Resilience, Ethnicity and Adolescent Mental Health (REACH) Project – In conversation with Dr. Gemma Knowles

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In this podcast we speak to Dr. Gemma Knowles, Research Associate of the Social Epidemiology Research Group at King’s College, London, and part of the REACH Project. REACH stands for Resilience, Ethnicity and Adolescent Mental Health.

REACH is a study of adolescent mental health based in inner-city London, working with a group of just over 4,000 young people providing information each year about their mental health.

Gemma discusses some of the key results, implications of the findings in terms of developing strategies for prevention and interventions, and translating research, such as REACH, into practice to help young people and their families.

Gemma started out at the University of Birmingham, where she studied for a BSc in Sport and Exercise Science before completing a doctorate in Epidemiology. Gemma’s primary area of expertise is conducting large, school-based research studies on physical and mental health. Gemma joined King’s in 2015, having previously worked at Imperial College London as coordinator of a school-based study of cognitive development during adolescence. At King’s, Gemma coordinates the Resilience, Ethnicity and AdolesCent mental Health (REACH, study, a school-based cohort study of adolescent mental health in inner-city London. REACH is investigating risk and protective factors for mental health among young people from diverse backgrounds. Gemma also coordinates an extensive public engagement programme and advises on several other school-based projects at the Institute.

Bio via KCL


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 Research Associate Dr. Gemma Knowles of the Social Epidemiology Research Group at King’s College, London, and part of the REACH Project. REACH stands for Resilience, Ethnicity and Adolescent Mental Health.

It took place in secondary schools in South London, and it will be the main focus of today’s podcast. 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. Gemma, thank you for joining me. Can you say a little about yourself by way of an introduction?

Dr. Gemma Knowles – Yeah. Hi, Jo. It’s great to be here. Thank you for the invitation. So I’m Gemma Knowles, I’m a Research Associate at the Centre for Society and Mental Health at King’s College, London, and as you say I’ve been working on REACH for the last five to six years as the Project Coordinator.

Interviewer – Well let’s directly turn to the REACH Study. Can you give an overview of REACH and its aims?

Dr. Gemma Knowles – Yes. So REACH is a study of adolescent mental health based in inner-city London, and what we’ve been doing is working in close partnership with 12 mainstream secondary schools based in the inner London boroughs of Lambeth and Southwark since 2015/16, and at those twelve schools we’ve been working with a group of just over 4,000 young people who have very kindly been providing us with information each year about their mental health and about things that we think might increase their risk of developing a mental health problem over time and also things that might be protective for their mental health over time.

We’re now in the kind of fourth wave of data collection for REACH and the broad aims of REACH are to look at the extent and nature of mental health problems among young people from diverse social and ethnic backgrounds, and to understand more about the things that influence young people’s mental health over time.

Interviewer – Can you say anything about some of the key findings?

Dr. Gemma Knowles – Yeah, of course. So I guess most of the analysis that we’ve done so far have been based on the baseline data and also some more recent data that we’ve been collecting around the impacts of Covid on young people. So I’ll just say a little bit about that. So I guess the first thing is that the data that we’ve been collecting provide quite strong evidence that the prevalence of mental health problems is higher in inner-city London compared with national estimates for secondary school pupils.

So in REACH it’s around one in five young people who have possible mental health problems, compared with nationally estimates range from one in ten to one in seven. So that’s probably the first thing, and I think quite interesting then to think about, you know, the implication being that possibly it’s context matters for young people’s mental health and what we see coming out of the big national studies of adolescent mental health in this country perhaps aren’t representative of different areas and different groups of young people.

The second thing is, I guess, broadly speaking that social experiences and social circumstances are strongly associated with young people’s mental health. So, for example, we found that young people who report experiences of racism are around two times more likely to also report behavioural problems. We found that young people from low income households are more likely to report self-harm and more likely to be struggling with their mental health, and similarly, factors like social support networks and experiences of discrimination against are strongly associated with young people’s mental health.

Interviewer – Think you, and Gemma you recently published some of these findings in the co-authored paper Mental Distress among Young People in Inner Cities, The Resilience, Ethnicity and Adolescent Mental Health, REACH Study, and that was published in the Journal of Epidemiology and Community Health. What were the other key takeaways from that paper?

Dr. Gemma Knowles – Yes, the purpose of the paper was to describe the extent and nature of mental health problems. So kind of general emotional distress and then also anxiety, depression and self-harm in REACH. So for young people in inner city London and I guess I’ve kind of given you a bit of a spoiler alert on some of the findings in what I was just saying, but I guess the three main things were, one, the prevalence seems to be higher in inner city London compared with nationally.

Two, that there were quite stark gender differences between, say, for example, girls were more likely to be struggling with their mental health, and that was across all aspects of mental health. So anxiety, depression, self-harm, general distress compared with boys, and that difference became more prominent as young people got older. So, for example, there was little evidence for gender differences in mental health when young people are in year seven, but then among year nine pupils there was a two to three fold higher risk of mental health problems among girls compared with boys.

And the third thing is we looked at variations by, kind of, socio-economic status or, for instance, we used free school meals as a marker for household income and by ethnic group, and I think the things there was that there were some variations by social and ethnic group, but I think possibly what’s more interesting is the similarities between these groups. So, for example, there were many similarities in the proportions with mental health problems by ethnic group, which is quite interesting when you consider that generally, on average, most racialised groups in this country do experience higher levels of social disadvantage and social adversity compared with white British young people, and these things are associated with young people’s mental health. So in trying to understand more about why that’s the case is quite interesting.

Interviewer – Will you follow up on that?

Dr. Gemma Knowles – Yeah, absolutely. So we’ve been collecting information from each participants for, as I said, for kind four waves in a row now. So we’re in a position to be able to look at longitudinally what are the kind of common trajectories of mental health among young people from diverse backgrounds, and what are the factors that kind of influence the probability that young people are in one trajectory over another? So, for example, you might have young people who have good mental health throughout adolescence, young people who struggle with their mental health throughout adolescence, and others who perhaps their mental health improves or declines over time.

So we’re really interested to look at what factors influence their trajectories and in that we’ll be looking at variations in trajectories by ethnic group and what factors account for those variations.

Interviewer – Just touching on something that you mentioned before. You said that there was an increase in prevalence of mental health issues, say, in year nine compared to year seven. Can you say, think about how you account for that increase?

Dr. Gemma Knowles – Yes, so that was in relation to gender differences. So what we what observed, and again this is cross-sectionally and something we’ll look at more robustly when we analyse the longitudinal data, but what we saw is that if you compare mental health among boys and girls in year seven the differences are quite, quite small and in some cases there was no difference between boys and girls. Whereas then in among year eight pupils and year nine pupils that’s where the gender difference really started to become quite prominent, and I think we all hear and it’s quite consistently reported that young girls generally struggle with their mental health more than young boys, or are more likely to, and this, I guess it suggests that with the caveats of it being cross-sectional it suggests that it’s those early years of secondary school that where perhaps the gender difference first emerges.

Interviewer – Can you say anything more? Is it social, biological?

Dr. Gemma Knowles – Yes. So we haven’t yet got into the crux of the analysis on that yet, but it could be a range of things really. I think on the one hand this could be genuine differences in mental health. It could also be differences in reporting of mental health by boys compared with girls as they get older and it’s something really for us to kind of look into and dig deep with our data.

Interviewer – Gemma, what are the implications of the findings from REACH in terms of developing strategies for prevention and interventions?

Dr. Gemma Knowles – One thing is context matters. So we need to potentially be taking a more tailored, localised approach to supporting young people’s mental health given that in some areas the young people have different experiences, and therefore different risks of mental health problems compared with young people living in other areas. So trying to collect data that’s more localised in other regions of the country could be quite important for us trying to understand where the greatest areas of need are and then be able to take a more tailored approach.

I think the second thing is that although obviously a lot of our analysis in the early days, there is quite a strong body of evidence suggesting that social circumstances and experiences are important for young people’s mental health, and I think at the moment, though interventions aren’t really my thing, it seems to me that there’s a lot of focus on schools when it comes to trying to improve and support young people’s mental health, and that makes sense.

Young people spend a lot of time in school and it’s clearly important and it’s a good place for us to be able to reach and provide support for young people. But a lot of the interventions that are being tried and tested in schools at the moment are generally things like mindfulness and CBT and so on, that try to support young people with emotion, regulation or with trying to cope better, and that’s all fine, but the evidence base suggests generally that those kinds of interventions tend to have quite short-term and often modest impacts on young people’s mental health, and for some groups of young people they’re not very effective at all. And possibly some of that comes down to the fact that those interventions aren’t trying to get at the root causes of distress.

So if for some young people their distress lies in difficult and social circumstances and experiences then, you know, something like a six-week CBT programme isn’t really going to tackle that. So I think possibly we could be doing more to focus on social drivers of mental health and with that keeping in mind the fact that, you know, schools, teachers and school staff are extremely busy, overworked and it’s not really what they’re trained to do to identifying people who are struggling with their mental health and provide that signposting and support. So I think maybe it kind of gives us some indications there in terms of what we might be able to do slightly different going forward.

Interviewer – That’s really interesting. Does that mean, though, given what you’ve said, Gemma, is it still right to consider schools as a place to focus on adolescent mental health programmes?

Dr. Gemma Knowles – My personal opinion is yes, but there needs to be a multifaceted approach. I think purely trying to offer those kinds of supportive interventions in schools without trying to tackle underlying causes of distress, as I said, we’re only ever going to have, kind of, short-term and modest impacts. So it does need to be more, I guess, comprehensive and multifaceted, but the factors that influence young people’s mental health are wide-ranging and complex. So I think kind of different types of interventions that we can offer young people the better.

Interviewer – And what about support for teachers then, and teaching management Are they sufficiently supported in implementing these measures?

Dr. Gemma Knowles – I think there’s possibly two side to the answer. One is kind of teachers’ mental health and wellbeing and whether they’re being supported well enough themselves with their own mental health, and I think possibly, the pandemic has kind of highlighted the stresses and the pressures on teachers and school staff are really quite immense. There’s some research that’s been happening I think in Leeds and York by a group of qualitative researchers where they’ve been following a group of school staff over time and looking at the impacts of the pandemic on their mental health, but also asking them to reflect on pre-pandemic situation in terms of their work-related mental health.

And you combine that with a body of research that suggests that teachers in this country their workload is higher than it is in other European countries, and teachers often report feeling that the support for their own mental health is insufficient and the pressures and workload on them is increasing and very difficult for them. So I think there needs to be more done to support teachers’ mental health themselves, and that’s important because we know that teachers’ mental health is associated with young people’s mental health, and also their learning and classroom behaviour and so on and their poor relationships with their teachers. So that side of it is very important. Then in terms of whether teachers feel, I guess sufficiently supported to provide more mental health support and signposting to young people, I don’t know. I’m not aware of any evidence, not to say that it doesn’t exist, but I’m not aware of any evidence to say whether that’s case or not.

But anecdotally, from working in our schools, teachers seem to feel quite anxious about taking on that extra responsibility where they don’t already have pastoral responsibilities. There are many teachers who work in pastoral roles who do a brilliant job on this side and are already very good at it, but there’s only so much they can do, and as we say, they’re already overstretched. So I think any support that is put into schools it needs to be thought through very carefully, kind of, the format of the delivery of those supports.

Interviewer – So what is the message then to policymakers, because it sounds like what you’re saying is the government’s focus on embedding mental health support in schools is perhaps too narrow or a quick fix maybe.

Dr. Gemma Knowles – Again, I think it’s important that we come from all angles because different things work for different young people depending on their circumstances. So it’s great to be able to do more to offer young people support in school when they need it. I think it’s quite well known that there is a massive gap in the access to, kind of formal mental health services for young people. So, for example, the young people who are trying to get referrals to CAMHs to get support for their mental health there’s a massive waiting list there, and there’s now for quite a long time been a gap between the level of need and the level of support that can be offered. So trying to bridge that gap and offer the support in schools to young people at the point that they need it is great.

But I think, you know, in terms of trying to tackle the underlying root causes of mental health, if things like poverty and racism and discrimination and housing and employment are linked to mental health, and there’s a strong body of evidence to indicate that then these are things that are linked to policy beyond the school setting.

So I think it needs a more comprehensive approach, and what we can do to support young people in the households in terms of things like income and employment and removing racism and discrimination and so on, the better.

Interviewer – Gemma, how do you go about translating research, such as REACH, into practice to help young people and their families?

Dr. Gemma Knowles – It’s difficult and we’re not quite at that stage yet. So I think we’ve collected data over four waves and we have so far really in-depth with the baseline data and the longitudinal analysis are ongoing, and of course it’s important for us to get those analysis out because it’s more robust in terms of the inferences that we can make from the data. So there is still a good amount of analysis that need to be done before we can start really making substantive policy recommendations, and one of the reasons for that is that we’ve over the last year we’ve kind of redirected our aim slightly to look at the impacts of the pandemic on young people’s circumstances and their mental health. So some of the work that we initially planned to do or have done by now has kind of been put on pause for that purpose.

I think the other thing that’s very important in terms of translating research into practice is the meaningful involvement of young people and local communities and their parents and schools in interpreting findings and deciding what next, and this is something that we’ve tried to do throughout REACH. So we’ve tried to involve young people and schools in every aspect of the study from first designing the study and how it was going to work and how we would collect data and what kinds of data we would collect.

But also then in terms of interpreting findings, shaping the research questions that we ask of data later on, and also in co-authoring papers and reports that we’ve produced. So, for example, we have a school’s working group who work very closely with us on all of that, and we also have a group of young people who are involved at different levels in our research. So, for example, we have two part-time peer researchers, Adna and Karima, who at age 17, who worked one day a week in our research team. They’re absolutely brilliant.

They make us think differently in everything that we do, I think, and really bring a different angle to our discussions and to our work, and I think that kind of thing is really important when you get into the point of trying to translate findings into practice, and likewise we have a group of young people, community champions aged 16 to 18, who work with us through the year on whichever elements of the project they’re most interested in.

We have a young person’s advisory group as well. A community research co-ordinator who recently came on board, who is trying to improve our links with local communities and local community groups so that we can really find the gaps in terms of what decisions are being made locally and how to use our data to support those decisions in an evidenced based way, but also in terms of trying to get or invite people from the community to advise us on what the priorities should be for our research going forward and how we can have an impact.

So I guess we’re not quite there in terms of kind of, kind of shaping practice, but we’re making steps towards it to make sure that we’ve got those good partnerships and links in place that are really quite essential to be able to do them.

Interviewer – That’s fantastic. I bet it makes a huge difference.

Dr. Gemma Knowles – Massive. I mean, I think, you know, if anyone is deliberating over whether to put some money into employing young people in their team, absolutely go for it. It’s brilliant. It really does make you think differently, and Adna and Karema, and all of the young people we work with actually, they really are brilliant and it enhances the quality of the research for sure.

Interviewer – Well let’s turn to your work around the pandemic. My understanding is that you’ve been asking participants to take part in a new online research project to look at the impact of school closures and social distancing measures on their mental health and wellbeing. What can you tell us about this?

Dr. Gemma Knowles – We’ll first just to say that this work is under peer review at the moment. So I will outline some broad findings tentatively, but just to say that’s kind of being reviewed. So what we did is it’s not actually a new study, what we did is at the start of the Covid-19 pandemic in the UK last year, we contacted young people who had been taking part in REACH for the previous three to four years and invited them to complete an online questionnaire about their experiences and about their mental health during that first period of school closures and the first lockdown.

And we’ve been looking at that data and comparing back to what young people… The information that those young people have provided us before the pandemic, and we were looking at, and we were looking at, first, whether there was any evidence to suggest that the proportions of young people struggling with their mental health increased at the start of the pandemic, compared with before the pandemic and also whether those impacts varied by gender, by ethnic group, by social background, and by their experiences before and during the pandemic.

And broadly what we saw is that we didn’t find any evidence to suggest the proportion struggling with their mental health increased during that first period of restrictions, and if you look on average at the overall proportion, and generally the inequalities in mental health that existed before the pandemic, so by gender, by ethnic group, by household income those inequalities seemed to persist, but not really widened in that early phase of the pandemic.

Instead, what we saw was that it seemed to be that young people’s experience is directly related to the pandemic were the things that were associated with variations in their mental health. So as an example, we asked young people about the social and economic consequences of the pandemic for their household. We asked about their thoughts about the impact on education and so on, and for young people who reported more negative impacts directly related to the pandemic, their mental health seemed to decline slightly during that first phase of restrictions compared with pre-pandemic.

Whereas for young people who reported fewer negative impacts and in some cases positive impacts, for example, not having exam pressure, experiencing less social pressure, having been able to spend more time with their family and so on, those young people generally on average seemed to experience a small improvement in their mental health during that first phase of restrictions. So they’re the broad findings, and what we’re doing now is continuing to follow that group at subsequent points in the pandemic to look at how things change in the longer term.

Interviewer – Thank you. Gemma, what next for REACH? What else will you be looking at?

Dr. Gemma Knowles – So I guess, and we’ve got a lot of data to analyse. So that’s one thing. The second thing is that we plan to continue following the cohort over time and we’re still now inviting young people to stay involved with this as they leave school, and when we first started REACH young people were aged 11 to 14. So they were in school year seven to nine, and they’re now aged 14 to 18. So they’re just entering that phase where they’re starting to leave school and leave education and enter that transition to adulthood. So the next focus for us will be looking at that transition to adulthood which is, I guess, increasingly difficult for young people now. Obviously following ten plus years of austerity and so on has impacted young people in that transition to adulthood, but also now the impacts of the pandemic on young people’s employment and so on. So, you know that will become our next focus.

We potentially also are quite interested to have a look at regional variations in mental health around the country, given what we found in London compared with the national estimates in terms of mental health, because it’s likely that this isn’t just specific to London. It’s perhaps representative of what the situation is in other diverse urban areas of the country as well.

Interviewer – Is there anything else in the pipeline that you would like to mention?

Dr. Gemma Knowles – Yes, so there’s a couple of papers under review at the moment that hopefully will come out soon is a PhD student of ours. Well, she actually recently finished PhD, but she’s recently published some very interesting work on social issues, such as the conduct problems in young people and has continued that work looking at the role of social networks in behavioural problems for young people as well, which is really interesting stuff, and that should be out quite soon.

There’s also findings of some virtual reality work that we’ve been doing. It should be out soon and of course, then the kind of longer-term impacts of Covid. So watch this space.

Interviewer – Great. Gemma, what is your take-home message for those listening to our conversation today?

Dr. Gemma Knowles – Based on what we’re finding in REACH I guess it’s important to remember that context and experiences and circumstances matter for young people’s mental health, and to try not to overlook that when we’re talking about how best to support young people.

Interviewer – Gemma, thank you ever so much. For more details on Dr. Gemma Knowles please visit the ACAMH website, 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.


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