This episode of our JCPP Advances series that focus on the papers and editors featured in the publication is with Dr. Nicola Wright, research associate at the department of Biostatistics and Health Informatics, Kings College London.
Nicola discusses her paper ‘Interplay between long-term vulnerability and new risk: Young adolescent and maternal mental health immediately before and during the COVID-19 pandemic’, including details of the methodology, results and implications of findings.
As well Nicola discusses the role of gender in their analysis, and highlights that one in four girls compared to one in ten boys, were experiencing clinically significant depression during the lockdown.
Nicola joined Kings in 2018 after completing her PhD in Clinical Psychology at the University of Liverpool, where she also completed an Msc in research Methods. She completed her PhD part-time whilst working as a Research Assistant on the Wirral Child Health and Development Study, an MRC funded prospective birth cohort study. Nicola’s areas of expertise include early-onset antisocial behaviour, particularly aggression and callous-unemotional traits.
Interviewer: Hello, welcome to a different type of In-conversation podcast from the Association for Child and Adolescent Mental Health, ACAMH where we will look at the paper “Interplay between long term vulnerability and new risk, young adolescent and maternal mental health immediately before and during the covid-19 pandemic”, recently released in the first issue of JCPP Advances. I’m Jo Carlow, a freelance journalist with a specialism in psychology, and I have with me Dr Nicola Wright, Research Associate at the Department of Biostatistics and Health Informatics at King’s College, London.
Nicola is the first author of the paper that we’ll be discussing today. 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. Hi, Nicola, thanks so much for joining me. Can you briefly introduce yourself?
Dr. Nicola Wright: Hi, Jo. Thank you for having me. I’m Nicola, a Research Associate in the Department of Biostatistics and Health Informatics at King’s College. My background is in psychology and my research focuses on understanding mental health problems in childhood.
Interviewer: And as mentioned in the intro, you have co-authored the paper “Interplay between long term vulnerability and new risk, young adolescent and maternal mental health immediately before and during the Covid-19 pandemic” published in JCPP Advances. Can you start with a summary of the paper? What did you look at?
Dr. Nicola Wright: We know that adolescent mental health was already a topic of major concern prior to the pandemic. Evidence shows that adolescence is a period of rapid increase in mental health problems. So it was really important to conduct high quality research to understand the impact of the pandemic on adolescent mental health. We focussed on a sample of young people all in the early stages of adolescence, they were all aged 11 to 12 years, and we tested whether there was an increase in young adolescent mental health problems from immediately prior to the onset of the pandemic in the UK to four months post onset of the pandemic in the lockdown.
We also tested for an increase in their mother’s mental health symptoms, and we examined whether there was any change in these symptoms that was moderated by Covid specific factors, such as having a parent who was a front-line worker or specific Covid related financial impacts. And we also examined whether any increase in mental health problems was moderated by child gender, because we know that the sex difference in a depression emerges in adolescence and by pre-existing mental health problems earlier in childhood.
So we could ask the question whether those with prior problems were disproportionately affected by the pandemic.
Interviewer: Can you say how you tested for this? What methodology did you use?
Dr. Nicola Wright: The young adolescents and their mothers are all part of an existed representative birth cohort study which is based in the Wirral, in the northwest of England called the Wirral Child Health and Development Study. It’s led by my co-authors, Professor Jonathan Hill, Professor Helen Sharp and Professor Andrew Pickles. I’m currently the postdoc on the study. I’ve worked on the study for 11 years. So we were actually already collecting questionnaire data from our families as part of the age 11 assessment wave.
We started this in December 2019, it was both online and paper questionnaires, depending on the preference of that family. As we assessed the sample every year or so, right through development, we were just getting another catch up on their mental health and various other outcomes. But when the social distancing measures were announced on March 17th we decided to pause the wave and we secured further funding to repeat the same questionnaires on the same families again.
Dr. Nicola Wright: We did this during the lockdown in June 2020. We were in a very unique position having collected data on their mental health immediately prior to the pandemic and then again during the lockdown, because most other studies which have examined for a rise in mental health problems, their pre-pandemic measures were often taken several years before the pandemic. So it’s much harder to readily attribute change to the pandemic itself for so much time.
Interviewer: Very fortuitous.
Dr. Nicola Wright: Yes, and what also sets us apart, as I mentioned, is that we collect both paper and online questionnaires. Most Covid surveys were limited to collecting from online only. We were able to reach a wider audience that way, but critically due to the high level of engagement that we already have from our families we were able to secure a really high retention rate and we got 89% of our post-Covid surveys completed. This is actually now at 96% because we set the cut-off date for this specific analysis, but we collected a few more after in the August. Ended up with a retention rate that is much higher than the other Covid surveys, which are typically around 30 to 50%.
And we also have both child and mother report of the young person’s mental health and we assessed a range of different problems with separate measures which have clinical cut-offs, which have been established against diagnostic interviews. So that means we can report on both an increase in symptoms and on increase in rates of clinically significant problems.
Interviewer: So it’s really comprehensive. Nicola, can you share a few headline findings?
Dr. Nicola Wright: We found that young adolescent’s depression symptoms increased by 44%, according to their own report, and 71% according to their mothers. The proportion with clinically significant depression, increased from 11% pre-pandemic to 18% post-onset, so four months later, on average. We also found that child behavioural problems symptoms increased by 46%, with rates of clinically significant problems
increasing from 6% pre-pandemic to 10% post-onset of the pandemic. We also collected data using a post-traumatic stress symptoms measure and we found symptoms increased by 26%, according to the young adolescent, and 43% according to their mother.
But we do note in the paper that this rise was driven by the symptoms which overlap with depression. We didn’t actually see a change in the symptoms that only represent post-traumatic stress. So we’re not that confident in that finding. But we found similar to the child, mother’s own symptoms of depression increased by 42%, but in both mother and in young adolescent there was no increase in anxiety.
Interviewer: I wanted to ask you about that. That seemed very curious. What you make of that fact there was an increase in symptoms of depression, but not anxiety.
Dr. Nicola Wright: Yes, because this is not something that many other studies have been in a position to show, because they often use combined measures of emotional problems which combine anxiety and depression. For the young people it is important to note that there was a difference in the measures that we use. Although the anxiety measure we used is frequently used in research and it has been shown to be sensitive to change over time, in it the symptoms are phrased in quite trait like terms and there’s also no defined rating period on the measure.
So in the depression measure the symptoms are asked for the prior two weeks whereas the anxiety measure there’s no rating period given. We also only collected mother report of child anxiety. We didn’t collect child report of their own anxiety because we do have a limit on how much we can ask these 11, 12 year olds. But as I said before, mothers’ report of child depression symptoms was actually greater than the child’s report of their own so that doesn’t really explain why we wouldn’t find an increase for mothers’ report and explain why we didn’t see an increase in the mother’s own anxiety, because that measure did have a rating period of two weeks, and it’s the most commonly used measure in the NHS for treatment outcome.
We’re not sure why, but just to speculate, it may be that in the short term the lockdown measures had led to a decrease in anxiety by removing some of the stressors associated with life outside the home.
Interviewer: So things like pressure from school, social anxiety, that type of thing.
Dr. Nicola Wright: Yes, something I’ll pick up on again later is perhaps by increasing the lockdown measures may have increased the availability of supportive resources within the family. This is only speculation though. We didn’t try out any specific mechanisms in this paper and of course, this is at the end of the lockdown in June last year. It would be very important to follow this up and look at anxiety levels over time.
Interviewer: I just want to return to the discrepancy between the parent and child depression rankings. What do you make of that, which is considered more representative of how things actually are?
Dr. Nicola Wright: It’s tricky with depression which is very internal. On the one hand, by this age 11 to 12, we expect children to be able to report on their own internal experiences fairly well, and we expect them to be more aware probably of their own internal experiences. We would favour the child’s report of their own symptoms. The mothers did report a greater increase, and depending on how open the child is, the mother will either be rating based on her observations of the child and inferring what’s going on. Or if the child’s very open with the mother then perhaps they are sharing, but symptoms of depression some of them are visible and some of them are not visible. At this age we consider the child report the best source.
Interviewer: Thank you. I think you said that behavioural problems increased by, was it 46%.
Dr. Nicola Wright: Yes.
Interviewer: What do you account for with this?
Dr. Nicola Wright: We’re very interested to see this. The focus in adolescents is very much on emotional problems and depression. So originally the world study was designed to look at the earliest origins of childhood cognitive problems, that we do have good measures of behavioural problems in our sample. To try and understand this a bit more and one of the strengths of conducting this study within our existing longitudinal study is that we have data on the children from earlier in childhood. We did look at the interplay between having had behavioural problems previously at age seven years and the increase associated with the pandemic.
The first finding to note is that previous behaviour problems were strongly associated with pre-pandemic rates of behavioural problems. 42% percent of children who had clinically significant problems at age seven years had clinically significant problems pre-pandemic and this then raised to 49% post onset of the pandemic. It really does highlight the stability of clinically significant behavioural problems from childhood to adolescence. The actual interplay that we found was that the increase in children without prior problems was disproportionately higher.
So that means that there are new onsets of behavioural problems associated with the pandemic, as well as an exasperation for those children who are already at risk for having problems from having had problems in childhood. We saw new onsets in those which we would speculate are associated with the pandemic.
Interviewer: Right. Let’s turn to gender. What did your study reveal about gender differences in depression in young people? Did Covid exacerbate existing differences?
Dr. Nicola Wright: We know that there is a gender difference in depression in adulthood with women suffering at higher rates than men and that this gender difference emerges in adolescence. So that’s why we wanted to look at the role of gender in our analysis. In the Millennium Cohort Study, which is a very large sample of UK children followed from birth to early adulthood their data showed very similar rates of depression in boys and girls at age seven and at age 12 years, and then at age 14 the striking gender difference emerges.
Within in their sample it was 24% of girls, compared to 10% of boys reporting clinically significant depression. We expected to find the same in our sample. We used the same measure, but we did actually observe a gender difference prior to the pandemic at age 12 years so it was already present at age 12 years in our sample. 15% of girls, compared to 5% of boys reporting clinically significant depression. What was interesting from our findings was that in our post-pandemic measures the rates of depression mirrored those observed at age 14 years in the Millennium Cohort Study, meaning that one in four girls compared to one in ten boys were experiencing clinically significant depression in the lockdown.
Whilst the pandemic hasn’t widened the gender difference because the rates of depression were already high in girls. By post onset of the pandemic they were at worryingly high levels. So we haven’t exasperated the gender difference, but the end result for the girls in the four months after the onset of the pandemic was quite worryingly high rates of clinically significant depression.
Our findings may suggest that the pandemic has brought forward this increase in rates of depression, which the Millennium Cohort Study only observed age 14 years. We need further follow up to examine whether this has persisted, but as we know that childhood and adolescent depression and behavioural problems predict lifelong risk and mental health problems and poorer functioning in adulthood, our results show that the pandemic has definitely added to this risk
Interviewer: Nicola, what other factors emerged as either protective or detrimental to mental health during the pandemic?
Dr. Nicola Wright: We set out to test a range of Covid specific variables. We pre-registered this analysis before we did it and we were looking at other papers that have been published and editorial pieces, aspects of the pandemic, which we thought might moderate the increase in symptoms. For example, a parent being a frontline worker or specific financial impacts related to the pandemic but we didn’t actually find that any of those variables moderated the increase. It is important to note that the sample that we had assessed pre pandemic is smaller than the whole Wirral sample as we conduct each wave in age order so we hadn’t approached the whole sample when March 17th came around. We do have less statistical power in our analysis to detect moderator effects.
Also I think something that we’ve heard a bit about in the media and certainly we’ve heard from families in our study, is that the impact of the pandemic is often a mix of both positive and negative experiences. Half of the mothers in our sample reported that the effects of the lockdown itself were more positive than negative, with many describing enjoying spending more time together as a family.
We can speculate that we may not get the whole picture if we analyse the negative impacts in isolation. But what we did find was a surprising finding for us was that family deprivation status, which we assess using a postcode based system called the indices of multiple deprivation, we found that this moderated the increase in both mother and child’s depression and it was that for those families who lived in less deprived neighbourhoods they experienced a greater increase in depression.
Interviewer: Oh really, deprived neighbourhoods.
Dr. Nicola Wright: Yes, so the less deprived families, but when we interpret this finding we have to consider it within the context that pre-pandemic those families had lower depression scores than those living in deprived neighbourhoods. What seems to have happened is the pandemic seems to have led to a sort of levelling up with the depression levels of those less deprived families reaching the levels of the deprived.
Interviewer: It’s really interesting.
Dr. Nicola Wright: And when we looked at the literature on the existing studies conducted with adults we did find some similar results. For example, one study showed that mental health problems increased more in those who were employed, compared to those who were unemployed.
Interviewer: The paper concludes that covid-19 has led to a marked increase in mental health problems in young adolescents and their mothers. What are the implications of this for professionals working in child mental health?
Dr. Nicola Wright: We think the main implications from our work are that there is going to be an increase in referrals and that mental health services need to be aware that these will be of two sorts. Those which reflect added risk from the pandemic for those children and those young adolescents who are already experiencing problems, who are already at risk, and new onset of problems which are associated with the pandemic, with the implication that they may need different treatment approaches.
Interviewer: Nicola, what message should policy-makers take from your findings?
Dr. Nicola Wright: As well as highlighting the level of need for mental health services for young people, we do hope that the main message taken from our findings is that the current unmet need of childhood and adolescent behavioural problems is now even greater, because at the moment behavioural problems are not universally accepted as a reason for a referral to mental health services in the UK. Despite evidence that behavioural problems predict adolescent and adult depression and poor lifetime functioning, and as I noted in our sample, as in many others, behavioural problems show strong stability from childhood to adolescence.
And then we’ve shown that this has increased with the pandemic and early intervention would reduce a substantial amount of these problems. So it seems incredibly important that behavioural problems are treated.
Interviewer: So should the referral system get some kind of overhaul?
Dr. Nicola Wright: Ideally, we would like to see behavioural problems being accepted and being treated more by mental health services.
Interviewer: Nicola, is there anything else that you want to highlight from this research?
Dr. Nicola Wright: Well, I would just like to highlight that research like this wouldn’t be possible without the amazing levels of commitment we have from the families taking part in our study and our team who work incredibly hard and are also unbelievably committed to the work that we do.
Interviewer: And are you planning some follow up research that you can reveal to us?
Dr. Nicola Wright: As I’ve alluded to, it’s very important to establish the long-term mental health impacts of the pandemic and we need to establish whether this rise in mental health problems that we’ve observed in the first few months post-lockdown has persisted. We are just about to collect data on our whole sample again a year later so that we can examine the long term impact, and this is important, considering that we’ve now experienced a second lockdown and the young adolescents have experienced more school closures and more separation from peers.
But we do also have more findings from our initial data collection that we’re writing up now. One focus for us is on identifying specific cognitive coping strategies which may be used to alleviate distress. If we can identify these, these can be used for intervention to reduce the mental health impact of the pandemic and also have broader utility and intervention for early adolescent depression. We’re interested whether being able to shift focus from brooding on how hard things are to thinking about positive or happy experiences. This is called positive refocussing, may help to reduce the risk of becoming depressed. So we’ve asked the young people to report on their tendency to do this and that’s an analysis that we’re working on now.
Interviewer: When can we expect those findings?
Nicola Wright: Well, hopefully soon, because we are writing them up now. It’s always a bit slow, isn’t it, in between and submitting findings for publication and them actually coming out, but that’s something we’re working on now. And then the next topic that we want to address, which ideally we’d wait for our next wave of data collection to be finished, is for us to try and understand how the changes in the social environment during the pandemic have affected these young adolescents, because typically as the child moves into adolescence relationships with peers become increasingly important and perhaps relationships with families less so.
But as the school closures and social distancing has led to separations from peers for prolonged periods of time, it will be really important to understand how well the adolescents have adapted to this change and how it’s impacted their wellbeing. Something that we’re particularly interested in, partly from what we’ve heard from the families in our study, is how the lockdown measures may have led to positive changes in family life and how this may be a source of resilience for young adolescents, because although our headline finding is that we have found an overall rise in mental health problems, there is a variation in outcomes.
This could be due to some young people being more affected by the pandemic or lockdown measures than others or there may be specific processes that moderate the effects. For example, supportive family relationships. In our post onset survey we asked the young people to report on whether they were turning more to their parents for support in this time. We plan to examine the longer-term impacts of that on their mental health. So this also has important implications for clinical practice, as intervention includes working with parents as well as with the young person. Identifying sources of resilience in the young adolescent parent relationship may prove to be an important intervention target. Co-author and PI of the Wirral Study, Jonathan Hill, a consultant child psychiatrist is leading this work on our data.
Interviewer: Presumably, it’s too early to say whether children and adolescents were turning more towards their parents.
Dr. Nicola Wright: We see that they were turning more towards their parents, but it’s too early for us to know the long-term impact. That’s what we’ll hope to find out in our new wave of data collection.
Interviewer: Finally, Nicola, what’s your takeaway message for those listening to our conversation?
Dr. Nicola Wright: I would say that young adolescent depression and behavioural problems may be an all-time high. So understanding the sources of risk and resilience for these problems is now more important than ever.
Interviewer: Brilliant. Thank you ever so much. For more details on Dr Nicola Wright 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.