Cathy Cresswell, Professor of Clinical Psychology, University of Oxford, discusses anxiety and ‘Emerging Minds’ – action for child mental health, with freelance journalist Jo Carlowe.
In this podcast Prof. Cathy Cresswell discusses some of the issues surrounding anxiety in children, the latest research and developments, and the different treatments available. Cathy also explains about the UKRI Research Network Plus called Emerging Minds, and how this aims to transform and promote good mental health.
NB – this podcast was recorded in July 2019, as such the Emerging Minds web is live visit the website.
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 Cathy Cresswell, Professor of Developmental Clinical Psychology and NIHR research professor in the Department of Experimental Psychology and Psychiatry at the University of Oxford. Cathy’s research focuses on the development, maintenance and treatment of anxiety disorders in children and young people. She is also the lead of the Emerging Minds Mental Health Network. Welcome Cathy. Thank you for joining me. Can you start by introducing yourself?
Prof. Cathy Cresswell: Yes. I think you’ve covered most of it but I suppose, the main thing to say is that my background is as a clinical psychologist and since I qualified as a clinical psychologist, I’ve worked with children and young people in a range of different mental health settings. But for the last 15 years, I worked at the University of Reading, where we ran the Anxiety and Depression in Children and Young People research unit and clinic. I’ve just moved, very recently, here to the University of Oxford where I’ll be carrying on and trying to build up the work that we do in child and adolescent mental health, generally and anxiety disorders.
Interviewer: Brilliant, and in your work, you’ve identified that a shockingly low number of pre-adolescent children with an anxiety disorder access evidence-based treatments. Can you give me some details of the prevalence of anxiety disorders in this group and also some idea of the percentage that actually access treatment?
Prof. Cathy Cresswell: Yes. So, figures vary quite considerably from study to study but there was a meta-analysis that brought together prevalence data from around the world that concluded that about 6.5% of children and young people will meet diagnostic criteria for an anxiety disorder. So, there, you’re talking about one or two children in an average sized class. So, it’s really quite a significant and common problem.
Then, you asked about the numbers who access treatment. Well, this is the bit where it gets particularly scary because really, in terms of evidence-based treatments, in terms of psychological therapies, which tends to be most family’s preference as a first choice treatment, the one treatment that has a sufficient evidence base for us to conclude that it’s effective is cognitive behaviour therapy.
In some recent work that Tessa Reardon from my group did, she went out around the country, to all the main regions of England and screened children in schools. Then, followed up children who appeared to have elevated levels of anxiety and conducted diagnostic interviews to determine whether children were experiencing a level of anxiety consistent with the diagnosis. So, it’s causing significant interference in day-to-day life and what she found was that, of those children, only 2% of the children who met diagnostic criteria for an anxiety disorder had access to CBT or at least, we’re aware that they could access CBT. So, I think it’s a really shocking story and if you think you know about any other health condition and said that only 2% of people were getting the evidence-based treatment, everybody would be rightly, appalled.
Interviewer: That is shocking. Why are the numbers so low?
Prof. Cathy Cresswell: Well, Tessa also looked into this when she was working with families to try to understand why the numbers were so low. I suppose an important thing to say is that she did find that, where children had an anxiety disorder, about two-thirds of those families had tried to seek support but in many cases, they haven’t managed to access any support. Where they had, so about a third of families, had got some sort of professional support. In most cases, it might have been support from in schools. Very few people accessed a mental health professional and very few accessed services. So, I think in many cases, people are either getting no support at all or they’re accessing general support from people around them who have expertise in working with children, but maybe don’t have the expertise or the resource, really, to be able to deliver evidence-based treatments. So, that was certainly a big factor but also, families reported a number of barriers that get in the way for them.
So, there were often challenges with recognition of children’s anxiety difficulties. We know anxiety is something that everyone experiences sometimes. So, it can be very hard for families to judge is this now something where we should be getting help? Particularly if children, maybe have had long-term difficulties with anxiety or anxious temperament and it’s gradually become more of a problem over time. Sometimes these things creep up on people and also, families may not be aware that these kind of difficulties can benefit from professional help.
Then, there were also barriers for families in terms of their willingness to seek professional help. Many families felt stigmatized, they were concerned that their children would be stigmatized. Parents would often experience stigma themselves and made to feel that they were to blame or responsible. So, those sorts of things could certainly be a deterrent.
Then obviously, we get the point where parents have got past all those barriers and do try to seek help but often don’t know where to get help, who to get it from. Don’t know what sense to make of all the different information that there is on the internet and which of it they should be taking any notice of. Then, families who had managed to get referred then talked to us about long waiting lists that they often encountered.
Interviewer: Right. Just taking a step back with regards recognition that there’s something not quite right. What are the tell-tale signs that a child or young person has an anxiety problem that requires intervention? What are the red flags, really?
Prof. Cathy Cresswell: That’s right. Many children will experience fears or worries and maybe want to avoid things that they feel nervous about doing, from time to time. Really, the point at which we would diagnose it is it’s interfering in children’s day to day lives. It’s preventing them from engaging in things that other children are able to do and it’s holding them back. Children might be expressing fears or worries. They might be experiencing uncomfortable physical sensations. Tummy aches, headaches and so on, problems with sleep and they might also be really trying very hard to avoid doing things that other children are doing. So, they might not be taking part in any activities that involve people that they’re not familiar with. They might be very reluctant to speak up at school in the classroom, in other situations or sometimes, children may try really hard to avoid situations and actually it ends up coming out as behavioural outbursts. So, it’s really if you’re seeing those kinds of difficulties and behaviours to the point that they’re preventing children from being able to really make the most of their childhood and do what other children their age are doing.
Interviewer: And who normally spots that? Is it the parents or is it teachers or health providers?
Prof. Cathy Cresswell: Yeah, so in the work that we’ve done we’ve been looking at questionnaire measures and how effectively they can help us pick up children who have anxiety problems. We’ve had children, parents, teachers, all complete different measures and in our pre-adolescent group, we tend to find that parents are often particularly effective reporters because they’ll see their children across a range of different scenarios. But teachers then, also have valuable information to add to that. The health providers will often be reliant on what they hear from children, parents and teachers and children obviously, can describe their experience. But in terms of questionnaires and things, it’s really parents and teachers that give us particularly helpful information for the pre-adolescent age group.
With the adolescents, it’s been looked at less extensively, but certainly, the impression is that obviously, as young people move into adolescence, they’re better able to describe their experience. They’re better able to compare their own experience to that of other people and have a sense whether what they experience is different. So, adolescents then, we become more reliant on their self report. But also, with very, very valuable information fed in from parents and teachers as well.
Interviewer: And what happens to that young person if nothing’s done or if they’re misdiagnosed or ignored?
Prof. Cathy Cresswell: Yeah. So, we know that anxiety disorders in childhood and youth are a risk factor for other problems in later life. So, I mean, it’s important to say that it’s not in anyway, a done deal. Some children do recover naturally. So, for example, if you look at children who are diagnosed with anxiety disorder about the age of nine, in longitudinal studies what they found is that about 50% of those children will continue to have an anxiety disorder two years later. So, that obviously means that there are 50% who have recovered naturalistically. Although, I think the fact that there were 50% who continue to have a problem over that important two-year period in development is obviously really concerning. We also know that those children who have had an anxiety disorder at some point in time are at increased risk of other anxiety disorders in the future, as well as problems with low mood and substance abuse, in particular.
Interviewer: What does the research show in terms of the indicators that predict the emergence of diagnosable mental health problems in children and young people?
Prof. Cathy Cresswell: It’s surprising, lack of information on this, really but the most consistent predictors for anxiety disorders in children seem to be inhibited temperament. So, children who, from an early age, are showing a temperamental style that is prone to avoid novelty, less likely to approach new situations, get involved in new things and more cautious and shy. That sort of inhibited temperament and we also know that anxiety disorders do often run in families. So, if there’s a family history of anxiety disorders, that is also a risk factor. Studies vary a little bit in whether they find interactive effects of some of those things. So, for example, if you have an inhibited temperament and there’s a family history, whether you’re more likely to experience problems later on. There’s a bit of inconsistency in that literature, but those two factors are probably the best supported and then, there are other more generic, but we don’t know very much about whether they’re risks for anxiety disorders specifically, as yet.
Interviewer: We’ve talked about pre-adolescent children with anxiety disorders, but what about teenagers? How well are they served?
Prof. Cathy Cresswell: Yeah. Well, that’s a really good question and we’ve actually got some work going on to look at this at the moment. So, one of our PhD students, Jerica Radez, with Polly Waite and Tessa Reardon, is currently doing some work in secondary schools, identifying young people with anxiety disorders and understanding more about access to treatment and what the barriers are for that particular group. So, at the moment, we don’t have those same figures to report for adolescents with anxiety disorders, specifically, but my hunch would be it’s probably a similarly sad state of affairs.
To be honest, in our AnDy Research Clinic, the majority of referrals are for teenagers, but that’s what we expect in line with prevalence figures. So, from the recent mental health of children young people in England survey, we did see that there were particularly high rates of anxiety disorders across the teenage years, but I think the pattern that we get is similar. I would imagine that we’re probably getting a similar sort of low number of young people through into our services.
Interviewer: Right, and what is being done in terms of policy and resources to provide that framework that’s needed?
Prof. Cathy Cresswell: We have seen a lot of developments in this area over the last couple of years and in response to the government’s green paper on mental health in children and young people, we’ve seen a real move to delivering more support for young people through schools. And so, now, we do have schools-based mental health practitioners who are currently being trained up in a number of pilot areas. So, there’s great potential there for that to make some difference and I think through that, there’ll be a lot of learning about what works best within the school context. What can be managed within schools, what needs to be managed in other settings, which sort of families are able to access support through schools, which aren’t? There’s a lot of questions that will be usefully addressed through that pilot work.
Interviewer: In terms of the trials that have taken place with regards adolescence, what treatments are shown to work best?
Prof. Cathy Cresswell: Yeah. So, I mean there are a lot less treatment trials for teenagers with anxiety disorders than children with anxiety disorders, which is quite odd in many ways because we do see the prevalence increase quite substantially during the teenage years. Certainly, for example, in our AnDy Research Clinic, the bulk of referrals are teenagers with anxiety disorder. So there’s no shortage of teenagers with anxiety disorder to include in trials. However, the majority of trials that have been conducted have been with a younger age group, often stopping at about 14, going down to about 7, typically having a mean age of around 9.
I think a lot of it is to do with the settings in which these trials have been conducted and they were often not conducted in NHS type clinics. They might be conducted in University Clinics where people advertise and recruit people that way and may aim at a particular age group. But my colleague, Polly Waite, is particularly interested in this and in adolescent anxiety disorder and we have been reviewing the literature with another PhD student to look specifically at what we can learn from trials with adolescents. The most striking thing is that there are just so many less trials that have looked specifically at adolescent populations and where they have been included, it’s often lumped together with younger children. So, we’re not able to learn that much.
In some cases, it’s looked like the adolescents have done less well from treatments, but that’s not entirely consistent across the trials, but there are some very promising examples. So, Eleanor Leigh, who’s based here in Oxford, has done some really promising work, adapting adult models of social anxiety disorder for teenagers with social anxiety disorder and has got really good outcomes across, including in child and adolescent mental health settings, NHS CAMHS services. So, there’s some very promising interventions coming and what we really need now is to be really rapidly evaluating those and then implementing them in practice.
Interviewer: Right. I’m not sure how much you can say on this. How should they be adapted, from what you’ve read of the trials, to make them more appropriate for teenagers as against adults?
Prof. Cathy Cresswell: Yeah. Well, what’s typically happened in many cases is that an adult program will be taken and the changes will have been about the presentation. Trying to make it look cooler to young people. Unfortunately, when adults try and make things look cooler, it often has the opposite effect. But actually, what I think we have seen is that actually, it’s less about that. Although, obviously things do need to be presented to young people in ways that young people find accessible and engaging but the key things is making sure that the particular aspects of the adolescent environment that might be important in maintaining anxiety disorders, is taken into account.
So, for example, adolescents are in really, such a very different environment in secondary schools than adults are once they leave schools, when we’re in a much better position to be able to make choices about how we live and who we spend our time with and these sorts of things. Obviously, during adolescence, there’s a particular proneness to be much more self-conscious and concerned about what other people are thinking. Though, these sorts of differences in the cognitive processes that might maintain anxiety disorders, which actually, from recent research, seems to be fairly small. But more thinking about the environmental differences that young people might experience, are really key. Thinking about interpersonal relationships, potential problems with things like bullying in school environments and particular focus on what other people are thinking about you and those sorts of things, are really critical to be taking into account. How families can be supported to make sure that their young people can get the most out of treatment, how schools can be supported to make sure young people get the most out of treatment. Really thinking about how the environment around the young person can really support progress as much as possible.
Interviewer: Cathy, tell me about Emerging Minds Action for Child Mental Health. What is this?
Prof. Cathy Cresswell: Emerging Minds is a UKRI funded research network. It’s actually called a Network Plus. I mean really, the vision underlying Emerging Minds is that we want to see a dramatic reduction in the number of children and young people who experience mental health problems. We feel that the best way to make that happen in a relatively short period of time, is to make full use of what we already know from developmental psychology research and to draw on knowledge and expertise from other disciplines to establish the best ways to enable research that’s going to reach and benefit large numbers of children and young people and families. So, we’re very focused on mental health promotion and the prevention and treatment of mental health disorders in children and young people and what we’re really trying to do is to bring together academics from broad range of disciplines.
So, for example, health research, arts, design, humanities, physical science disciplines. Bringing them together with experts by experience as well as industrial partners, third sector partners and others to really develop creative, sustainable stakeholder-led solutions to the problems that we face with child and adolescent mental health. So, for example, we can learn from a lot of other disciplines about things like what makes health messages stick over time? What creates sustainable change in people’s behaviours in ways that are associated with good mental health? We want to be bringing together those different disciplines in order to facilitate action for child mental health.
Interviewer: I appreciate that Emerging Minds is still relatively new but can you describe any advances that have arisen from the network that helped to further our understanding about the causes, development and treatment of mental health problems in children and young people?
Prof. Cathy Cresswell: Yes. Well, I don’t think we could claim any of any of that yet. So, we are new and the first work package that we had proposed and that we’re just coming to the end of in Emerging Minds, has been quite a substantial consultation exercise where we’ve been working with the Centre for Mental Health and also, with YoungMinds, who have conducted a number of workshops with different stakeholders to really help us to focus.
So, what we’ve been doing over the last six months is conducting that wide stakeholder work and recently, we’ve been pulling a huge amount of information together and conducting a lot of thematic analysis to pull out what are the particular research challenges that we should be focusing the network on, going forward? We’re just at the final stages of putting those together and we’ll be releasing them fairly soon and that will really then, be guiding the work we do from there, on, which will involve workshops that people can come together with others from other disciplines to design proposals where we’ll have relevant experts by experience in the room and others for people to benefit from. We’ll have plus funds that people can apply to, to pump prime work or to organize meetings to develop other grants further. We will have a wide program for early career researchers to access training to really help them to be able to take full advantage of all the other things we’re able to access within the network. So, we’ll be starting our first training events for early career researchers in the Autumn this year.
So, then people will be able to start applying for money to get particular research projects underway and we are going to be focusing very much on research, which is very much at the implementation end. It’s really about what will make a difference. We’ve been encouraged by our stakeholders to really encourage people applying, to learn from what we already know from other disciplines and other areas of health research and also, what’s been done in other countries. So, we’re going to be really focusing on projects that have got a fairly short time window. We’re certainly going to be prioritizing supporting research projects that have a pretty quick window, to making a difference.
Interviewer: And will these be projects that support children and young people and their families or will there also be an emphasis on supporting the development of professionals who work in child mental health in terms of training?
Prof. Cathy Cresswell: Yeah. Well, actually, both of those things. It’s been really interesting going through the consultation process. I mean, there are certainly some very clear questions about what we need to do for children and young people. But there was also a lot of discussion in the consultation about what training or support is needed for adults and young people who have a lot of interaction with young people who may have mental health problems or who may be at risk of mental health problems and how those people around the child can be supported in ways that are going to be most helpful.
We won’t be delivering training, directly ourselves, in that way, but we’ll certainly be keen to be supporting research which will tell us how we should be training or supporting people who have regular interactions with children and young people so that they can help promote good mental health.
Interviewer: If people who are potential stakeholders want more information about Emerging Minds, is there a link, a URL you can give me?
Prof. Cathy Cresswell: Our website is about to go live very soon. (NB now live here) We’ve had some really good stakeholder input in that, so that’s been a gradual process, but that’s about to go live anytime. But in the meantime, the best thing for you to do is to follow us on Twitter. It’s at Emerging Minds UK and then, as soon as the website goes live, we’ll be able to let people know that way.
Interviewer: Cathy, what else is in the pipeline? And this could be in terms of new trials, projects, policy changes, anything that interests you, really.
Prof. Cathy Cresswell: Yeah. Well, one of the main things that we’re interested in a moment is, because we’re really driven by this problem of access that children and young people are not… We have treatments that work pretty well but there are very, very few people who are accessing them. That’s one of the main challenges that we’re really keen to address at the moment.
So, we are thinking a lot about how we can use digital tools to do that but also in terms of digital we’re also really interested in looking at virtual reality. So, we’ve been working with Daniel Freeman here at the University of Oxford, to develop virtual reality environments that can be used to help young people to test out their fears in, for example, social situations. So, we’re at a very early stage of that but we’re really excited about that as a mechanism, again to increase access to effective treatment.
Interviewer: Right. How is that going to work?
Prof. Cathy Cresswell: So, the work we’ve been doing has been based very much on the work that Daniel Freeman has been doing with virtual reality with adults. So, he’s got a number of successful programs that they’ve developed but for example, they have a really effective height phobia virtual reality treatment. And in that, there is an avatar who’s a therapist, who’s there to support you through the process and basically, what you’re able to do through virtual reality is, within the kind of comfort of a clinic room or another environment, you can visit the sorts of situations and scenarios that would make you feel anxious, would elicit your negative automatic thoughts. You’re able to then, put those thoughts and your negative expectations to the test but in a virtual situation.
So, what we found with young people, while we’ve been co-designing our scenarios, is that, even though they know it’s not real, they report still getting all the same thoughts and feelings that they would get in a real situation. But because it’s not real, they find it easier to start to put things to the test and try out doing things differently. Certainly, from the work that Daniel has done with adults, there’s good evidence that that learning that you get within the virtual reality then generalizes once you go out and try these things in the real world.
So, particularly, we found for young people, where there’s sometimes an ambivalence about whether or not to engage in treatment, we found that this virtual reality approach actually can be really engaging. Young people are often very keen to try it and like the idea of it and it’s really about we need to just create a whole range of different virtual environments that young people can then use to test out their fears.
So, as I said, we’re at a very early stage, but it feels like quite an exciting area to go forwards. Also, through having those kind of virtual reality environments, it gives us a really great way to be testing out different mechanisms that maintain anxiety problems in young people and really working out how to perfect and further improve our interventions by having those virtual environments to test things in.
Interviewer: Cathy is there anything you’d like to add, perhaps as a takeaway message for people listening to the podcast?
Prof. Cathy Cresswell: I mean, I think the thing that’s really important to me is to get across that there are effective treatments out there for many common mental health problems in children and young people, such as anxiety disorders. We need to make sure they’re reaching people that would benefit from them. We need to make sure they’re being delivered in ways that means that they still do benefit people. I think, across all the work we’re doing, one of the things that’s really critical for me is to make sure that we’re working with families in ways which respect and recognise the experience that families are having. It’s a huge strain that can’t be underestimated, the amount of strain it places on families when children and young people are having problems with mental health. But families often find it very difficult to access support and then, don’t always find that the support is most helpful for them as families. So, things that make it very difficult for them to engage in it and I think it’s absolutely critical that, across everything we’re doing, we’re thinking how can we make our treatments accessible and engaging and acceptable, both to children and young people and also, just as importantly, their family members?
Interviewer: Cathy, thank you so much. For more details on Professor Cathy Cresswell and Emerging Minds, visit the ACAMH website, www.ACAMH.org and Twitter at 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.
Cathy is a Professor of Clinical Psychology at University of Oxford, NIHR Research Professor,
Honorary Consultant clinical Psychologist (Oxford Health NHS Foundation Trust). Her research mainly focuses on the development, maintenance and treatment of anxiety disorders in children and young people. Her team apply a broad range of methods (including experimental, longitudinal, clinical trial and qualitative methods and systematic reviews) with children, young people and families in both community and clinical settings, with the ultimate aim of improving access to and outcomes from psychological treatments for these common conditions. (Bio via University of Oxford)
Cathy is the lead of the UKRI Research Network Plus called Emerging Minds: Action for Child Mental Health. Emerging Minds aims to transform the promotion of good mental health, and prevention and treatment of mental health problems in children and young people by developing an interdisciplinary and cross-sector research network, providing training opportunities for early career researchers, and facilitating the development of research projects.