ADHD, Self-Harm, and the Importance of Early Childhood Intervention – In Conversation with Dr. Melissa Mulraney

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In this podcast, we talk to Dr. Melissa Mulraney, Senior Lecturer and co-leader of the Child Mental Health Research Centre at the Institute for Social Neuroscience in Melbourne, Australia, Honorary Research Fellow at the Murdoch Children’s Research Institute in the Department of Paediatrics at the University of Melbourne, and Associate Editor of CAMH.

Melissa discusses what influenced her to specialise in child and adolescent mental health, as well as highlights some of her most recent papers that focus on her research interests (ADHD, emotional dysregulation and sleep).

Melissa also discusses her work at the Murdoch Children’s Research Institute, including her work on several clinical trials of behavioural interventions for child mental health problems.

Melissa has won the World Federation of ADHD Young Scientist Award in both 2019 and 2021 and, in this podcast, talks about her work on suicidality and self-harm in adolescents with ADHD.

Furthermore, we hear Melissa talk about the importance of evidence-based research when it comes to children and young people’s mental health, plus what more can be done to disseminate and promote evidence-based science.

You can listen to this podcast directly on our website or on the following platforms; SoundCloudApple PodcastsSpotifyCastBox, DeezerGoogle Podcasts and (not available in the EU).

Dr. Melissa Mulraney
Dr. Melissa Mulraney

Dr. Melissa Mulraney, PhD is a lecturer and co-leader of the Child Mental Health Research Unit at the Institute for Social Neuroscience in Melbourne, Australia. Dr. Mulraney is an Associate Editor of CAMH and contributes to the editorial management of the systematic reviews and meta-analyses submitted to CAMH.

She is also an Honorary Research Fellow at the Murdoch Children’s Research Institute, and in the Department of Paediatrics at The University of Melbourne. Dr. Mulraney received her PhD from Monash University and completed post-doctoral training at the Murdoch Children’s Research Institute. Dr. Mulraney’s main research interests are in ADHD, emotion dysregulation, and sleep. She has authored multiple publications on these topics. She is recognised as an emerging leader in the field of ADHD, having won the World Federation of ADHD’s Young Scientists’ Award in 2019 and 2021.


[00:00:27.782] – Jo Carlowe: 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. Melissa Mulraney, Senior Lecturer and co-leader of the Child Mental Health Research Centre at the Institute for Social Neuroscience in Melbourne, Australia. Melissa is an Associate Editor of CAMH and an honorary research Fellow at the Murdoch Children’s Research Institute in the Department of Paediatrics at the University of Melbourne. Melissa’s main research interests are in ADHD, emotional dysregulation and sleep.

[00:01:08.073] If you’re a fan of our In Conversation series, please subscribe on iTunes or your preferred streaming platform and let us know how we did with a rating or review and do share with friends and colleagues. Melissa, thank you for joining me. Can you introduce yourself?

[00:01:22.371] – Dr. Melissa Mulraney: Thanks Jo. It’s really great to be here. As you were saying I’m based in Melbourne in Australia which is a really fantastic place to live and work. I completed my PhD at Monash University and then moved to the Murdoch Children’s Research Institute for my postdoctoral training, and that’s where I began working in ADHD research. I have co-ordinated a couple of randomised control trials of psychological interventions for children with ADHD, and as much as I love my research, a real passion of mine is teaching. Last year I accepted a teaching and research position at the Institute for Social Neuroscience and my role at the Institute, as co-leader of the Child Mental Health Research Centre, has really provided me with the opportunity to further pursue my research into understanding and treating irritability and emotion dysregulation in young people.

[00:02:18.749] – Jo Carlowe: What made you specialise in child and adolescent mental health?

[00:02:23.169] – Dr. Melissa Mulraney: Probably some of the main drivers were that we know a lot of adult mental health problems have their origins in childhood, so being able to effectively identify and treat those problems before they become really entrenched is super important, and there’s also a lot of research that shows that mental health problems are really under recognised in children, and some of the work that I’ve published over the last few years has shown that children are often experiencing mental health problems for a number of years before they’re accessing services.

[00:02:57.122] So this has some really, really important and potentially lifelong consequences because we know mental health problems impact on children’s ability to be able to do well at school and to develop friendships and social skills. So I think that childhood is a really crucial time when we should be doing whatever we can to identify mental health problems so that we can intervene as early as possible and ideally prevent these children from developing mental health disorders.

[00:03:27.728] – Jo Carlowe: Let’s turn to some of the work you’ve published on this. You’ve authored multiple publications on your research interests. Can you highlight some of the most recent papers and anything that stands out from these?

[00:03:41.127] – Dr. Melissa Mulraney: Actually, my most recent paper really closely relates to what I was just saying. A few weeks ago I published a review of the literature in neuroscience and bio-behavioural reviews, and this paper looked at all of the papers that have been published where children were assessed for mental health problems in childhood, and then they were followed up into adulthood and assess their mental health disorder, and what we found was that experiencing mental health symptoms in childhood, even as young as five years of age, were predictive of mental disorders well into adulthood.

[00:04:18.839] And across all the studies that we reviewed there was more consistent evidence of a link between elevated symptoms and adult disorder than between a diagnosis in childhood and a diagnosis in adulthood. So what this really points to is a need for us to be intervening early before those symptoms that children are experiencing progress to disorder because the children won’t necessarily grow out of any difficulties that they’re experiencing.

[00:04:46.833] – Jo Carlowe: Talking of interventions I want to turn to your work at the Murdoch Children’s Research Institute. So you’ve worked across several clinical trials of behavioural interventions for child mental health problems. Can you tell us something about these interventions? What did they aim to tackle and what were the outcomes?

[00:05:06.228] – Dr. Melissa Mulraney: These trials that I’ve worked across were mainly related to treating common problems that children with ADHD experience. So two in particular come to mind. One was a trial to treat sleep problems and another to treat anxiety in children with ADHD, and the reason why we did these studies is that children with ADHD often experience a broad range of difficulties that make their day to day life a lot more challenging than it is for the average child, and this is even if they’re being effectively treated for their ADHD symptoms.

[00:05:41.687] We wanted to see if treating these common problems would improve overall quality of life and general wellbeing for these children. So I might just give an example of the sleep intervention trial that we conducted. So in this intervention that we tested, we teach parents and children about how to put in place healthy sleep habits, as well as giving them strategies to manage specific sleep problems that their child might have. So, for example, if a child is having a lot of trouble falling asleep, say their bedtime is 7pm and they’re not falling asleep most nights until around nine or 10 o’clock at night, we might suggest something that we call bedtime fading.

[00:06:23.012] So what bedtime fading involves is temporarily changing the child’s bedtime to when it is that they’re actually falling asleep. So, as you can imagine, this is very popular with children and less so with parents, and the idea is that that’s when the child is falling asleep naturally. It sort of circumvents those couple of hours of arguments and fighting back and forth when the child is not falling asleep, and then the idea is that once the child is easily and quickly falling asleep at the new bedtime, every few nights to gradually move that bedtime forward by ten, 15 minutes or so, so you eventually get to the point where they’re falling naturally asleep at the bedtime that they should be falling asleep at.

[00:07:08.769] Basically what it’s doing is retraining the child’s body clock. We used a really flexible approach to make sure that the strategy matched the child’s sleep problem and what the family was able to manage, and we found that the intervention was really effective. It improved the child’s sleep, and it also had benefits in terms of reduced ADHD symptoms and improved quality of life for the child and some impact on improved parent mental health as well.

[00:07:34.585] – Jo Carlowe: Melissa, you are actually recognised as an emerging leader in the field of ADHD, having won the World Federation of ADHD Young Scientist Award in both 2019 and 2021. For the recent award, 2021 one you focus on suicidality and self-harm in adolescents with ADHD. Can you tell us about your work in this area and any takeaways from it that feel important to share?

[00:08:03.476] – Dr. Melissa Mulraney: This is an area that I’ve only recently started working in, and I won this award for a paper that I wrote where I used data from a nationally representative sample of Australian adolescents. So within that sample, around six and a half percent had ADHD but there were also 20% of adolescents who had a number of symptoms of ADHD, but they didn’t quite meet the criteria for a full diagnosis. So we’ll call those kids sub-threshold ADHD, and what we found was that compared to those young people who didn’t have any symptoms of ADHD, the adolescence who had ADHD and who had sub-threshold ADHD were both more likely to have suicidal thoughts, and they were also more likely to have attempted suicide in the previous twelve months.

[00:08:57.601] Probably the key finding from this study to me was that the adolescence with sub-threshold ADHD were just as likely to be reporting self-harm and suicidal thoughts as those adolescents who had a full diagnosis. So this is really important information for health and education providers, because knowing that these kids are at risk of self-harm even if they’re not meeting the full diagnostic criteria, means that we can look out for those symptoms and better identify and provide support to those young people who might be needing them.

[00:09:34.571] – Jo Carlowe: Were the sub-threshold ADHD young people more likely to be missed?

[00:09:39.210] – Dr. Melissa Mulraney: Yes, they were much less likely to have access to services or to have been diagnosed with any mental health disorder.

[00:09:48.509] – Jo Carlowe: So what’s the message then to professionals working in the field of mental health and in education in terms of spotting those children or signposting them to the right places?

[00:10:01.267] – Dr. Melissa Mulraney: It’s a tough question. So the symptoms of ADHD include things like being quite impulsive, which has been known for a long time to be a risk factor for suicidal behaviours. I think being quite aware that these kids could potentially be at risk just because they may be presenting as a bit milder doesn’t necessarily mean that they’re not struggling, that they’re not suffering, that they don’t need additional support.

[00:10:32.750] – Jo Carlowe: It sounds really important. Melissa, what else are you working on currently?

[00:10:37.467] – Dr. Melissa Mulraney: So I’ve just actually recently begun a clinical trial to test whether a family based psychotherapy is an effective treatment for children with severe irritability, and the reason why we’re undertaking this study is that irritability is a really common issue that’s experienced by children and adolescents that actually increases the risks for future anxiety and depression, and we know that around half of the young people who are accessing mental help services are actually experiencing severe irritability that’s impacting on their day to day lives but despite this we really don’t know very much about how to best treat irritability in young people.

[00:11:20.501] So the intervention that we’re testing involves parents and young people working together with a clinician to identify and solve problems that are consistently leading to anger and conflict. So we’ve just begun recruitment for this study this month, actually. So it’ll probably be a couple of years before we know the outcomes of it.

[00:11:41.980] – Jo Carlowe: Sounds really interesting. We’ve focused on a fair bit of your research. Can you say something about how you go about translating your research into practice?

[00:11:51.681] – Dr. Melissa Mulraney: So this is a really big challenge for most researchers, I think, and there’s a number of different approaches that I take. So I teach postgraduate psychology students in my role at ISN and I’m always making sure that I am incorporating findings of my own research, but also other people’s research into the content that’s being taught to these trainee psychologists. I’ve also been fortunate enough to have the opportunity to run some workshops. Training clinicians, so paediatricians and psychologists, for the most part, in the sleep intervention that I was speaking about earlier, and a really unique opportunity that happened two years ago now is that in Victoria, which is the state of Australia that I live in, we had a Royal Commission into mental health services across the state.

[00:12:44.374] So a Royal Commission is a major investigation that’s independent of government, and it has really broad powers to hold public hearings, call witnesses and compel evidence, and the point of a Royal Commission is to investigate matters of great importance to the public, and they collate all of their evidence and then table a report to the government with recommendations about changes to policy that need to be implemented.

[00:13:13.617] A number of the papers that I had recently published about access and use of mental health services in children were actually tabled at this Royal Commission, and they published their final report late last year, and a number of the recommendations that they’ve made which have been taken up by the government actually related directly to increasing access to services for primary school aged children. So that was very exciting.

[00:13:42.180] – Jo Carlowe: As we’re talking about policymakers, what message should policymakers take from your findings more generally around child and mental health issues?

[00:13:53.021] – Dr. Melissa Mulraney: The number one message from all of the research that I’ve conducted is that government and policymakers need to be investing in child mental health. As we’ve already spoken about today, my work’s shown that mental health problems in primary school aged children can have lifelong impacts and those papers that I submitted to the Royal Commission showed that children were often experiencing elevated symptoms of mental health problems for several years before they first access services, and what we found that when they were accessing services most children only attended one to two appointments, which is really very unlikely to be enough to appropriately treat whatever issue that they had.

[00:14:39.924] And there were also major barriers to accessing care, including very high costs and long waiting lists. So a lot of these problems could potentially be solved through greater investment in child mental health services.

[00:14:53.914] – Jo Carlowe: Are you optimistic that the recommendations from the Royal Commission will be taken up?

[00:14:59.096] – Dr. Melissa Mulraney: Some of them have already started being put in place. So I think, yes, I’m very optimistic they’ll be taken up. I think that there will be some teething issues, and I don’t think it’s going to solve everything, but we’re taking steps in the right direction.

[00:15:17.013] – Jo Carlowe: Melissa, you’re an Associate Editor of CAMH and you contribute to the editorial management of systematic reviews and meta-analyses submitted to CAMH. What advice do you have for current and future contributors to CAMH?

[00:15:32.331] – Dr. Melissa Mulraney: So I think probably the most important thing is to be really clear about what the clinical message of your paper is. So what do your findings mean in practical terms for clinicians working in the field? Any papers that have a really clear clinical message about how we can support child and adolescent mental health and that are based on good science will always be looked upon favourably by the editorial team.

[00:15:58.052] – Jo Carlowe: Why is evidence-based research so important when it comes to children and young people’s mental health?

[00:16:05.624] – Dr. Melissa Mulraney: Evidence-based research is really important in every field. It’s particularly critical to make sure that we’re providing young people with the care that they need to ensure that they’re having the best possible start to life. So perhaps if I provide an example, the Royal Children’s Hospital in Melbourne regularly conducts national polls on different topics related to child mental health, and a few years ago a poll found that one in three parents believed that children would grow out of their mental health issues and that it was best to leave them alone to work it out themselves.

[00:16:42.561] So when we combine that with the work that I’ve already been talking about today, that’s shown that this is clearly not the case that informs us that to be making sure that we’re getting the best outcomes for children, not only do we have to invest in services and prevention programmes, but we also need to be investing in increasing mental health literacy in the population.

[00:17:04.486] – Jo Carlowe: Given what you just said about one in three parents believing their kids will grow out of it. What more can be done to disseminate and promote evidence-based science of both the professionals and I suppose also to the layperson?

[00:17:18.797] – Dr. Melissa Mulraney: That’s a really good question and I think that as academics we’re really good at writing for and communicating with other academics, but we’re not so good when it comes to explaining our work to the general public and to policymakers. I think we probably need a combination of approaches and probably most importantly we need to start working closely with those people who are skilled in those types of communication and working with them so that we’re crafting our message in a way that’s understandable and digestible to the general public and the layperson. I also think we need to be better at using the power of social media platforms as well as traditional media to get our messages across.

[00:18:05.546] – Jo Carlowe: Thank you. Melissa, what else is in the pipeline for you that you’d like to mention?

[00:18:10.283] – Dr. Melissa Mulraney: Probably the other major project that I’m working on at the moment is I’m working with a global team of clinical experts, researchers and patient advocates on a collaborative project with the International Consortium for the Harmonisation of Outcome Measures. It’s quite a mouthful. They go by the acronym ICHOM. So the project is actually funded by the NHS to develop a standard set of outcome measures for neurodevelopment disorders, and the aim of creating these standard sets is to make sure that the outcomes which are most important to patients themselves are being measured in a standard way, and doing this helps make sure that the treatment decisions that clinicians are making are those that are most likely to improve the outcomes that are really important to the patient. So we’re sort of a third of the way through the process of that and looking to have the standard set complete early in 2022.

[00:19:12.059] – Jo Carlowe: And finally, what is your takeaway message for those listening to our conversation?

[00:19:17.514] – Dr. Melissa Mulraney: I think the number one message that I’d like to get across is that young children can and do experience mental health problems. It’s not just something that begins to be an issue during adolescence, and these problems are unlikely to resolve themselves. So it’s critical that we’re really vigilant for these issues in younger children so that we can put in place appropriate care and support.

[00:19:44.295] – Jo Carlowe: Excellent. Melissa, thank you ever so much. For more details on Dr. Melissa Mulraney please visit the ACAMH website, and Twitter @acamh. ACAMH is spelt A-C-A-M-H and don’t forget to follow us on iTunes or your preferred streaming platform and let us know if you enjoy podcast with a rating or review and do share with friends and colleagues.

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