ADHD, Comorbidity, and Longitudinal Research

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For this podcast, we are joined by Dr. Aja Murray, lecturer in psychology at the University of Edinburgh, and winner of ACAMH’s Kathy Sylva ‘Rising Star’ Award 2021.

Aja begins by providing us with an insight into her background, her research interests, and her role as a developmental psychologist who specializes in mental health, before commenting on what it meant to her to have received the ACAMH ‘Rising Star’ Award in 2021, for best scientific contribution to child and adolescent mental health by a person within 10 years of their first published paper in a peer-reviewed journal.

With Aja’s primary research interests relating to the developmental aspects of mental health phenotypes and their comorbidity, with a particular interest in ADHD, autism, and conduct problems, Aja shares some recent highlights from her work.

As the deputy director of the Evidence for Better Lives Study, Aja also discloses the aims of this study, plus their findings so far. In addition, Aja also mentions her work with the Zurich Project on Social Development from Childhood to Adulthood with a focus on violence prevention. Aja also details further projects that she has been involved in, including securing grants for a project supporting student mental health, and another to address the adverse impacts of domestic violence during pregnancy.

Furthermore, Aja comments on the translation of evidence-based research into practice, why evidence-based research is so important when it comes to child and young people’s mental health, plus what can be done to disseminate and promote evidence-based science.

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Dr. Aja Murray
Dr. Aja Murray

I joined the Department of Psychology, University of Edinburgh as a Lecturer in Psychology with Quantitative Focus in 2018. My research focuses on developmental aspects of mental health, especially ADHD, internalising problems, externalising problems, and their co-occurrence. A second area of focus is on quantitative methodology, especially longitudinal methodology and psychometrics. I currently lead projects on student mental health, domestic violence during pregnancy, and survey methodology and am the deputy director of the Evidence for Better Lives Study.

Prior to joining the department, I was a Research Fellow at Emmanuel College, University of Cambridge where I researched developmental trajectories of mental health issues and their co-occurrence. I also previously worked as a Research Associate in the Violence Research Centre at the University of Cambridge. There I worked on developmental trajectories of ADHD symptoms and conduct problems in the Zurich Project on Social Development from Childhood to Adulthood (z-proso) and later on the Evidence for Better Lives Study. (Bio from The University of Edinburgh)

Transcript:

Jo Carlowe: Hello, welcome to 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 am interviewing Dr. Aja Murray, lecturer in psychology at the University of Edinburgh, and winner of a ACAMH’s Kathy Sylva ‘Rising Star’ Award 2021.

If you’re a fan of In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with the rating or review and do share with friends and colleagues.

Aja, welcome, and congratulations on winning ACAMH’s ‘Rising Star’ Award. Can you start with a bit of background about who you are and what you do?

Dr. Aja Murray: Yeah, thank you. So I would typically describe myself as a developmental psychologist who specializes in mental health. So I’m interested in mental health and the factors that influence mental health pretty much across the entire life span. So beginning, already, with what factors influence mental health and neurodevelopment in the prenatal period and going all the way to well-being, mental health in older adulthood. I do, probably, take a special interest though in mental health in and around the adolescent period and in the emerging adulthood. In terms of mental health outcomes, actually my research covers quite a broad range of different mental health phenotypes and also their interconnections.

So I’m interested, for example, in identifying and understanding mechanisms related to transdiagnostic mental health factors. So things that are related to quite a broad range of different mental health symptoms and domains. And for example, how different mental health symptoms connect through, say, developmental cascades in which one mental health issue might increase the risk for developing others subsequently. That said, although, I do have quite a broad interest in a range of different mental health phenotypes. I do take a special interest in some specific mental health phenotypes, particularly, ADHD– attention deficit hyperactivity disorder.

And in terms of research approaches, given that I’m interested in developmental aspects of mental health and I’m a developmental psychologist, I do a lot of longitudinal research where children and adolescents are followed up over the course of many years. And that includes, for example, using pre-existing data, for example, the UK Millennium Cohort Study or the Understanding Society Studies that are these really nice large UK population representative studies.

Recently as well, I’ve been working quite a lot on linking long term development with short term daily life experiences. So linking these longer term studies to designs that collect information about what people are thinking, feeling, doing in the course of their daily lives in the short term using smartphone-based data collection. So I think that pretty much sums up what I do.

Jo Carlowe: OK, brilliant. We’ll look at some of the research in more detail shortly. As I mentioned in the intro, you received the ACAMH’s ‘Rising Star’ Award. This is given for best scientific contribution to child and adolescent mental health by a person within 10 years of their first published paper in a peer-reviewed journal. Aja, what did winning the award mean for you?

Dr. Aja Murray: So obviously, I’m really pleased to have won the award. And I think primarily, it makes me feel very grateful to have had the fortune of working with so many amazing collaborators, to have had the support of so many great mentors, to have had the privilege of working with so many great students as well. And just having the opportunity to work on so many exciting projects focused on advancing our understanding of child and adolescent mental health. So definitely, it makes me feel very grateful for the opportunities that I’ve had. And obviously, I hope that I can pay that forward and help support the next generation of early career researchers in the mental health field to maximize their opportunities as well.

Jo Carlowe: Aja, as you just described to us, your primary research interests relate to developmental aspects of mental health phenotypes and their comorbidity with a particular interest in ADHD, autism, and conduct problems, I believe. Can you share some recent highlights from this work?

Dr. Aja Murray: So recently, probably quite a key area of focus for me and my collaborators has been aiming to advance our understanding of what the mechanisms are linking ADHD symptoms to internalizing problems such as anxiety and depression. We know already that individuals who’ve got elevated ADHD symptoms have got an increased risk of anxiety and depression. And so it’s important to understand what are the mechanisms linking ADHD to those outcomes? To help inform the prevention of those outcomes.

So to give you one recent example, in a study recently led by two former undergraduate students at the University of Edinburgh, Milla Pihlajamäki and Evelyn Antony, we looked to data from the Millennium Cohort Study and found that over the course of childhood development ages three through to seven, emotion regulation difficulties that are associated with ADHD symptoms have the tendency to lead to increases in anxiety and depression. And so what that does is it highlights emotion regulation as potentially a really important target for intervention to prevent the development of anxiety and depression among individuals who have elevated ADHD symptoms.

Another complementary example recently, now focusing rather than on childhood, focusing on emerging adulthood, our group conducted a series of studies where we used an ecological monetary assessment design. So smartphone-based data collection where respondents complete information about what they’re thinking, feeling, doing repeatedly over the course of the day and then extended over a couple of weeks. Using that design, we looked at emotion processes in daily life and the role that they might play in linking ADHD symptoms to anxiety and depression.

So one study, which was led by Lydia Speyer who’s a former PhD student now a postdoctoral researcher, we found that individuals who have elevated ADHD symptoms have got higher levels of daily life stress. They tend to have higher levels of daily life negative emotions. They have stronger persistence of stress over time. So once becoming stressed tend to stay stress for longer and also stronger links between stress and then having later negative emotions. And actually, the higher daily life negative emotions and the stronger tendency for stress to persist over time will seem to act as mechanisms that linked ADHD symptoms to developing anxiety and depression. So again, this highlights that stress management is going to be a potentially quite promising target for intervention to prevent anxiety and depression developing an association with ADHD symptoms.

Jo Carlowe: I want to ask you about the Evidence for a Better Lives Study. You’re the deputy director of this. This is an innovative global birth cohort study in eight cities across the world. What are its aims and what have you found so far from this study?

Dr. Aja Murray: The Evidence Better Lives Study is basically a parallel birth cohort study in eight different countries across the world. So those countries are Ghana, Jamaica, Pakistan, Philippines, Romania, South Africa, Sri Lanka, and Vietnam. There’s really three interconnected aims and the first is to provide new insights that can help support early child development and a strong component of that is the prevention of exposure to violence and other adversities. The second aim is to influence policy connected to these issues through partnerships with local policymakers and international actors in the area of child development and violence prevention. And then the third connected aim is to help build capacity in child development and violence prevention research.

So where we’re at with that study at the moment is we have collected already three waves of data and are planning further data collections. At the same time as analysing the data that we’ve collected already from the prenatal period shortly after birth and for some of the sites, also a data collection in early childhood.

We do have a full list of publications and a report at the website, but to give you one example of some of the findings so far, we recently used the data to help address the gap in research on the impact of ADHD symptoms in the prenatal period. So maternal ADHD symptoms. That’s a really under-researched area at the moment. And what we found was that for women who’ve got higher levels of ADHD symptoms, they tended to have lower social support, higher levels of stress, higher levels of depressive symptoms. They tended to use more tobacco, and we found that they tended to have pregnancies that were more likely to be unwanted and it was also associated with a greater likelihood of premature birth. So it’s preliminary research, but it underlines the need for more research on the issue of ADHD symptoms and pregnancy and suggests already that women with known ADHD symptoms could benefit from having greater mental health support during their pregnancies.

Jo Carlowe: And too early, presumably, to talk about how those issues might be addressed?

Dr. Aja Murray: Yeah, I think in this field, it’s such a stage that it’s really in its infancy. There’s been so little research, actually, even looking at ADHD symptoms during the pregnancy period that yeah, it’s probably too early for translation, but I think already, we could think about the ways in which women are supported and the things that are screened for during pregnancy and think about whether that potentially should be more intensive and happened earlier for women with known ADHD symptoms. I think one of the issues is that it is often under-recognized in that group. So ADHD is difficult to diagnose during pregnancy because there’s a lot of symptoms that could be easily mistaken for ADHD or confused with ADHD or mask ADHD symptoms. There’s also the challenge, basically, of identifying ADHD symptoms during pregnancy.

Jo Carlowe: That’s very helpful. You mentioned the violence prevention component of that work. Violence prevention is something that’s also part of the Zurich Project on Social Development from Childhood to Adulthood, which you’re also involved with. Can you talk about this?

Dr. Aja Murray: The Zurich Project on Social Development from Childhood to Adulthood, usually we abbreviate it to z-proso. That study is a longitudinal study of youth in Switzerland. And it has followed the lives of around 1,500 youths from age seven and that was in 2004. And it’s actually still ongoing to this day. So the most recent data collections were during the pandemic. Then the participants were around age 23 and the next data collection is planned for when the participants will be around age 25.
So I joined the z-proso study as a research associate once I finished my PhD in 2015. And with this study, I’ve primarily worked on the mental health data, which is really rich in that study. So it was available for self-reports, teacher reports, parent reports in various combinations for the full span of the study. And I use that to examine various developmental hypotheses about mental health outcomes. So for example, looking at what is it that differentiates individuals with ADHD symptoms trajectories that are characterized by earlier onsets in childhood versus later onsets in late childhood or early adolescence. And in that work, we find that for many individuals, especially, those who are female, those symptoms, those ADHD symptoms might not actually escalate until the point of adolescence. And by the time those individuals reach late adolescence, their patterns of impairments are actually very similar to those who had an earlier age of onset. And so that might point to the idea that the diagnostic criterion for ADHD of symptoms having to have appeared before age 12 is actually too restrictive because it’s excluding those who might have impairments and who might also benefit from intervention from technically being able to have a diagnosis.

More recently within z-proso, I’ve been leading an ecological monetary assessment add on to the study which we call the ‘decade-to-minutes’ study reflecting the fact that it links long term development to short term processes in the ecological monetary assessment component. And so basically, that involved implementing a two-week long ecological monetary assessment, a protocol that allows us to, as I say, link long term developmental histories going all the way back to age seven to daily life functioning in adulthood in terms of what people are thinking, feeling, doing on a day-to-day basis. And actually, the example I mentioned before looking at stress and negative emotions in relation to ADHD, that was an example of one of the findings from this study.

Jo Carlowe: You’ve already talked about a number of projects, but you’ve also secured grants for a project supporting student mental health and another to address the adverse impacts of domestic violence during pregnancy. Once again, can you share something about these projects?

Dr. Aja Murray: Sure, so starting with student mental health, so together with collaborators in Cambridge and Northumbria University, we received a grant from the Smart and UKRI Network. And that was to leverage existing population representative data to look at what factors influence mental health among UK students. And the value of doing that is that although there have been quite a few studies looking at the predictors of student mental health in specific samples, it’s really important to do that in population representative samples or, at least, probability samples so that we can ensure that we’ve got an accurate picture of what actually are the most important factors to consider when we’re designing policies and designing interventions to support mental health within higher education settings.

So for that project, we use the Understanding Society data set to look at predictors of mental health for UK students and we found that being female, being in the emerging adult, young adult, middle-aged adult age groups as compared to being a younger student and the youngest age group of students was associated with having worse mental health as was having not been born in the UK. Ethnicity was associated, being unemployed was associated with poor mental health. And being in poor health overall were predictive of worse mental health as a student. That gave us information about what groups might benefit from more intensive or more tailored interventions for mental health. For example, we know that interventions such as optional pre-transition courses to prepare people for the transition to university or schemes like peer mentoring or buddying schemes have a lot of promise with student mental health. So those are the kind of interventions that with knowledge of which groups are most at risk, we could help tailor or target those interventions for those groups.

Jo Carlowe: Was the impact of COVID factored in at all?

Dr. Aja Murray: The data that we had was collected prior to COVID. So yeah, I think that’s drastically changed the situation and actually now we’re doing some more new data collections with students to better understand their mental health in the post-COVID era because I do think that has definitely, at least in the short term, had a big impact on student mental health.

Jo Carlowe: What about the project on domestic violence during pregnancy? Is there anything to tell us about that one?

Dr. Aja Murray: In terms of that project, I think I mentioned earlier that I’m interested in mental health from the very beginning of the lifespan. Beginning, actually, in the prenatal period. And in that respect, domestic violence exposure during pregnancy is a really important topic of study because pregnancy is a critical period for detecting domestic violence– for intervening and preventing it. But it’s also a time when it’s impacts extend beyond the impacts on the mother and can actually impact the developing foetus as well through mechanisms such as physiological stress or maternal mental illness or disrupting the bonding process between the mother and the foetus. Like the emotional bonding process.

So in that project, which was funded by a British Academy Wolfson Foundation Fellowship, basically using existing data from the ALSPAC study and the Evidence Better Lives Study, which I mentioned earlier, to look at the impacts of domestic violence during pregnancy on outcomes for the mother, but also for the child. Because there’s a big gap there about what are the longer-term impacts on the child and also what are the mechanisms that lead to those impacts?

So for example, in one study, we’re looking at whether HPA axis activation during pregnancy, so stress processes during pregnancy, mediate the links between domestic violence exposure during pregnancy and later child outcomes. And we actually began that project with a review of reviews, an umbrella synthesis of literature on domestic violence during pregnancy. That was led by Siu Ching Wong who was in the role of a research assistant on the project. And one of the key things, I think, to come out of that review was that there’s really a lack of interventions for domestic violence during pregnancy that focus on or try to target the potential impacts it might have on the child. So we hope that that project can help accelerate progress in developing those interventions or adapting the interventions that currently exist so that they can extend their reach to those child outcomes as well.

Jo Carlowe: You’ve described a lot of projects. Can you say something more about the translation of evidence-based research into practice? How you go about it and what the barriers are?

Dr. Aja Murray: I think the key thing to facilitate translation is to engage users from very early in the process to make sure that the research questions that you’re asking and the way that you’re doing it is going to yield results that are going to be relevant for those users because, I think, that, obviously, improves the uptake of the evidence once it becomes available. So I think that’s probably one of the most key things. I’m not clinically trained. So it’s really important for me to work with people who are clinically active to understand what are the issues actually on the ground and how can I inform clinical practice and come out from the ivory tower somewhat.

Jo Carlowe: Aja, as well as the projects described, your other focus is on quantitative methodology, especially, longitudinal methods and psychometric. Why is evidence-based research so important when it comes to child and young people’s mental health?

Dr. Aja Murray: I think it’s definitely hugely important that policy and clinical intervention is rooted in an evidence base that is, itself, based on strong research designs. We definitely know that mental health is an area where treatments can be effective and where policy changes can make a big difference.

Obviously, that’s only going to be the case if they’re based on rigorous evidence. And I think that means not only having well-designed studies, but also taking steps to improve transparency and to avoid biases such as publication biases through following open science principles, for example. Making materials available and making sure that not only positive findings are published.

And I think, obviously, there’s a responsibility for that on the side of researchers but also in other places such as journals who ideally going forward could, perhaps, make it more possible to do registered report styles of publication where studies are evaluated on the basis of their methodology as opposed to on the results to, again, help reduce the publication bias in the field.

Jo Carlowe: And what more, in your view, can be done to disseminate and promote evidence-based science?

Dr. Aja Murray: So I think there’s actually a lot of really great initiatives already making important contributions to that through, for example, making evidence more accessible to broader audiences. I think one that’s been happening recently in the last few years is there’s been a really positive trend also towards more user involvement in actually designing and conducting mental health studies. So in adolescent mental health research, for example, it’s becoming more common to actually involve adolescents themselves– either as advisors or actually as co-producers in the research process. And I think the idea is that, you have greater user involvement. That helps you ensure that your study is addressing a question that’s important to the group that’s most affected by your research at the same time as giving them more insight into the evidence generation process. And so really, that is something that should lead to better uptake of the evidence, ultimately.

I think, though, that it’s something that is challenging to do well and it’s something that researchers are not necessarily trained to do as part of their training. Probably, one thing that could help to promote more dissemination, more promotion of evidence-based science would be to help better equip researchers to have the skills and the confidence to take on approaches that involve users much more as well as to develop infrastructures to facilitate that more as well.

Jo Carlowe: Aja, what more needs to be done to influence policy makers to take heed of evidence-based research as it relates to child and adolescent mental health?

Dr. Aja Murray: I think there’s probably three key things. I think the first thing is that researchers should try to have a good understanding of the policy landscape to know where a study that they’re doing can actually contribute and part of that is knowing who the relevant stakeholders are. So for example, when we were implementing the Evidence Better Life Study, we conducted quite a comprehensive needs and resources assessment which was all about understanding what are the current policies and resources in each of the eight cities in which we were working with respect to the prevention of violence against children. And that involved a combination of [inaudible] research and also interviewing and engaging with the relevant stakeholders on the ground. And that helped us to identify what areas we could, potentially, make a contribution to supporting policy change.

I think the second thing is to engage relevant stakeholders pretty much throughout the whole lifecycle of the research projects. So for example, again, with the Evidence Better Lives Study, we held quite a number of meetings locally and internationally with policymakers and relevant stakeholders already from the stage of planning the study and then continued through to the dissemination stage. And that, I think, helped us to guide the direction of the study to maximize its contribution and also help facilitate the translation of findings as well.

And then I think the third one is to translate the findings into very specific concrete and also realistic recommendations that properly take into account the current policy resources situation. So it’s usually not going to be sufficient to say these findings have got some implications for policies or interventions but to, instead, point to specific policies or specific interventions that could be introduced or perhaps adapted if there’s pre-existing policies or interventions in light of the findings of the study. Which, again I think, being able to do that probably requires quite good ongoing engagement in keeping up-to-date with what’s happening in the real world as it were.

Jo Carlowe: That’s very helpful, very clear summary of the way to approach it. Aja, is there anything else in the pipeline for you that you’d like to mention?

Dr. Aja Murray: I think a big area of focus for me in the coming years is going to be aiming to contribute to illuminating how short-term processes in daily life are related to long term changes in mental health and vice-versa. So for example, improving our understanding of how our cumulative experiences in daily life impacts the developmental trajectories of our mental health and then how changes in mental health over time also impact our daily life experiences.

For example, emotional processing in daily life. Those kinds of experiences. And so that’s going to involve using measurement burst designs in which you have short bursts of ecological momentary assessments. So the smartphone-based daily life data collection repeated over intervals of maybe months or years to see how those daily life experiences are reciprocally related to development in mental health outcomes. And I think that’s an important direction that would help us give us a more comprehensive picture of how mental health develops, but also open up new daily life intervention targets. And at the same time, probably, helping to inform smartphone-based interventions for mental health which are becoming increasingly popular.

Jo Carlowe: Finally, Aja, what is your take home message for those listening to our conversation?

Dr. Aja Murray: I don’t know about like a take home message, but probably it would be apparent from our discussion that I tend to collaborate very widely and work across quite a wide range of different topics and disciplines and with academics and non-academics practitioners. I think as researchers, were often encouraged to specialize quite narrowly, but certainly for me, maintaining a broader focus has been really valuable in terms of developing my thinking about mental health and I think through, for example, the cross-fertilization of ideas that you get across different disciplines and working with such a broad range of collaborators has ultimately strengthened the contributions that I’ve made to the field. Probably I would say that for early career researchers who are concerned about finding their specific niche, that at least for me resisting that has, in some respects, been quite positive and perhaps arguably something to actually be embraced.

Jo Carlowe: Thank you. Aja, thank you so much. For more details on Dr. Aja Murray, please visit the ACAMH website, www.acamh.org and Twitter @acamh. ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do you share with friends and colleagues.

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