Mental Health in Lockdown and its Impact on Children, Adolescents and Families – In Conversation with Dr. Polly Waite

In this podcast we talk to Dr. Polly Waite, Associate Professor of Clinical Psychology at the University of Oxford and at the University of Reading.

Polly discusses her research on anxiety in adolescents, the Co-Space study on how families are coping during the COVID-19 pandemic, and her recent JCPP Advances paper

Polly also discusses further areas of her research interests, including the development of brief psychological treatments for adolescents with anxiety disorders (such as adapting an effective psychological therapy for panic disorder in adults for use with adolescents) and how new technologies can be used to optimise psychological treatments for adolescents.

Furthermore, we hear Polly talk about the role of teachers in supporting students and delivering mental health interventions, as well as whether teachers felt that they were getting adequate support and future research projects, especially with regard to the Co-SPACE study.

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I am a clinical psychologist and my primary areas of interest are cognitive behaviour therapy (CBT) and adolescent anxiety disorders (which include social anxiety disorder, panic disorder, specific phobias, generalised anxiety disorder and separation anxiety disorder).

I am interested in developing our understanding of what causes and maintains anxiety disorders during this developmental phase, as well as improving the effectiveness of treatments for adolescents. (Bio via University of Reading, School of Psychology and Clinical Language Sciences)

Transcript

Interviewer: Hello and welcome to the In-Conversation podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology Today I’m interviewing Dr. Polly Waite, Associate Professor of Clinical Psychology at the University of Oxford and at the University of Reading. The focus will be on Polly’s research on anxiety disorders in adolescents, which includes the Co-SPACE study on how families are coping during the COVID-19 pandemic. We will also look at a paper on this topic recently published in JCPP Advances.

Polly is funded by an NIHR post-doctoral research fellowship. If you’re a fan of our In-Conversation series, please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating or review and do share with friends and colleagues. Polly, thank you for joining me. Can you say a little about yourself by way of an introduction?

Dr. Polly Waite: Yes, thanks, Jo. So I’m a clinical psychologist by background and prior to the pandemic my research mainly focussed on anxiety in adolescents and in particular really understanding how anxiety disorders develop, what keeps them going and how we should treat them through psychological interventions, but then when the covid pandemic struck last year my colleague at Oxford, Cathy Cresswell, and I were really keen to better understand the impact of such a huge event on young people’s mental health. So in the last year or so a lot of my work has been really focussed on that.

Interviewer: Well let’s look at some of that work. So let’s start with Co-SPACE study. Can you give an overview of Co-SPACE and its aims?

Dr. Polly Waite: Yeah, definitely. So we’ve been running the Co-SPACE study and the real aim of it has been to track the mental health of children and young people over the course of the pandemic. It’s a UK based monthly online survey of parents and carers of children and teenagers aged four to 16, so those at school, and adolescents aged 11 to 16 can also contribute by reporting on their own mental health, and we launched the survey on the 30th of March last year.

So it was a week after the UK’s first national lockdown. At the time we didn’t think we were going to be running it for as long as we have been. So it’s been running now for over a year, and over that time more than 8,700 families have been providing data. It’s important to say, actually, that the study, it uses convenient sampling. So it’s not a nationally representative sample and we don’t have pre-pandemic data.

We wish we’d thought of starting it beforehand, but sadly we didn’t. So we can’t answer things like how the pandemic affected the prevalence of mental health problems, although there’s other really good studies that do look at that, but what Co-SPACE, I think, does provide is a really unique opportunity to think about how things have changed over time, throughout the pandemic and really importantly how they’ve changed for particular groups of people, and then on top of the survey we’ve been doing interviews with young people and parents and carers and people who work with young people to get a much more in-depth understanding of people’s experiences during the pandemic.

Interviewer: You recently published some findings in the co-authored paper, ‘How did the mental health symptoms of children and adolescents change over early lockdown during the COVID-19 pandemic in the UK’, and that was published in JCPP Advances? Polly, can you give us an overview of the paper?

Dr. Polly Waite: Yes. So in this paper we looked at how mental health symptoms in children and adolescents changed over a month of full lockdown in the UK. That was really early on between March and May 2020. So at that time children weren’t going to school. Restrictions were at their highest. So in this study, around 2,700 parents and carers of children and young people completed the online survey about their child’s mental health, and that was at two time points.

So they completed the baseline survey between the 30th of March and the 30th of April last year, and then they did a follow up survey a month later, and we were interested in looking at different aspects of children’s mental health. So we used a really widely used measure, the Strengths and Difficulties questionnaire, and that looks at three particular areas. So it looks at emotional difficulties, so that’s where children are feeling worried, unhappy, clingy; and then we looked at behavioural difficulties that children might experience, so that’s things like having tantrums, not doing what you’re being asked to do; and then thirdly we looked at sort of restlessness, inattention, difficulty, so this is where children are being fidgety, restless, difficulty paying attention, that kind of thing. So we looked at the changes in symptoms over time, and then we also looked at the proportion of children who might be, what we call, a possible or probable case. So that’s in terms of the possibility or probability of having a mental health difficulty.

Interviewer: Can you say anything about the findings, I know it was a small time period?

Dr. Polly Waite: So in terms of findings, what was particularly interesting is we saw really different patterns depending on the child’s age. So we grouped the children into two age groups. So there were primary school aged children, so children aged four to ten, and then we had another group of children who were aged 11 to 16, and what that showed was that it was the younger child group that seemed to be particularly affected over this one month period, which perhaps is a surprise to people.

I think often they think about teenagers being affected in terms of mental health. What we saw in this study was that the findings highlighted a particular deterioration in the mental health symptoms for the primary school, the pre-adolescent children. What we saw were increases in cases across all those three areas in terms of cases for emotional symptoms that went up by 10% and then for hyperactivity and attention symptoms that went up by 20%, and then for behaviour problems that went up to 35%.

So really quite significant changes over time, but we didn’t see that with the teenage groups. Actually, the changes amongst the teenagers were much smaller. So they were for hyperactivity and inattention actually they just went up by four% and eight% for behaviour. And then actually we saw a little bit of a reduction in emotional symptoms over that time. It was really interesting to see how different experiences were on the basis of age.

Interviewer: Yeah, it’s so interesting. In your view why has the increase in mental health difficulties been most pronounced in primary school aged children?

Dr. Polly Waite: That’s such a good question and I think, you know, we don’t know for sure, but we have some hypothesis and things that we’re testing out at the moment through looking at the data further, but one of the things that was really striking was, at the beginning of the pandemic, two-thirds of the parents in our study reported that they were struggling to meet the demands of their work and of their children. The majority of the parents in this survey are working parents, a mix of full-time and part-time.

But that balancing act was proving to be really, really challenging and it’s likely that the demands of home schooling at that point, alongside trying to work at the same time, were particularly challenging for parents who had younger children because they would have just been so much more reliant on their parents for support with the schoolwork that they were trying to do, as well as just sort of generally monitoring what’s going on, getting them lunch, just providing for them and having to respond to them the whole time.

So that’s likely to have been very different. Whereas for the adolescents, they’re likely to be much more independent during lockdown. So the family stress, I think, is probably likely to be a factor, and then the second factor that we think probably is really relevant is how able the children/teenagers were to be able to have contact with their friends and their peer group. So for teenagers, the majority will have access to a phone. They’ll be able to message chat with their friends.

We know a lot of the teenagers were gaming with friends online, so there was a lot more access to your peers. Whereas for the younger children we could see that that wasn’t the case and parents describe to us real difficulties of even having a Zoom meeting with a child’s friend and actually that not being how children would choose to interact with each other. They’d be playing and doing stuff together and actually just stare at each other on a screen was just in no way kind of compensation for how they’d normally be interacting.

So we’re looking at the potential impact of family factors and peer relationships, and we’ve got two papers that we’re working on at the moment to really understand how these different factors might explain some of the findings that we’re seeing that relate to differences in age.

Interviewer: Before we look at the implications of the findings, are there any other key takeaways from the paper that you’d like to highlight?

Dr. Polly Waite: Overall, there were relatively few differences in changes over time, depending on demographic characteristics, but what was such a concern to see was that children and young people in low income households, those with special educational needs and neurodevelopmental disorders, so things like autism or ADHD, they just had much, much higher symptoms at both time points and caseness. So just to give you an example, when we looked at children from low income backgrounds over that month period, the number of children experiencing significant problems was around two and a half times greater than those from high income backgrounds.

We know that there are these health inequalities, but actually it was really stark in our data to see that that was also the case, and on the graphs the lines were just so much higher when we looked at those groups in terms of just this elevated presentation across both time points.

Interviewer: Polly, what are the implications of the findings from Co-SPACE and the JCPP Advances paper for professionals working in child and adolescent mental health, and in terms of developing strategies for prevention and intervention.

Dr. Polly Waite: I think the main implication from the paper is just really about the impact of this lockdown and really the restrictions on children and young people’s well-being and being mindful that this has a particular impact on younger children. In terms of prevention and intervention, I think the first thing to say is that if we’re thinking about developing those kinds of strategies involving parents and carers and children that needs to be really at the centre of the plans to think about how we can best support families.

But I think the findings from the study they just really emphasise how important it is to have schools open and keeping children in school where that is possible and safe, and it’s really clear that school isn’t just about the educational content, but all those other really important aspects, getting the right support around your learning, spending time with your teachers and your school staff, spending time with your friends, playing, having fun, being physically active. All of those things are just really, really important.

And I think in terms of prevention and intervention it’s going to be really important to think about what do we need to do when children and young people can’t attend school, for example, at the moment when they’re having to self-isolate, and then I think obviously the findings really emphasise the needs of particular groups that were elevated throughout. There’s going to be huge variability amongst children and young people. Obviously, we’re just looking at a sort of general group level.

So I think for many children getting back into school, seeing friends again, that’s enough, and obviously it’s important not just to focus on catching up on schoolwork, but prioritising their well-being, relationships, all those other important aspects, but there’s obviously going to be other children where that isn’t the case and I think it’s about being able to identify who those children might be in order to provide them with sort of more targeted support, and from a research point of view really understanding who has struggled, who hasn’t bounced back so that we can spot them and think about targeting really good interventions for them.

Interviewer: And what about policy-makers? What message should they take from your findings?

Dr. Polly Waite: Yes, I think in terms of policy, obviously, it’s really important to prioritise children and young people’s needs and how important it is to be at school. So I think really about keeping children in school as much as possible and recognising the function of school beyond just delivering the educational content, and I think policymakers need to be thinking about how they can mitigate the impact when children and young people can’t attend and that’s obviously going to be important not just for children during the pandemic, but there are many children who aren’t educated in a physical school environment anyway.

So actually, if we can figure out how to give them the best opportunity across the board that’s going to be really important. Then obviously there’s children from low income families and that’s going to be really important. That policymakers are thinking about how to support those families at a basic level, if they’re not physically in school, providing them with the means to access education and support from peers and that’s including things like having the space to work or having a laptop and WiFi.

And then in terms of sort of mental health support, we know that this has been harder to access during the pandemic and the number of children and young people being referred to CAMHS now, I understand increased by nearly 30%. So it’s going to be really important that policymakers are thinking about ways for children and young people to access evidence-based mental health support that can overcome those barriers, many of which have been really exacerbated by the pandemic.

Interviewer: Polly, let’s turn to some of your other research, to improve the identification of anxiety problems in adolescents, you point to the importance of developing appropriate screening measures. What work have you done in respect of this?

Dr. Polly Waite: This was some research led by Jerica Radez as part of her PhD, and as we know, anxiety and depression are really common mental health disorders in adolescents, and recent evidence suggests that they’re on the rise, and one of the real barriers of young people being able to access support relates to the fact that many people that work with them, so teachers or other people that might be involved in supporting them like GPs often find it really difficult to identify.

So the purpose of this study was to develop a brief screening questionnaire because we know that professionals are really time poor. So it needs to be a measure that’s going to be brief and also reliable and valid. So we took items from a really well used questionnaire, the revised children’s anxiety and depression scale, so that we could develop a briefer screening questionnaire and we also looked at whether adding some other items could improve it, Jerica’s work involved comparing two samples of teenagers and their parents.

So we had a community sample recruited through secondary schools and then a clinic referred sample. So the young people in this sample all met diagnostic criteria for an anxiety disorder or and a depressive disorder, and we were able to identify a set of 11 items, which is a real improvement because the full measure has 47 items. These 11 items accurately discriminated between the community and the clinic referred sample, which was great. We also found that if we put in two optional symptom impact questionnaires, so sort of asking about the level of impact the symptoms had that increased the accuracy even more.

So we obviously need to do some further evaluation, but what’s really exciting is it looks like this measure potentially has the impact to quickly and accurately identify teenagers with these disorders in community settings, which will be great.

Interviewer: Has it been rolled out to clinical settings?

Dr. Polly Waite: Not yet. I think there’s more work to do on the measure. What lots of clinicians tell us is that actually at the moment it can be really burdensome and when we do interviews with young people about their experience in reaching clinical care settings, often they talk about how helpful the questionnaire measures are in terms of being able to understand their difficulties and measure progress, but also the burden. So I think that there is an appetite from both young people, their families, and also from clinicians to have something that’s much briefer but can be effective.

Interviewer: Polly, one of your other research interests includes the development of brief psychological treatments for adolescents with anxiety disorders. This includes adapting an effective psychological therapy for panic disorder in adults for use with adolescents. Can you tell us more about this project?

Dr. Polly Waite: So this is part of my NIHR fellowship which is based at Reading University. So within that I’m currently running a feasibility study and that’s evaluating a brief form of cognitive therapy. So this therapy was originally developed by Professor David Clarke and colleagues for use with adults and a number of years ago now, but we have developed a version that’s been adapted for teenagers with panic disorder. So we’ve adapted it in a number of ways to make it more acceptable in terms of the way that it’s written and we’ve had adolescents involved in that process, and of course, we inevitably, with the treatment, have to involve family members more and school is also really important to involve too. So it’s sort of adapting in that way as well.

So the study is going to test the feasibility of a randomised control trial to compare brief cognitive therapy to an existing CBT treatment for adolescents with panic disorder. So we are towards the end of the trial. So we’re just finishing recruitment in the next couple of months and then they’ll be the really exciting bit where we get to look at the outcomes. So we should be able to report back on those next year, but as well as the early parts of the project we wanted to better understand what routine treatment in NHS Child and Adolescent Services, so CAMH services, might look like for teenagers with panic disorder. So actually another one of our PhD students, Holly Baker, conducted a national survey with CAMHs clinicians who were treating young people for panic disorder and a range of anxiety disorders.

And so part of this study actually involved clinicians reading a case study of a young person who met diagnostic criteria for panic disorder, and then we asked the clinicians what they thought was going on and how they might treat it, and the results were really interesting because actually what we could see was over half the clinicians wouldn’t identify the problem as related to panic disorder or panic symptoms. They tended to think of it in a sort of more general term of just sort of anxiety more broadly, which might not be a problem if you sort of think a general anxiety treatment would be the first line of treatment.

But if we are delivering treatments that are disorder specific, then it’s obviously a problem if identification rates are low and treatment wise the clinician suggested using CBT as the main treatment approach, but what was really concerning was that nearly half of them lacked any training in CBT and the majority of them weren’t aware of any specific evidence-based treatment protocols to treat panic disorder, either within a disorder specific treatment or a more general anxiety treatment. So clearly, there’s a lot of work to be done on this.

So we’re really looking forward to seeing the kind of outcomes of the trial. So since then we’ve been doing further work, including qualitative interviews with teenagers about their experience of having panic disorder and also their experience of having treatment. So we’re really looking forward to looking at the study outcomes next year and we’ll be looking at a range of things, things like the acceptability of the treatment, recruitment, whether people dropped out and also exploring young people’s outcomes, so things like looking at their symptoms, diagnosis and other outcomes.

Interviewer: I was curious, actually, because you talked about the clinicians not having any experience in the use of CBT. So I wondered how teenagers are being treated at the moment when they have panic disorder.

Dr. Polly Waite: The majority of the clinicians talked about using CBT, which is the evidence-based treatment, although the NICE guidance for panic disorder actually doesn’t mention young children and young people. Panic disorder is very much a kind of adolescent anxiety disorder. So we don’t tend to see it in children, but nevertheless the NICE guidance don’t mention it at all, but broadly for anxiety we would be looking at a CBT approach and the clinicians did talk about using CBT. So that was really encouraging. They are delivering it, but a good proportion of them are delivering it in the absence of any training.

Interviewer: Let’s turn to new technologies. How can these be used to help optimise psychological treatments for adolescents, and can you highlight any research that you’ve done in this area?

Dr. Polly Waite: I think the last year has really brought this issue into stark relief when we suddenly had to switch to online working and many clinics and CAMHS teams were having to deliver treatment remotely. So we did this study a few years ago now but actually this is particularly on our minds of how do we move to delivering treatments in ways that are robust and evidence based. So we did do some research on this. It was published in 2019. There’s quite a good literature on computerised treatment showing that it’s effective in young people with anxiety disorders, but this is largely within research settings.

So when we did this research we were really keen to test a computerised treatment within a CAMH setting to understand whether it translated with similar levels of effectiveness, and these were with adolescents referred for the treatment of an anxiety disorder. So the online treatment was a treatment that was developed in Australia. It’s got really great outcomes in the main trial paper. It was published by Sue Spence and her colleagues. The programme was brave for teenagers online, and this involved the teenager logging in and doing ten sessions of CBT, but they had therapists support.

So the therapist would regularly email them with feedback and they’d also have a telephone chat to help plan part of the treatment, and we were also interested to see if providing sessions to parents made a difference to their child’s outcome. In terms of the findings we found that around half the teenagers were free of their primary anxiety disorder and six months after completing the programme, those treatment outcomes are reasonable but what we found was that that treatment wasn’t significantly more effective than a wait list treatment.

So essentially doing nothing. We also found that the parent sessions didn’t provide any significant additional benefit, which might be a bit of a surprise, but actually what we found was that the parents typically had some level of involvement in their child’s treatment. Even if they weren’t doing their own sessions, they generally had informal involvement. So they’d basically know what their child was doing and might have seen a bit of the content. So that suggested that adding in specific parent sessions might not be necessary to the treatment. On the basis of our findings that the treatment wasn’t significantly better than the wait list.

It’s probably premature to use this in routine clinical services, and as part of the study we conducted qualitative interviews with the adolescents to look at the acceptability of the treatment and this paper is currently under review. So we hope that it’s going to be published later this year, but I think what this sort of underlines is the importance of involving young people in developing treatments and being involved in research in order to make sure that treatment is acceptable, and also really thinking about as we’re developing new treatments, how can we optimise outcomes in terms of what the treatment looks like, what components are necessary, what’s the most efficient way to deliver that treatment?

So I think there’s lots of questions and lots of things to do going forward in order to be able to really use computerised treatments with high levels of effectiveness.

Interviewer: You’ve also looked at the role of teachers in supporting students and delivering mental health interventions. What can you tell us about this research?

Dr. Polly Waite: This research was led by Lucas Chellamey as part of his PhD, and again, just thinking about the other research we’ve done and what we’ve been saying about teachers being so important and able to spot early signs because they have so much contact with students. So we’re really interested in that because teachers are in a really great position to identify students, but we were keen to hear about their experiences of supporting young people with mental health difficulties. So, Lucas’s research involved doing qualitative interviews, one-to-one with teachers for a variety of different schools.

What was interesting about his findings were that the participants expressed huge amounts of caring for their students, but also it was interesting to see there were a lot of negative worries and thoughts about the fact that they lacked training, they lacked resources, they didn’t have adequate guidelines. So a real sense of feeling helpless and that they felt like that they’d failed their students. A really common theme was a lack of knowledge about what to do and the right way to respond to students with mental health difficulties.

For many of the participants there were really strong emotional reactions and they seemed to relate to two things in particular. So the first one was how they saw their own role in relation to supporting their students. They all saw, understandably, their primary role as being that of an educator, but there was a real mix in terms of how much they felt they should get involved around mental health and also a real balancing act between being able to provide adequate support, but being worried about getting too close to students and the consequences of that, and for many of them there was a real dilemma in how you get that right. Then the second thing that obviously influenced how they felt about it all was whether they were getting effective help from the school, from external services, the CAMHs or other clinical services or from the teacher. So that also influenced it too.

Interviewer: Right, and were they? Did they feel they were getting adequate support?

Dr. Polly Waite: I think it was really mixed. So for some they felt that the school was well resourced. They had a really good pastoral care team, good relationships with external service providers, but for others they had the opposite experience. Things were really difficult. It might be that this study was carried out a few years ago and in the last few years we’ve obviously seen the development of mental health support teams, clinicians, education, mental health, wellbeing practitioners, providing schools with more direct support.

So I’d hope that actually as schools are begin to be in receipt of this support more closely, that hopefully will have a positive impact and they may feel that there’s more support available and that will improve things.

Interviewer: We’ve looked at lots of different aspects of your research. How do you go about translating research into practice so that families benefit?

Dr. Polly Waite: I think that stakeholder involvement is a really key part in all of our research when we’re thinking about translating research into practice. So the kind of people that we would typically think about involving are obviously young people themselves, parents and carers, and then people who work with young people. So that might be teachers, but it might also be clinicians and services and then really involving them at all stages of the research, from the design of the study to what measures are used, whether the measures are understandable, involving them in the intervention and what that looks like, and then the kind of processes of how we conduct the treatments or the research.

And I think that’s really key in all of this. We also tend to use mixed method approach. So we make really good use of qualitative interviews so that we can really directly hear about what’s working and what isn’t working, and I think that’s particularly the case with our clinical research actually where we really want to know about where the treatments are acceptable and how we can optimise them, and that’s not only for young people, but also thinking about how you get them rolled into services and clinicians.

Then the other thing that we really do is work hand in hand with policy-makers. So that’s been particularly the case in the Co-SPACE study, actually, where we’re regularly feeding back our data. We’ve done regular reports throughout the pandemic and we feed that data back to hundreds of mental health organisations and community groups and charities, and we also have produced some reports in response to specific questions that policymakers might have. So that goes to also policymakers like Public Health England and the Department of Education, Scottish Government. So I think all of those things are really important to make sure that the findings really do have a tangible impact for families.

Interviewer: Polly, is there anything else in the pipeline that you’d like to mention?

Well, with the Co-SPACE stud, we’ve got further papers in press and in preparation. We as you can imagine, we have got tons of data and we’re going to be making it open access at the end of the project so that other researchers can use it because there’s really important questions and we’ll have a limit to the scope of what we can do within the period that we’re funded for with Co-SPACE. So that’s a great opportunity for other people to be able to use the data.

But at the moment we’ve got papers looking at parent mental health and child communications I mentioned earlier. Then we’ve also got the findings from our qualitative work which we’re going to be submitting for publication over the next few months. Then in terms of other projects that relate to adolescent anxiety we’re working on a range of research projects really that relate to things like understanding the relationship between things like depersonalisation and anxiety. Lots of work on developing our understanding of how applicable adult cognitive models, how they apply to young people with different kinds of anxiety disorder, and then thinking about how do we optimise treatments for anxiety and then things like the impact of treatment on sleep. So we’ve got loads of things going on that’s all keeping us pretty busy.

Interviewer: That’s great. And finally Polly, what is your take-home message for those listening to our conversation?

Dr. Polly Waite: One of the key take-home messages is while the prevalence of mental health difficulties, especially things like anxiety, depression, they seem to be on the rise but there is lots of research going on at the moment, I think, to really help us better understand difficulties, and that’s in the context of the pandemic, but beyond that too, so that we work out how we can best support young people for them to be able to lead the kind of lives they really want to live.

And although massive inequalities persist and that’s been particularly evident in Co-SPACE, you know, and clearly the answer to that is about tackling them on a number of levels, but I really hope that the research that we’re doing and others are doing in this field will fundamentally make a difference to children and young people.

Interviewer: Brilliant. Thank you so much. For more details on Dr. Polly Waite please visit the ACAMH website www.acamh.org and Twitter at ACAMH.  ACAMH is spelt ACAMH and don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.