In Conversation… ADHD with Dr Sinead Rhodes

In this podcast, Dr Sinead Rhodes discusses ADHD and neurodevelopmental disorders with freelance journalist Jo Carlowe.

Sinead discusses her latest research, cognitive factors underlying mental health and tailored interventions. Additionally, Sinead talks about Research the Headlines, a multidisciplinary project she set up focused on improving the public’s understanding of research presented in the media.

You can listen to this podcast directly on our website or on the following platforms;  SoundCloud, iTunes, Spotify, CastBox, Deezer, Google Podcasts and Radio.com (not available in the EU).

Transcript

Intro Speaker: This podcast is brought to you by The Association for Child and Adolescent Mental Health, ACAMH for short. You can find more podcasts and other resources on our website, www.ACAMH.org and follow us on social media by searching ACAMH.

Interviewer: Hello. 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. Sinead Rhodes, senior research fellow at the Center for Clinical Brain Sciences at the University of Edinburgh. Sinead is a developmental psychologist with an interest in the cognitive factors, underlying behaviour and learning. Sinead, thanks for joining me. Can you start with an introduction?

Dr. Sinead Rhodes: I am a developmental psychologist who is primarily interested in cognitive functions. In particular, the thinking factors underlying behaviour, learning and mental help. My research mainly concerns children with identified neurodevelopmental conditions, such as attention deficit hyperactivity disorder, ADHD, autism spectrum disorder or developmental coordination disorder or DCD. I also research typically, developing children and conduct research for children where there is concerns about their development, but they don’t readily fit criteria for a diagnostic condition. My research is fundamentally multidisciplinary in nature.

For example, a current project involving the development of a school-based intervention for children with ADHD includes paediatrician and education collaborators. A further project I am currently setting up is focused on mental health in children with autism and includes collaborators from clinical psychology, paediatrics, psychiatry, speech and language therapy and public health medicine. This multidisciplinary input is vital for appropriately informing the design and practice of the research, enabling me to draw on a wide variety of discipline-specific expertise. The clinical and practitioner input is also important for recruitment and appropriate dissemination of the findings with clinicians and education practitioners.

Interviewer: As you explained, your research focuses primarily on cognition in children with neurodevelopmental disorders, such as ADHD and autism spectrum disorders. I’m wondering what brought you into this field of work?

Dr. Sinead Rhodes: I undertook a research project for my master’s dissertation on children’s early cognitive development and from that point, I became interested in the development of children’s cognitive function and how thinking processes are implicated when children show a delay or difference in their behaviour learning or mental help. My PhD focused on examining cognitive factors implicated in ADHD, and how these are impacted by medication. This research highlighted that the cognitive difficulties in ADHD go far beyond attention and indeed, an array of memory difficulties may explain a lot of the difficulties these children show.

Interviewer: As you mentioned, some of your research looks at the area of memory and associated executive functions in children with neurodevelopmental disorders. Can you give an overview of some of the specifics of this particular research?

Dr. Sinead Rhodes: We have found, like other groups have now shown, that memory processes related to executive functioning, such as those involving using a strategy or updating memory, are a source of difficulty for many children with ADHD. However, we see the biggest affect sizes and the largest number of children affected, as this is a highly heterogeneous condition and children differ from one another in their profiles, on memory tasks that do not primarily have an executive function component. In particular, on tasks that tap delayed short-term memory, where the child has to hold an item in memory over delay period. Our research has consistently shown that they have difficulties in performing this kind of task. It is important to note that, on this type of task, they don’t have to update their memory or use a strategy to remember the item, but they just simply have to hold the item in memory, over time. Significantly, we’ve shown that this difficulty in maintaining information in memory over time is predictive of later ADHD symptom severity. We conducted a longitudinal follow-up of children over a five-year period and were able to show that.

We’ve also seen, in other work that we’ve conducted, that this difficulty in maintaining information and memory over time is predictive of a wide range of functions. One example, in a recent study that we’ve completed, is its implication in children with ADHD’s poor ability in terms of their pedestrian skills.

I’m now running a large scale research study looking at the role of this type of memory and other cognitive factors, on children’s academic learning. In this project, we’re breaking up the components of cognitive functioning, and educational learning, across a wide range of literacy and mathematics learning, to identify what thinking processes underline the difficulties children have with their reading, writing or maths. A really important aspect of this study and all of the studies that I do, is measuring the presence of co-occurring symptoms of related conditions. For example, in this ADHD study of autism and DCD, because it is highly likely that their presence influences for example, in this case, educational profiles, that co-occurrence within neurodevelopmental disorders is highly common. So it’s the norm. It’s not the exception. Most children will show symptoms of another condition that either at a clinical or subclinical level, might be explaining actually, a lot of their behaviours, rather than the primary diagnosis they have.

Interviewer: This may not be your line of research but I’m just wondering have you looked at any of the interventions? Is there anything that can be done to assist these children with their memory deficits, really?

Dr. Sinead Rhodes: One of the key lines of work that I’ve taken in that area is looking at the effects of stimulant medication on cognition and behaviour and ADHD. This research revealed a couple of novel insights into how stimulant medication as an intervention improves cognitive function.

First, we show that the difficulty many children with ADHD have in maintaining information in memory over time, we see the greatest improvement on this aspect of cognitive function with stimulant medication. It improves this and improves this function for a much greater number of children. Then, we see for example, in relation to executive function, showed this using quite a strong design. So, it’s a randomized controlled trial and we looked at children’s acute and chronic responses to stimulant medication. The children were drug naive so they were on a waiting list, having just been diagnosed and on waiting lists for medication. So, they were naive to prior medication use.

A second aspect of this, in terms of how stimulant medication works as an intervention is though, that it improves self-regulation. There’s been a commonly held belief that what medication does is slows down the child, solely and that this is how it works. Using a wide array of tasks, we were able to show that medication sometimes slows down performance. So, when children had to perform a complex planning task, where it was good to stop to work out all the steps, to think out all the steps involved and not respond before you had worked all of them out, that in this case medication slowed down performance and they had longer planning times. We found the reverse on some other tasks. So, on a simpler task, such as on a reaction time task where it was actually good to show speed in performance, so that you were encouraging the child to perform the task quickly and performing it quickly had a minimal effect or nothing at all on accuracy. And in this case, we actually saw the responses speed up, with medication. So, the medication seems to work by self-regulating the child and aligning them to the timing required for optimal task performance.

Interviewer: It’s really interesting. You’ve also examined cognitive factors underlying mental health, especially around depression and anxiety. And once again, I’m wondering a little more about the nature of the work and if there any findings that you can share?

Dr. Sinead Rhodes: Well interestingly, my research in the area of mental health has also really emphasized the importance of memory, including some of the aspects that I’ve mentioned already, but also other types of memory. So in one study, for example, we showed that adolescents who were clinically depressed showed an array of difficulties on a wide range of memory tasks, both those tapping short-term memory, but also long-term memory. These difficulties really stood out because they were generic to the memory tasks, but the participants also performed a whole range of very complex executive function tasks, like quite a difficult planning task. Also, a task involving attention flexibility and what we found was they actually had completely intact performance on this task. So, suggesting quite a specific set of difficulties in relation to memory.

The memory seems to be quite important in depression and that earlier work has really framed a lot of my later work, including applying study of memory in terms of mental health in neurodevelopmental conditions. In recent work, I’ve been focusing on the nature of depression in young people with autism spectrum disorder. This work has shown, firstly the depression is highly prevalent in young people with autism. Having a neurodevelopmental disorder is like a risk factor for developing mental health conditions.

Interviewer: Sinead, in your research, you’ve explored the role of reflective pondering and brooding rumination in adolescents and how these relate to the way we process emotional information. I’d like you to say something more about your findings, but I think in the first instance, it would be helpful to describe what behaviours typify reflective pondering and brooding rumination?

Dr. Sinead Rhodes: Of course. Reflective pondering is a non-judgmental attentional focus on problem-solving. So, it’s an adaptive form of thinking that is not negatively associated with symptoms of depression. Brooding rumination, on the other hand, is a maladaptive form of thinking. So, involving a passive attentional focus on the meaning of negative and self-blaming thoughts and has, in contrast, been positively associated with depression symptoms in adolescence. Our research has shown that reflective pondering, so the adaptive process, is a highly beneficial process. In impacting the other aspects of cognitive function that researchers have shown now, across studies, to be implicated in depression. So these for example, include over general memory, which has been associated with depression and the development of depression.

Interviewer: The association between over general autobiographical memory and depression is well documented, as you’ve described. Can you describe how your research has furthered the understanding of this relationship and the mechanisms at play?

Dr. Sinead Rhodes: This research has shown that reflective pondering may be an adaptive process, in relation to its interplay with other cognitive factors implicated in depression. So, we have shown that, in the context of engaging in high levels of reflective pondering, as executive function requirements increase and particularly, we see this when a person is processing emotional information, which is very relevant to depression, we see a decrease in over general memory. Of course, as I was mentioning, over general memory being implicated in depression and we found, in this longitudinal study of adolescents, that this relationship held after controlling, for baseline over general memory and symptoms of depression and anxiety.

What this points to, is the possibility that engaging in reflective pondering, this style of adaptive thinking, might be a protective factor in developing the memory problems that are associated with depression. But of course, this needs further verification and we need to examine this in relation to clinical samples.

Interviewer: Looking at some of your other areas of interest, I see you’re looking at cognitive predictors of mathematics and literacy in ADHD. Can you tell me a bit more about this work?

Dr. Sinead Rhodes: This is the key project I’m conducting at the moment. It involves recruiting children who are on the waiting list for ADHD assessment at child and adolescent mental health clinics, take part in a study that is primarily focused on cognitive function and academic learning. We’re looking at the role of a wide range of aspects of cognition, such as memory and executive functions and their relationship to educational learning. We’re looking very comprehensively, at academic learning examining, for example, written and oral expression, as well as word reading and reading comprehension. So, bringing up the components to look at quite discreet aspects of academic learning.

For example, within the comprable mathematics part of the project, we’re breaking up maths learning. So, rather than looking maths learning as one unit, we’ve broken it into components of factual, conceptual and procedural learning, based on work of others in the literature, but here, relating this to look at what cognitive factors might be influencing the components of learning because we know the children with ADHD have a lot of difficulties in their mathematics learning. We also know that they have significant difficulties in cognitive function, but we don’t fully understand yet, how these are interplaying and we really need to understand this if we are able to successfully build strategies to help children with these learning difficulties.

We’re building our more generic learning difficulties cohort because we include children who don’t receive a diagnosis but who obviously work hard because there is a significant cognitive or behavioural school-based issue, but might fall a symptom short or might not fall, neatly within a diagnostic category. We’re very interested in looking whether they are different or indeed, very similar to children who do receive a diagnosis in terms of their cognitive profile and their learning difficulties.

Interviewer:  You touched on this earlier, but I know you’ve been looking at tailored interventions to improve learning in ADHD. What does this research hope to show to be most effective when it comes to interventions?

Dr. Sinead Rhodes: I recently received funding to develop school-based intervention in relation to the project I was just describing, there, looking at cognition and learning. This project involves taking a toolbox approach to intervention. The current project has begun to show that there’s a wide variety of factors, cognitive and otherwise, that impact learning and huge individual differences in children’s learning profiles. Therefore, a one-size approach does not fit at all here. And this is why we want to develop a toolbox approach. We will be developing a range of strategies and techniques to facilitate learning. At first, with these children with ADHD.

So, just to give you an example, some will include an intrinsic focus. So, using mental strategies to aid learning like mental imagery, for example. But we’ll also be trialing the use of a variety of external tools that might help children with their organization, their timing and their ability to work out the steps in a task and to do goal-setting with those tools. Different children will need different components. So, this is the whole importance of using a toolbox approach, where teachers can decide which strategies will best fit with the child.

A really important part of this, though, is taking an individualized approach and the central part of developing the intervention lies around psychoeducation. Many children with ADHD are not fully aware of their symptoms in terms of how they specifically affect their behaviour and learning. So, understanding that their timing is not quite aligned, that they aren’t engaging in planning as long as another child is doing. That they’re having a difficulty in holding information in memory. They might not fully be in tune with this and a huge part of the intervention, within the first few weeks of it, will be conducting what’s called psychoeducation. So, teaching the child, facilitating them to learn about their own symptoms, so that we can then apply strategies that would be relevant to that particular child. It’s not that we necessarily need an individualized approach in terms of if we have 100 children, 100 different interventions. We expect children to fall into profiles where children will be similar to one another. That might be because a group of children also have co-occurring autism. So, they are the children who have sensory difficulties, for example, and that needs to be understood and applied in terms of strategies around their learning. Or it might be that those children were all born, premature and they have a certain profile associated with that. We believe that there’s a whole range of factors that might influence children’s profiles. Fundamentally, by profiling them across a wide range of aspects of cognitive function and educational function as well, we can actually tailor, using this toolbox approach.

Say there are ten components. A particular child might need seven of those ten. The next child might need a different seven, etcetera. A less impaired child might need three or four but they would tailor to do the difficulties that they have. A really important part of this project as well, is we’re developing it with class teachers and additional support needs teachers. It’s extremely important in work in this area, that what we do is sustainable and what we do is practical. So, we’re involving teachers to see what will ultimately be feasible within the classroom.

Interviewer: I was wondering if what you’ve described in terms of your research around both tailored interventions, your research around memory, your research around the use of medication, whether your findings are starting to become integrated into clinical practice?

Dr. Sinead Rhodes: A key aim is that this work will be integrated, both into clinical practice and within educational practice. There are a couple of ways in which we’ve initiated this to go along that pathway. Firstly, in terms of clinicians. We produce a clinical report based on the child’s educational and behavioural functioning, from the range of tasks that we do with the child. We visit the child at home at school. So, we have a range of data and we provide this to the clinical team and because they’re on the waiting list, this is timed exactly at the time of diagnosis, so that the clinicians actually receive this report on the child. So, it delivers a short-term impact from the research. Often, the impacts we have in research are three, five, even ten years down the road. They’re medium and long-term impacts. We’ve incorporated that. There is a lot of obviously, leg work involved in doing that and in clinical time, but we think it’s a really worthwhile short-term impact. From the off, is including the clinicians directly in the research and understanding the data in that respect, in the way it relates to an individual child. But ultimately, then, in relation to putting all of that data, anonymized together, and being able to produce identifying implications from the research in relation to cognitive function, behaviour, co-occurring symptoms, educational learning.

Then, in terms of the second part, in terms of schools, that touches on what I was referring to earlier. We’re involving both class and additional support needs teachers. We’re going to pilot the feasibility of including either or both within the design of the intervention. So, although a researcher is going in to develop and deliver the intervention, they will be testing out the feasibility of including teachers into the delivery. Because obviously ultimately, for the teacher, it is expected to be around an eight-week intervention. For the teacher to be able to use those strategies beyond, they need to be directly involved, both for that child but we’re hoping then, they would then apply those kinds of techniques to other children.

Interviewer: Sounds hugely important. Sinead, what other research projects excite you in this area?

Dr. Sinead Rhodes: There’s a couple of things, really. In terms of research that’s similar to ours, there are really exciting research outputs coming from a clinic in Cambridge called the Centre for Attention Learning and Memory or CALM Clinic, for short, that are really very interesting. They’ve taken a data-driven approach to examining cognitive function and learning difficulties, in many ways, similar to what I’ve been describing. They’ve been showing that this is successful in identifying profiles of children. So, regardless of diagnostic status.

More generally, in terms of the research field, I’m quite excited by the changing focus I’ve seen within research within the last couple of years in neurodevelopmental disorders in relation to co-occurrence. My research has consistently shown, from the first study that I conducted over 20 years ago, that co-occurrence is the norm. We increasingly know that the difficulties that a child has, might not be arising from the core symptoms of their condition. We know that children with ADHD often have difficulties in the classroom that might be down to sensory issues. But we don’t necessarily box that within an ADHD. It doesn’t fit within the diagnostic criteria for that condition. But often, these children have co-occurring symptoms of other conditions, which means we need to think very carefully when we’re thinking about difficulties the child has. We always need to be measuring co-occurrence. In this regard, it’s been really good to see work going on, more broadly.

In particular, the Embracing Complexity movement, which was launched a few months back by the charity Autistica. This movement brings together charities involved with neurodevelopmental disorders, to improve outcomes for children in relation to co-occurrences. So, focused on creating more joined-up approach for research, health and social care services these children need. It’s really good to see that that is operating on that level and I think we will see a shift over the next few years. We’re beginning to see that already but a continued shift whereby researchers, clinicians, etcetera, acknowledge the commonality of co-occurrence and that less spoken about children having a single condition. We tend to fall into, and I’ve done already in this podcast, children with ADHD versus children with autism, etcetera. Whereas, we need to be thinking much more broadly than that, but I think we’re definitely on that path now. So, that’s a really exciting development in this area.

Interviewer: Thank you. Sinead, you are the founder of the Research the Headlines project. Can you tell me what Research the Headlines is all about?

Dr. Sinead Rhodes: Research the Headlines is a multidisciplinary project, focused on improving the public’s understanding of research, as presented in the media. So, the group, which I formed back about five years ago, are members of the Royal Society of Edinburgh Young Academy of Scotland. They come from a wide range of disciplinary backgrounds. So, from psychology, to history, to astronomy. We write blog posts and in typical posts, we take recent media coverage of a research study as a starting point and discuss the sourced research in greater detail, outline what it might mean for the reader and allow them to reach a better understanding of what the study involves. The blog was inspired by the highly successful NHS Choices’ Behind the Headlines project. Research the Headlines moves beyond a focus on health-related stories, with posts coming from researchers and professionals spanning the diverse backgrounds that I’ve already described.

Among the most read blog posts we have, are pieces discussing research about the predictability of weather forecasting, health issues around alcohol consumption and bits about the refugee crisis. So, really quite a wide range of topics. We also complement existing blogs by taking an educational approach. We have a special series of how to Research the Headlines, which provides ten top tips on interpreting media reporting of new research. That series is often referred to by our writers within the regular posts as a means of highlighting the simple but, you know often very recurring issues in research as reported in the media, explaining how to weigh up the evidence and how research is conducted.

Interviewer: Can you discuss research that has been in the media spotlight that you’ve explored through Research the Headlines?

Dr. Sinead Rhodes: Well, I guess coming back to my pet topic, ADHD. We frequently see ADHD being misrepresented in the media, where myths about the condition are repeated and dramatized. Some of this has included media coverage of work that I have covered. So, on stimulants. So, for example, referring to a hike in prescriptions in the UK, without mentioning the caveat that this increase reflects what was a very low baseline of prescription rates, to actually what is still now, a very low rate, given the number of people we know are affected by those symptoms and who would benefit from the medication. ADHD is very much under-diagnosed in the UK, in relation to other countries, but we don’t see that kind of representation in the media. We’ve written numerous articles on this topic in a style that’s accessible to the general public. So, parents can understand what the research is actually showing. I’m very involved with a range of parent support groups, particularly ADHD parent support groups and they regularly message me, linking a media article. They’ve had comments from family or friends. Oh, ADHD is caused by this or caused by that or over-diagnosed or you know, things about stimulant medication. I will then blog about that in a way that’s accessible, in a way that they can understand it and that explains and for them, helps to validate their child’s condition to those who’ve been asking questions or linking them to these articles.

Interviewer: Why is engagement of this sort so important?

Dr. Sinead Rhodes: People don’t have the ability to access information. Sometimes the articles that we publish are not readily available, free. There is an open access movement but not all articles are available online. This work, where we take the research and describe it in ways that are generic, that the general public can understand, is extremely important. They know, whether they go to NHS Behind the Headlines, because they blog about the same sort of articles, or Research the Headlines, that they can understand and trust the research descriptions that they’re reading.

Interviewer: What is the website for Research the Headlines if somebody wants to take a look at that?

Dr. Sinead Rhodes: It’s just researchtheheadlines.org, and we’re also on Facebook. If you just go into Facebook and put Research the Headlines and on Twitter @RestheHeadlines.

Interviewer: Brilliant. Sinead, what else is in the pipeline that you’d like to mention?

Dr. Sinead Rhodes: One of the areas I’m very keen to develop within my research is improving understanding and interventions for mental health, but in children and young people with neurodevelopmental conditions. So, it’s very much marrying up the two strands of research that I’ve been conducting over the past 20 years. Looking at them in isolation and bringing them together and this is really important because of what I was describing earlier as a huge risk factor having a neurodevelopmental condition is for mental health. So, for example, in autism some reports suggest one in every two will develop depression. The risk is extremely high and we don’t understand why. There will be a range of social, cognitive, behavioural factors and that are inputting into that and it’s really important that we have research in that area.

But going back, we’re really at a very fundamental stage, I think, in terms of research in that area because going back, methodologically, a lot of the screening measures that we have so, the first thing that we do when we conduct a study is we are recruiting participants and we are describing their characteristics but the tools that are used to measure mental health, have mostly, although there is some advancement in this area, have been normed with typically developing children and young people. So, they often include items that are just not… That confound with symptoms. So, I’ve just recently started a study where we’re going to develop a new screener for assessing depression symptoms in children and young people with autism. As a first stage in being able to conduct research where we know the participants that we’ve recruited, that we are assessing them on tools that are actually suitable in relation to their condition. This also applies to ADHD and other conditions, not just autism.

Interviewer: Sinead, is there anything I haven’t asked that you would like to add?

Dr. Sinead Rhodes: I think a final point that I would like to make is just to touch on the complexity of conducting research with children and young people. Fundamentally, the research I’m describing cuts across health and education. As you’ve heard in the description of the project, this involves NHS recruitment so that we have comprehensive medical profiling, so that we can recruit children on waiting lists before they’ve taken medication, etcetera. That also recruits them when they’re early in terms of the pathway of just being diagnosed. But also fundamentally, children spend most of their days in school and when we’re interested in learning or other areas like mental health, we really need to understand those processes in the place where they spend most of their time. This provides quite a lot of complexities in terms of the different organizations, the different ethical permissions that we need to get. It’s quite complex, but also, it’s quite complex in terms of funding because a lot of funding schemes are specifically aligned to health or to education. So, it poses some challenges, but I do believe if we are to understand children, systematically, we need to do so within the settings in which they spend time with. So, although it takes a lot of time to do this research. It’s fundamentally important to understanding the complexity of their conditions and its impact on their behaviour, learning and mental health.

Interviewer: What is your takeaway message for those listening to this podcast?

Dr. Sinead Rhodes: I think my takeaway message would really follow on from that, in that research with children and young people in relation to their cognitive function behaviour, their learning, mental health, is very complex. And so, I think to achieve a satisfactory understanding of children’s development in relation to having a delay or difference, we need a complex approach. So, multidisciplinary and a multi setting approach. In that way, I think we can ensure that we deliver world-class research in this area. Input from a variety of professionals with different disciplinary backgrounds, as well as including children and their families from the very early stages of the design of the research, right through to testing and assessing them in the settings in which they attend, will ensure that we have true understanding and can resolve their difficulties in a way that’s feasible and sustainable.

Interviewer: Sinead, thank you ever so much. It was really enlightening. To learn more about Dr. Sinead Rhodes and her research into the cognitive factors, underlying behaviour and learning, visit the ACAMH website at www.ACAMH.org and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H.

Close: This podcast was brought to you by The Association for Child and Adolescent Mental Health, ACAMH for short.

ENDS

Sinéad is a developmental psychologist who is interested in the cognitive factors underlying behaviour, learning and mental health. Her research has principally focused on cognition, especially memory and associated executive functions, in children with neurodevelopmental disorders, including ADHD, ASD and Williams syndrome.

She also examines cognitive factors underlying mental health especially depression and anxiety, and is particularly interested in cognition and depression within the context of neurodevelopmental disorders. (bio via The University of Edinburgh)