In this podcast we speak to the head of The Centre for Attention Learning and Memory (CALM) Dr. Joni Holmes, at the MRC Cognition and Brain Sciences Unit, University of Cambridge. Joni discusses the main aims of CALM, the research they have conducted, and the implications for identifying children’s mental health needs.
Joni draws attention to a shift away from diagnostic centred approaches towards child centred approaches, adding that we need to assess individuals strengths and difficulties, and use those to form interventions.
Check out the blog on ‘The Centre for Attention Learning and Memory (CALM) Approach to Neurodevelopmental Research‘.
Joni is currently Head of the Centre for Attention Learning and Memory and Senior Scientist at the MRC Cognition & Brain Sciences Unit. Joni also runs the Cognition Emotion & Education (CEE) group. She is interested in understanding the cognitive and behavioural factors that predispose children to learning and mental health problems.
Interviewer: Hello, welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Joe Carlowe, a freelance journalist with a specialism in psychology. Today I’m interviewing Dr. Joni Holmes, Head of the Centre for Attention, Learning and Memory, CALM, at the Medical Research Council’s Cognition & Brain Sciences Unit at the University of Cambridge. Joni will give us an overview of the CALM project and its key findings. There’s also a blog on the topic available on the ACAMH website.
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. Joni, thank you for joining me. Can you start with a brief introduction of who you are and what you do?
Dr. Joni Holmes: Yes. It’s lovely to talk to you today Jo. So my name is Joni Holmes and, as you say, I work at the Cognition & Brain Sciences Unit at Cambridge University. So I have a PhD in psychology and a real interest in understanding children’s development, and particularly in trying to understand what might affect what we might call typical development. So, in my current role, I run the Centre for Attention, Learning & Memory, where we’re really trying to understand the sort of cognitive, neural and genetic underpinnings of children’s difficulties.
Interviewer: And how did you come to be interested in child and adolescent mental health?
Dr. Joni Holmes: So my work primarily focused on understanding why children struggle from a cognitive perspective. And that really started through my PhD work many years ago. And over time I was really trying to understand and delineate the cognitive profiles of children with different diagnoses such as ADHD or dyslexia. And, through this work, I really started to understand that, first and foremost, children’s profiles overlapped across different developmental disorders and also overlapped with children who didn’t have any particular diagnoses. And that really led to some of the work I’m doing now in the CALM project.
But I also realised that children who had these cognitive and learning difficulties were at greater risk of mental health problems. And that’s why my work has started to move towards that direction.
Interviewer: Let’s turn to CALM. Can you give a general overview of CALM? So what types of research is conducted in CALM and what are its aims? And then we’ll go into more details of the research itself.
Dr. Joni Holmes: So the broad aim of CALM is really to take what we would call a trans diagnostic approach to understanding why children might struggle at school. And trans diagnostic is a very fancy way of saying that we want to move away from just studying specific groups of children with specific diagnoses and instead recruit a broader sample of children that captures children with milder difficulties that might not meet the thresholds for diagnoses, or perhaps the cut off scores we might use for inclusion in some studies, and also to capture children with more complex and co-occurring needs.
So, essentially, we wanted to create this sample, this big sample of children who were struggling in different ways. Some of them had milder problems and some more complex problems. And then we collected a whole bunch of data on these kids. And this included everything from sort of mental health, learning and cognition through to looking at neural data, as well as collecting some genetic data from the children. So what we were trying to do is really take away the assumption that children with different diagnoses are different to one another and instead use the data to tell us about how children who were struggling might be performing and what might be leading to their difficulties.
Interviewer: Right. There’s CALM 1 and CALM 2. Can you start with CALM 1, what was CALM 1?
Dr. Joni Holmes: So, CALM 1 was the beginning of this project. So we set about, in 2014, trying to recruit children from health and education practitioners. And these children…we said to the practitioners, “Can you just send to us any child aged between five and 18 who is struggling in the areas of attention, learning and/or memory?” And we wanted to recruit any child who had a particular difficulty, whether they had a diagnosis or not.
And we had no idea how this study might go. So we opened it up to sort of local health and education practitioners, started our recruitment and thought, well, who knows, we might get 100 children or we might get 1000 children. We were really lucky and the referrers were really keen to work with us and to send children to us for the study. So we ended up recruiting 800 children aged five to 18. And then we decided, well, now we need a comparison sample.
So we’ve actually been out to the schools that are attended by those who had been referred. And we’ve now got some data on a comparison sample. And we call this whole set of data on the 800 children who were referred and the 200 children in the comparison sample, we refer to that as CALM 1. So that was our initial assessment of the children. And this included all those different measures I mentioned earlier. So we were looking at mental health, we were looking at learning, at cognition, at brain function, and structure, and also collecting genetic data.
So, we did all of this over the course of about five or six years. And then we thought, wouldn’t it be great to go and follow these children up and to see how they’re doing five years later? That’s when we started what we call CALM 2. So essentially, it’s a follow up study where we’re re-inviting everybody back five years after their initial assessment to see how their performance might have changed.
Interviewer: OK. And when does the five years come up with CALM 2 then?
Dr. Joni Holmes: So we started the assessments. So we saw…because our testing protocol is really long, it took us about five years to see every child the first time around. And so we’ve now started the follow up, we started that just before the pandemic hit. Obviously, we’ve had to pause for the past year.
And now we’ve resumed the assessments and we’re hoping to finish within about the next two and a half years.
Interviewer: Joni, let’s turn to some of the key findings of the project. So as you’ve already stated really, CALM’s mission is to identify the cognitive, behavioural, neural and genetic dimensions that underpin a range of cognitive difficulties faced in childhood. Can you highlight some of your findings that relate to these basic underpinning mechanisms?
Dr. Joni Holmes: Yes, of course. I’ll give you maybe three or four highlights of our findings. So, if we’re thinking about, sort of, cognitive dimensions or cognitive mechanisms that might be related to learning. So, what we know is in typical samples. So, in samples of children recruited from schools who have not been selected because they’re struggling, we see the phonological processing difficulties. So the ability to, sort of, process sounds that you hear and being able to internally represent those sounds is closely related to how children learn language and how they perform in literacy at school.
And we found that, within our sample, exactly the same thing came through. So, the children who were really struggling in literacy, had really pronounced phonological processing deficits. We also found that executive function skills that are related to mathematical outcomes, in typical samples, that association was also there in our data. So essentially at the cognitive level, we found that there was nothing fundamentally different in terms of the relationship between cognition, and learning, in our sample of struggling learners, that the links were the same, it was just that our children were really at the bottom end of performance on both sets of measures.
Interviewer: How is this knowledge used then to develop diagnostic techniques?
Dr. Joni Holmes: One thing that we do, at the moment, so, I guess, I’ve really just talked about cognitive dimensions there. Other things that we found in the data which are more related really to diagnostic techniques, when we try to look at whether the, sort of, children’s cognitive profiles will map onto any particular diagnosis they might have. So we would group children together based on cognitive profiles and then say, “OK, are all the children, for example, with ADHD represented in one of these groups?”
And we’ve found that that’s not the case. And this extends across the cognitive data and the behavioural data. So what we’re showing is that the children who are struggling have cognitive profiles, and behavioural profiles, that don’t align with our current diagnostic systems. So, the kinds of symptoms children might present with wouldn’t necessarily fit into those neat diagnostic boxes. So in terms of thinking about diagnosis, our data seemed to be pointing to the fact that maybe our current diagnostic systems and checklists aren’t really fit for purpose because they’re not really capturing the ways in which children might present with different symptoms out there in the real world.
So we haven’t developed any alternative system where, sort of, many years away from being able to do that. What we are suggesting is that rather than using these diagnostic centred approaches, we probably need to move towards more child centred approaches. So we need to start thinking about assessing individual children’s strengths, and difficulties, and then using those to inform the kinds of interventions that we might use.
Interviewer: Is that starting to happen?
Dr. Joni Holmes: We haven’t started that work yet. We are really just now starting to pull together sort of a body of evidence from all the different studies and the different sort of slices through the data that we’ve taken so that we can start then trying to advocate for this kind of approach.
Interviewer: OK. It has got huge implications though, hasn’t it ?
Dr. Joni Holmes: Oh, it has huge implications, yes, it has. I think it has fantastic implications for the children, and families, because if we can really identify areas of need for specific children and then try to support those, you would hope their outcomes would be much improved. But it does have huge implications for the whole system around identifying and supporting children’s needs.
Interviewer: Absolutely. Joni, CALM’s research is also being used to create new, effective, interventions. What can you share with us in this regard?
Dr. Joni Holmes: So we haven’t actually developed any interventions. What we’re doing in the early stages is trying to use our data to advocate for the shift away from diagnostic centred approaches toward child centred approaches. So in terms of interventions, just to give you sort of maybe a bit more of a concrete example. If we had a child with autism where we might traditionally have focused on diagnostic based features, such as, trying to improve their communication skills, trying to improve their sort of socialisation skills, we’re suggesting, well, they are the diagnostic features that we might target intervention towards.
But, actually, there are other symptoms not included in the diagnostic criteria that are highly prevalent and really impactful for children. So one example is that anxiety is not a diagnostic criteria for autism. Yet we know children with autism can be highly anxious and that that has a really profound impact on their day to day life. So we’re suggesting that perhaps focusing interventions on anxiety might be a better approach compared to focusing on just those features of the diagnosis.
That’s really important. CALM established a research panel used to recruit children with targeted cognitive and behavioural profiles for other research studies. What can you tell us about this?
Dr. Joni Holmes: So, for every family and child who came to the CALM clinic to take part in the main study, we asked them if they would be interested in signing up to a research panel or a database that would allow us to re-contact them to take part in other studies that other people might be interested in. So one example of this, actually, which relates a bit back to interventions, is that we had some colleagues who were really interested in trying to trial an attention based intervention for children with attention difficulties. And in our CALM database we actually have many children who had attentional difficulties.
So we used our database to then re-contact those families to see if the children would be interested in coming in to take part in another study where we would trial this intervention with them. So, essentially, it’s a database that children could sign up to, or the families can sign up to that would allow us to re-contact them so that they could come back and take part in related studies. And many of the families were very keen to do this.
Interviewer: Great. Joni, translating research into practice is often an area that researchers struggle with. How has CALM managed to be successful at this?
Dr. Joni Holmes: So we’ve used a number of strategies. The first one is that we actually work very closely with health and education practitioners in all aspects of our research. So I described earlier that we asked the practitioners themselves to refer children to us. So they were engaged from the word go. And then what we did is every year we’ve held an annual conference for the practitioners where we share with them the progress with the project, we update them on any key findings, we ask them for their input into our research.
So one strategy is really to try and have a big impact in practice very directly by working with practitioners, in addition to, sort of the engagement in the studies and also having our conference. We do things such as write articles for the Times Education supplement. We do podcasts such as this or we might write blog posts for ACAMH. We try to also make many resources available for practitioners. And I think that that’s a very direct way to have a small influence on your local set of practitioners.
The other way, which we really are just starting to touch the surface of doing is pulling together the evidence so that we can start forming documents that would describe sort of changes to policy that we’d like to implement, and then using our scientific evidence to reinforce and back up the kind of changes we’d like to see. And then we’re going to try and actually campaign to the decision makers to suggest that actually the ways we do things need to be rethought through. So I guess that’s a sort of very clumsy way of saying we try to translate research into practice, first, and foremost, through direct interaction and communication with practitioners, but also through level of policy, where we try to think about preparing policy briefs to appeal to decision makers.
Interviewer: And why is evidence based research and its translation into practice so important when it comes to child and adolescent mental health?
Dr. Joni Holmes: So my view is that we know that practice is largely based on diagnostic systems that evolved many, many, years ago through observations of children, adolescents and adults. And these were really just behavioural observations. And it was…it came at a time before we had the sort of scientific methods and technology to really understand why children might struggle. And now we have these at our fingertips. As our research has shown, the diagnostic systems that we use don’t really reflect the reality of what it’s like to be a child with learning or mental health problems.
And the symptoms that practitioners are trained to look for don’t really map onto underlying mechanisms. But I think it’s really important to translate the evidence about why children really are struggling so that we are able to actually really help them. So we need to understand why they’re struggling and direct intervention towards underpinning mechanisms. And we can only do this if the evidence that we gather in our scientific studies is translated into practice.
Interviewer: Right. I think you’ve partially answered this already. But in an age where there is so much disinformation, what more needs to be done to further evidence based research and to disseminate the findings?
Dr. Joni Holmes: I think one of the biggest challenges, and this crosses many aspects of science, is that as scientists we are encouraged, primarily, to publish our scientific findings in academic journals. These are often paywalled and restricted to certain people, i.e. other academics, to access them. And, also, the science is typically written, in these journals, in a language that only experts can understand. So I think it’s about making all science open access and written in a way that most people could understand. And I think that we really sort of need to also equip people with the skills to discern what is disinformation and what is actually credible.
And I think we’re probably a long way from being able to do that, the, sort of, systemic changes are really needed to the scientific model in which us academics tend to work.
Interviewer: Thank you. Joni, what else are you working on currently?
Dr. Joni Holmes: So my current focus really for the past few years has been on the CALM clinic and on, sort of, running this enormous cohort study. But, in addition, I’ve been running a range of projects that are investigating children’s problem-solving skills. And in this work with one of my PhD students, we’ve been trying to understand how, and when, children’s problem-solving skills come online throughout development and looking at how that might predict how well they do within things such as reading and maths. So that’s a really nice line of work that I’ve been involved in.
And I currently have a postdoctoral researcher with me who’s really interested in looking at early symptoms of ADHD in childhood and how they might impact on adult wellbeing. So these are both quite related projects that have slightly different feels to them and the CALM project.
Interviewer: So, lots going on? Is there anything else in the pipeline that you’d like to mention?
Dr. Joni Holmes: One thing that might be of interest to your listeners is that, as you’ve mentioned, we have an ACAMH blog post that has come out, describing the CALM study. And we also have an opinion piece coming out in the next year or so that describes the trans diagnostic revolution in developmental disorders. And that’s going to be published hopefully in the Journal of Child Psychology & Psychiatry.
Brilliant. Finally Joni, what is your take home message for those listening to our conversation?
Dr. Joni Holmes: The primary message is that the way that we think about how, and why, children struggle needs to be challenged. And we need to really start to move away from these diagnostic systems and start to embrace individual children’s needs if we’re able to support them properly.
Interviewer: Thank you ever so much. For more details on Dr Joni Homes 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.