sanghi, the then Head of Audiology and Speech Therapy Department at the T N Medical College & B Y L Nair Charitable Hospital, Mumbai. Image Source: Yan Krukau on Pexels I’ll never forget my first session with Maya. We chatted before she made me speak into a mirror, so that I could see my facial tics when I encountered letters or words I had trouble with. Then, as we finished and I got up to leave, she smiled and told me that this would likely be our second-to-last session. Dumbstruck, I asked her if I’d offended or upset her. She smiled and said that when stammerers start speech therapy “this late” in their 20s, the main work is undoing the trauma of years caused by laughter, pity, and unsolicited advice. I clearly didn’t suffer from any of those problems, she said, so the only thing I needed to learn was techniques to help ease it out. This would take only one more session, Maya said. My experience with therapy is something I have previously written on here at Inspire the Mind. Every day since then, I’ve given thanks that my parents raised me as they did. It enabled me to make a career as a copywriter, a job based on my ability to pitch and sell ideas to colleagues and clients. Now, on behalf of other stammerers to whom fate has not been as kind, I’d like to share some advice based on my own experience that will help make life immeasurably kinder for us. Image Source: Mei-Ling Mirow on Unsplash Don’t Complete Our Sentences We know you mean well, but this makes us feel helpless and incompetent. Useless, even. Instead, wait, however long and trying it might seem. It’s longer and more torturous for us to know what we want to and not be given the time to say it than it is for you to wait for us to say it. Also, we’ll never forget the kindness of patience.   Don’t Look Impatient Speaking of being patient, please mean and look the part. We see the rolling of eyes and the curling of lips, and that often makes us stammer more as we try to force the words out before we feel we’ve lost you. Don’t Think We Don’t Notice A lifetime of being laughed at because of the way we speak attunes us to hearing the unspoken. The softest snigger, the suppressed smirk – you’re not as good at hiding it as you think you are. And it cuts us to the quick, especially if you’re someone we care about.   Don’t Throw Us Into Public Speaking Did you watch The King’s Speech? Stammering in public is our collective nightmare come to life, but it is one that can be faced and overcome. I’ve had clients and colleagues come to me after I’ve made a presentation to learn how I was able to face one of our worst fears – presenting our ideas to an audience and risk coming across as underconfident, only because we stammered. This leads many of us to diminish our public personalities and even choose careers out of the limelight. So yes, we’d love to give a toast, as I did at my sister’s wedding. Just let us know in advance, please? Don’t Suggest Cures or Hacks Roll marbles in your mouth, meet a healer/guru, try this potion or that powder, pray to a god or godman – we’ve heard them all. The best help you can offer is the patience to let us share with you whatever is screaming for release inside us.   Don’t Lampoon Us Would you laugh at someone who limped? Or was in a wheelchair? Then why not treat us with the same sensitivity? Children can be (unknowingly) cruel, and we grow up being laughed at by our classmates and peers. Films and popular media love to create characters who stutter to get a chuckle from the audience. This encourages a buffoon-like public view of speech impediments. Please don’t add to it. And Please, Please Don’t Pity Us We do enough of it for all of you. While a sympathetic clucking and “It’s okay” can help us in the moment, it’s not much help when we meet someone new. So, whether it is for a stammerer whom you know and love, or for someone you’ve just met, treat them with the kindness of attention that you’d treat anyone else who spoke ‘normally’. All we want is to know that the invisible impediment that we will carry our entire lives is not going to be an obstacle to how you treat us. Image Source: Mikhail Nilov on Pexels   This article has been sponsored by the Psychiatry Research Trust,  who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.