In this podcast Dr. Maria Loades discusses Covid19 and its implications for young people’s mental health, the Rapid Systematic Review exploring the repercussions of the pandemic on social isolation and loneliness, together with her work on the IMPACT study.
She also talks about her project to develop a school-based intervention in South-Africa for preventing anxiety and depression, through a CBT based approach, to be delivered by counsellors in classroom settings to young adolescents.
Dr. Maria Loades is a Senior Lecturer/Clinical Tutor for the Doctorate in Clinical Psychology programme at the University of Bath. She is a qualified Clinical Psychologist, working in a variety of mental health settings, including adult mental health, a children’s inpatient unit, and various community CAMHS. She has a post-graduate diploma in CBT for children, young people and families from the Anna Freud Centre/University College London, and a Postgraduate Certificate in the Supervision of Applied Psychology Practice at the University of Oxford. She secured an NIHR doctoral research fellowship in 2016 to further her research into depression in paediatric Chronic Fatigue Syndrome at the University of Bristol, and the Paediatric CFS team at the Royal United Hospital in Bath. Her research interests include: developing and delivering CBT for children and young people with depression, including those with chronic illnesses, therapist competence in delivering CBT, particularly in the field of child and adolescent mental health, and CBT supervision. Follow on Twitter @MariaLoades
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 Clinical Psychologist and Accredited Cognitive Behavioural Psychotherapist Doctor Maria Loades who is a Senior Lecturer at the Department of Psychology at the University of Bath. Maria recently published a rapid systematic review exploring the impact of Covid-19on social isolation and loneliness in children and young people.
We’ll focus on this in today’s interview and also mood problems in adolescence. 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. Maria, welcome. Thank you for joining me. Can you start by introducing yourself?
Dr. Maria Loades: Yes. So as you said Jo I work as a Senior Lecturer in Clinical Psychology at the University of Bath which means that what I do is help to train clinical psychologists of the future, and previously I worked with for many years in Child and Adolescent Mental Health Services and then came to the University and what I’m really interested in is how we can best help young people who’ve got problems with their mood and particularly those who have also got a chronic illness, like cancer or HIV to live the best lives that they can.
Interviewer: And as you’ve mentioned you’ve worked in a variety of mental health settings including various CAMH Services and you were a CBT therapist on the Improving Mood with Psychoanalytic and Cognitive Therapies Study. The IMPACT study. How did you come to be interested in this area?
Dr. Maria Loades: Yeah. So when I was working in CAMHs I felt really frustrated by the lack of evidence base and attention for depression in teenagers compared to anxiety. We have pretty effective treatments. So CBT for anxiety and as a clinician I could draw on that evidence of what tends to work to help the young people who came to see me in clinic and generally they tended to get better, but the evidence is much more mixed and not nearly as well developed for those with mood problems and what was so exciting about getting involved in the impact study as a therapist was the impact study was a massive step forward in helping us to understand more about what helps young people with huge problems.
Interviewer: What did you learn from the impact study in terms of those sort of best approaches to take pacifically with young people with mood problems?
Dr. Maria Loades: So what I learned more than anything is that it’s really hard to keep a young person with mood problems coming to therapy. So no matter which arm, there were three arms in the impact study, three different psychological treatments that young people are randomised to. No matter which therapy a young person went into it was really difficult to keep a young person engaged in coming to treatment and in each of the arms on average young people only attended half of the sessions that they could have had.
So I think that was the first really big learning point for me was actually we’ve got to pay extra attention to how we can keep young people with mood problems coming back to therapy and that’s particularly important to attend to in the first meetings with them to inspire them with hope and to instil in them the confidence that we know how to help and that if they keep coming we can enable things to get better.
I think we also need to work harder with the systems around them. So the systems can help them to keep coming and what I mean by that is people like parents but also staff at school who might be coming into contact with those young people every day to keep encouraging them and supporting them to come to therapy. You know, I think sometimes it’s practicalities that get in the way as much as the mood itself. So if it’s difficult to do something and you’re feeling low in mood you’re probably going to find it hard to problem solve. For instance, if you don’t know how to get to your session it might be hard to problem solve your way around that if you’re struggling with your mood.
So really enabling the system to help the young person to keep coming to therapy is important. The Impact Study was my first experience of working as a therapist on a randomised controlled trial. Normally I would work in a routine clinic setting where young people and their families would be offered a range of treatment options and they would choose which one they felt was the best fit or which one they wanted and in impact because treatment allocation was random for the first time I was working with young people and families who didn’t necessarily feel that the treatment I was offering with CBT fitted with them and maybe they had wanted something different, and really I guess from that it highlighted to me the importance of patient choice and of enabling patients to choose which treatment they feel best fits for them and that they’re much greater in terms of buy-in if they’ve chosen which treatment they’re going to have. Rather than a randomized controlled trial which by necessity allocates them randomly but means that people end up having something that doesn’t necessarily fit very well with them.
Interviewer: Was it possible to be effective when you were working with people who had an intervention that was imposed that they didn’t feel necessarily fitted?
Dr. Maria Loades: I think to some extent it was, but the great thing about CBT specifically is that it’s really collaborative and really engages the young person as an expert in their own difficulties and sets very specific goals that they are motivated and reaching.
So by applying those basic principles of the CBT approach often even if they weren’t sold on the approach to begin with it was possible to engage them in trying it out and experimenting with it, and they might then find out and discover that it was helpful and that helped their buy-in to it. There were a couple of instances where I think it was more difficult and, you know, I don’t know whether they would have been better placed in a different therapy or whether the same difficulties with engagement would have happened despite the therapy, but I guess that’s always a question of if they could have chosen maybe that would have empowered them if they could have had a different approach. Maybe that would have enabled them.
Generally I think using that collaboration and that let’s experiment and try it out together approach we had good success in overcoming that initial resistance or perhaps reticence to engage in CBT.
Interviewer: Maria I want to move on to one of your current projects. I understand you’ve been involved in a Wellcome Trust funded project in South Africa around developing a school-based intervention for preventing anxiety and depression in young people. Can you tell us about this project?
Dr. Maria Loades: I mean the problem is this in South Africa rates of mental health problems are high. There are lots of factors that play a part in that, like poverty, violence, trauma for instance and also access to treatment because actually there are very few mental health practitioners and a lack of really accessible system for mental health care. So in that context it’s really important that we try to build resilience and promote well-being wherever possible to prevent mental health problems from emerging and to help these young people to weather the reality of their lives the best they can.
We know that classroom delivered approaches, like the friends programme for instance, which is CBT based have worked really well for promoting well-being and preventing anxiety and depression in high income countries, but we don’t know nearly so much about how that might translate to the South African context. What we’ve done is we did a systematic review to find out what approaches have been used in other low or middle income countries and we found that there is some evidence that CBT approaches might be promising but none have been trialled in South Africa before.
I’m so we set out to develop a CBT based approach to be delivered by counsellors in classroom settings to young adolescents. So we know that the age of around ten to 13 is where mental health problems really start to become quite likely to emerge. So we want to target that age group at that vulnerable time, and what we did to develop our intervention was interview young people, parents, teachers and counsellors to find out their thoughts about this kind of programme and then use this information together with the knowledge about what programmes have been used elsewhere in the world, like the Friends Programme to create a bespoke programme called the Four Steps to My Future and this program has got four parts to it aimed at enhancing self-esteem, developing emotion regulation skills, developing more helpful thinking strategies and empowering goal focused action, and we’ve now trained colleagues in South Africa to deliver this and just as soon as schools allow for it post lockdown we’ll be doing a study to look at the feasibility and acceptability of this programme in practice in two schools in South Africa and getting feedback on it so that we can then look to do a larger trial in the future.
Interviewer: So it’s not been delivered yet, but I’m just wondering how receptive were teachers, parents and I don’t know if the children would be aware of it yet, but how was it received?
Dr. Maria Loades: They were incredibly receptive. We were really heartened by the response. There’s a real desperation for this kind of input and actually parents wanted the same kind of help for themselves because they said they felt like they didn’t have the skills themselves to necessarily deal with the realities of their lives in terms of mental health.
So there was a real appetite for this kind of programme and even a year on from us having done these interviews we’ve actually been getting back in touch with some of the young people we interviewed to find out how lockdown has been for them and they remember us. They remember about our study and they are still really enthusiastic and hopeful that this will be something that’s implemented soon.
Interviewer: I do want to turn to your work on Covid-19 and its implications for young people’s mental health, but before focusing on your own research I was interested to learn there was a study from 2013 that focused on mental health outcomes for children in a pandemic context and I just wondered what can be extrapolated from those older findings?
Dr. Maria Loades: Yes. So that’s actually a study we included in the rapid systematic review we did. So I do know quite a bit about it. It’s a study from Sprang and colleagues who looked at trauma outcomes as reported by parents. So they had a sample of about 400 parents, about a quarter of whom reported on children who had been subject to social isolation or quarantine measures during H1N1 SARS and the Avian Flu pandemics in America. They found is that those who have been subject to those disease containment measures were much more likely to require mental health service input and to have trauma symptoms as well as symptoms of acute stress and grief than those who hadn’t been subject to disease containment measures.
Now there are problems with this study. So for example, it relied on parent report and on retrospective recalls, so it might be affected by memory biases over time and there’s also some detail lacking in the published paper which makes it difficult to know quite how generalisable it is. So for example, and the paper is missing the data specifying the ages of the children being reported on.
Also what we need to bear in mind here is that Covid is so unprecedented as a pandemic because it’s so universal. So in this pandemic context that sprang had looked at some children were exposed to disease containment measures, but most weren’t and of course in the current situation almost everyone across the globe is exposed to disease containment measures. So those that Sprang paper suggests that we might see an increase in Mental Health Service need and in difficulties like trauma we really don’t know for sure.
It might be that because everyone is experiencing this rather than just some people that that’s protective or it might be completely the reverse. We just don’t know and it’s really important that we see research coming out in this context that helps us to understand the emerging difficulties.
Interviewer: Okay. So let’s turn to your recently published Rapid Systematic Review which was published in the Journal of the American Academy of Child and Adolescent Psychiatry. So this explored the impact of the pandemic on social isolation and loneliness. What have you found?
Dr. Maria Loades: We were interested in finding all the studies that have looked at the mental health impact of social isolation and loneliness in children and young people and we found that there was little evidence specific to the pandemic context. We only found that Sprang Study that we’ve just talked about, but we did find much more evidence though that loneliness is associated with depression and anxiety both when they’re mentioned as the same time, but also over time. So loneliness is associated with later depression and anxiety in children and young people up to as much as nine years later. There’s a link that loneliness will increase as a result of the social distancing measures and actually that’s exactly what we’re seeing from the surveys that are being done and published in the Covid context and it seems that young people are the group who are most affected by loneliness, rather than older people and actually what our research is suggesting is that learning is one of the factors in the current context that could pose a future risk problem, a future risk factor, pardon me for future mental health problems in children and young people.
Interviewer: So why is it higher in children and young people than say other groups?
Dr. Maria Loades: Lockdown loneliness does seem to have been a particular problem for young people more than any other age group and we think that that’s most likely due to the developmental context. So it’s important to remember that friendships are where we develop and refine our social skills and friends and social life look different and have different functions at different stages of child development. So pre-primary children mainly just play alongside each other, but at primary school age friends start to become more important and play becomes the main way through which children connect with others.
Although family relationships still remain the main influence on development for children at this age. Moving into the teens though friends become a very important source of identity and belongingness, much more so than the family it’s really important for teens to have shared experiences with their peers and a social group for a teenager is the way to experiment with doing new things and especially things that are different from what their families do and therefore to enable them to move towards independence.
Interviewer: So because friendships have got such a developmental importance for children and young people that’s why we think that loneliness is much more of a problem for this group than any other group. Is there likely to be a sort of missed window then of opportunity?
Dr. Maria Loades: Two things, one is the kind of online interactions that they’ve been doing with friends and peers and the interactions they’ve been having with siblings will at least to some extent make up for the gap that they’ve got currently and seeing people face-to-face, but also I think generally young people are resilient and will bounce back. So once they had the opportunity to be back and seeing their friends in person that’s happening some now and here in the UK, but as that increases I think most young people will bounce back and we’ll catch up quite okay.
For some young people I suspect they will get a little more stuck and they might need a little bit more help and I think the people who might struggle most are the people who were lonely already before lockdown and for whom this has become even more isolating then it will then be really difficult to get back in to interacting socially once they get back out there again.
Interviewer: And that ties in with what you said earlier then that the effect of loneliness can be lagged, a sort of time-lag. So I’m wondering what that actually means in terms of understanding the long-term impact of Covid-19 on children and adolescent mental health.
Dr. Maria Loades: Yeah, I mean in short it means that even several years down the line we might still be seeing the mental health impacts of loneliness now. So I think loneliness has been an unintended consequence but a consequence all the same of the disease containment measures and actually that could have a long-term effect.
Interviewer: As we speak, so schools and other services have started to open up post lockdown. My understanding is that you’re finding suggests that children and adolescents are probably more likely to experience high rates of depression and probably anxiety. So not only during but after enforced isolation ends. So what do you envisage the end of isolation will mean in terms of child and adolescent mental health?
Dr. Maria Loades: Yeah. Well, you know, we’ve talked already about the potential long-term mental health impacts of loneliness, but actually I do think anxiety is going to be a particular issue as things open up. Anxiety around resuming life when there is still a level of threat in the world. Covid hasn’t gone away but also pressure, for example, academic pressure.
Pressure to catch up with the missed work, for instance and you know I think that many children and young people are going to feel a bit wobbly to begin with. In fact many of us of any age are feeling a bit wobbly going back out there into the world again when there is this threat still around and when there are things we’re doing now that we haven’t been doing for a long time, but I do think as we do things more we’ll get to feel more comfortable with doing them, but again there might be some for whom the anxiety gets in the way of them getting back to doing the things they want to do or their mood remains low and those are the young people who are going to need that extra help from services and I think we need to make sure that that help is on hand as much as possible.
That they know that that help is accessible and that they can get it without having to wait for too long.
Interviewer: And of that help what kinds of interventions or support systems are needed then to both help now and to prepare for this predicted future spike let’s say in child and adolescent mental health problems.
Dr. Maria Loades: So you know now more than ever we want children and young people to be resilient, don’t we? So we want them to be able to manage stress and cope with change and bounce back from difficult life experiences so that they can have positive outcomes. So what we need to do to really build resilience and promote well-being is to build up protective factors and to decrease risk factors wherever we can.
So our work has indicated that a key risk factor is loneliness. So we need to minimise the duration of loneliness wherever possible and I guess for me the key message is physical distancing doesn’t have to mean social disconnection, and I think it’s unfortunate that it’s ended up being called social distancing because actually I think that doesn’t do a service to the fact that we can keep in social contact even when we’re physically distancing, but as schools resume I think we really need to prioritise a social and emotional catch-up as much as an academic catch-up and reconnecting socially through play is really important, but also the academic expectations we set need to allow for the social and emotional catch up.
So we need to give messages to teachers and to young people and to parents that it’s important to allow time for social and emotional catch-up on top of academic catch-up.
On the other side though to build the protective factors we need to promote well-being wherever we can. So I’m in favour of schools and communities but also nationally sending out public health messages about activities that support well-being, like being physically active, socialising, doing enjoyable activities. Having a daily structure and routine, for instance, and for those young people who continue to struggle I think we need to have that more targeted and individualised approach to help with mental health.
So we need to make sure that children and families know who they can talk to if they’re struggling and that there are a range of supports in place. So for lower ends of intensity this might include how a parent led self-help approaches and computerised cognitive therapy based programmes which generally have small but positive effects on mental health, but we know that those kind of programmes tend to work best if there’s some kind of therapist input.
So we need to ensure that that’s in place and at higher levels of intensity we need to ensure that actually more specialist Mental Health Services are prepared to deal with that increase in demand and that they can provide evidence-based treatments in a timely and accessible manner including of course remotely while disease containment measures are still in place.
Interviewer: And is that happening? Is that input, those types of support that you’ve mentioned is that starting to happen?
Dr. Maria Loades: I’ve heard of loads of great examples of schools putting in place ways to prioritise play and social connection and to promote wellbeing, but I’m concerned that these are case examples and as far as I can see there’s nothing broader and it’s not a consistent picture.
We’ve heard from the Prime Minister about the academic catch-up, but I’m really keen to hear more about social and emotional catch-up for children and young people and we know that emotional distress gets in the way of performing academically. So we really, really can’t ignore this. If we want our young people to bounce back academically we need to enable that social and emotional catch-up.
Interviewer: And your review team was involved in an open letter to Education Secretary, Gavin Williamson emphasising that the ease of lockdown restrictions should be done in a way that provides children with the opportunity to play with peers in and outside of school. Now I know from my own teenage children’s experience that that isn’t happening in all schools. So how might it be achievable given social distancing requirements?
Dr. Maria Loades: Yeah. I mean play is key to social development as I’ve already talked about, but what also actually helps with regulating stress and with emotional processing and those things are really important in this context. This has been very stressful for families, for children and young people and there’s also a massive amount of emotions that people need to process. So play helps with all of those things and I do think there are great ways to be creative about how we can enable this even in the current context. So yes, the social distancing requirements are challenging but parents, teachers and young people working together can figure out the really most ingenious ways of overcoming these barriers and I’d encourage them to do so in ways that are fit for their specific contexts.
Interviewer: What else would you say to policymakers in light of the Rapid Review findings?
Dr. Maria Loades: There is two clear things that I would like to see. One is clear public health messages about how to promote children’s well-being. How to recognise mental health problems and where to seek help, and the second is to ensure that schools and specialist Mental Health Services have funding in place that they can enable the right support at the right time for young people who do struggle.
Interviewer: Are there any other key takeaways that you want to share from the Rapid Review?
Dr. Maria Loades: Yeah. I think what it highlighted to us more than anything is that although there is research out there particularly around the pandemic context actually we know very little. So it really does highlight that we need to ensure that we take the opportunity now to do as much quality research as we can to understand for context like this going forward if we might experience this again in the future. That we better know how best to help and that we have a better evidence base to draw forward.
Interviewer: Maria, what else is in the pipeline for you that you’d like to mention?
Dr. Maria Loades: Yeah for me an area I’m keen to work on is developing treatments for fatigue and whatever the reason for that fatigue. So we know that fatigue is a common symptom of depression in young people and that it’s also common in a number of chronic illnesses, like cancer and HIV, for instance, and I’d really like to further the range of treatment options that are available for fatigue and develop the evidence for those further, including self-help options like apps but also more therapists led treatments, like cognitive behaviour therapy. We’re looking at fatigue in adolescents with cancer and understanding their experience of that and also starting to explore their thoughts about using apps as a way to help themselves to overcome fatigue and we’ve also published some papers on fatigue in young people with HIV in Southern Africa.
Interviewer: Finally, what is your takeaway message for those listening to our conversation?
Dr. Maria Loades: So what I would say is if your child or teen or children or teens that you’re working with are presenting with symptoms that make you concerned about their mental health don’t hesitate to ask for help or encourage them to seek help, be that from the GP or school staff in the first instance who can sign post. For professionals what I would say is do take the time to explore what lockdown has been like for children and families. The experience of lockdown and has differed from person to person and I think it’s easy to assume that it’s been the same for everyone, but we do hear stories of young people for whom it’s actually been a blessed relief not to be at school and for whom they’ve done much better not being at school than they normally do whilst at school.
Dr. Maria Loades: So I think for professionals taking that time to really understand what lockdown has been like you different individuals is really important.
Interviewer: Maria, thank you ever so much. For more details on Doctor Maria Loades 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 and let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.