In this podcast, Professor Nick Allen, Director of the Centre for Digital Mental Health at the Department of Psychology at the University of Oregon talks about developmental transitions from childhood to adolescence.
Nick discusses the types of mental health problems that commonly emerge during or after this period, and details some of the interesting interventions he is using. This includes the exploration of digital ways of tracking and analysing behaviour to detect mental health needs, using digital tools for the detection of mental health difficulties, and its provision of personalised interventions.
Nicholas Allen is an academic expert in mental health, mood disorders, sleep, digital and mental health and prevention research. At the University of Oregon, he is the director for the Center for Digital Mental Health and the director of Clinical Training. His academic areas of interest are: Clinical, Adolescent Development and Mental Health, Mood Disorders, Sleep, Developmental Social and Affective Neuroscience, Family Processes, Digital Mental Health, Assessment and Intervention, Prevention Research. Bio via University of Oregon. He is on Twitter @Prof_Nick_Allen
Interviewer: Hello, and 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 specialist in psychology. Today I’m interviewing Professor Nick Allen, Director of the Centre for Digital Mental Health at the Department of Psychology at the University of Oregon. Today we’ll be looking at the developmental transitions from childhood to adolescence. If you’re a fan of our In-Conversation podcast 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. Nick, thank you for joining me. Can you start with an introduction?
Professor Nick Allen: Certainly, and thank you for inviting me. It’s a great pleasure to speak to you. I’m a clinical psychologist by training, although I currently work in the United States. I’m originally from Australia and I’m Professor of Clinical Psychology at the University of Oregon, and my interest throughout my career, both in terms of clinical practice, clinical training and research, has been on adolescent and youth mental health, and particularly with a focus on the causes and treatments for the emergence of depression and substance use during those times in someone’s life.
Interviewer: How did you come to be interested in child and adolescent mental health?
Professor Nick Allen: I was always interested in child psychology generally, and when I did my original clinical training that was an emphasis in my training, but the thing that really pushed my interest into adolescence was this remarkable change in the epidemiology of mental health problems that occurs during early to mid-adolescence, and the first time I saw a figure depicting this rapid acceleration in the incidence and prevalence of depression in particular that occurs, you know, just after the time of puberty, I really thought that’s a really remarkable phenomena that deserves not only understanding better, but understanding how we can use that clinically to understand how to help people for early intervention and prevention.
Interviewer: What strikes me is that there is masses of literature on early phases of childhood development, but I’m wondering is sufficient focus given to that transition from childhood to adolescence?
Professor Nick Allen: Well I think historically there hasn’t been sufficient emphasis. I think that’s changing. I think there’s been a lot more understanding and emphasis of the particular developmental processes that occur during adolescence over probably the last decade in particular, but I think initially, you know, there have been various inaccurate beliefs about adolescence in terms of their brain development and other aspects of development, kind of, in their adult form by early adolescence and of course, the brain imaging research has shown that that’s not true at all.
So I think, you know, the understanding of adolescence is a distinct developmental period with distinct challenges, opportunities and risks has probably been under-emphasised, and the other thing to say is that, you know, obviously early child development is incredibly important and our focus there is quite valid, but we do want to understand the adolescent period as its own developmental phase.
Interviewer: Why do you think it’s been under-emphasised, the adolescent period?
Professor Nick Allen: I think the developmental changes that occur during that period are more subtle, and they have largely to do with social and emotional learning, which is perhaps a little different from the developmental processes that occur early in life where there’s language development, there’s massive cognitive development occurring, and of course these things continue into adolescence but, you know, those of us who study adolescence many of us see that adolescence is the most important developmental processes are in this area of social and emotional learning, and they can be more subtle and maybe it’s taken us a while to really understand all the plasticity that’s occurring with respect to those processes during that phase of life.
Interviewer: The transition from childhood to adolescence is often a time when mental health problems emerge, such as depression and substance use. Does that mean that there is something protective about early childhood with regards to mental health?
Professor Nick Allen: I think rather than characterising childhood as protective per se, I think what I’d say is that as the human person develops and their cognitive, emotional and social capacities increase, their challenges in these areas also increase. So a metaphor might be as the machine constructs itself and becomes more complex there’s more… It introduces new ways in which things can go wrong. So some of the capacities that emerged during adolescence that are very positive, for example, the capacity to project into the future and think about long term outcomes, such as what will my career be?
What kind of partner will I have? What kind of community do I want to live in, which are all very positive social cognitive developments that are occurring as adolescent onsets may also lay the foundation for new types of vulnerabilities. So, for example, worrying about the future. Having a sense of hopelessness. Worrying about what other people think of you and what your reputation is. So these sorts of things of course which are very characteristic of problems like depression, often the capacity for that kind of thinking comes online and has both burdens and advantages.
Interviewer: And can you see what’s happening, develop mentally then that means adolescence is a riskier time in terms of mental health?
Professor Nick Allen: Well I think there’s many things occurring. As I said, there a dramatic brain development occurring which is laying the foundation for these new ways of thinking, often related to being able to think more in abstract terms. So you’re able to think not just in terms of the concrete things that you can see in front of you, but also these more abstract concepts such as popularity and reputation and the future and hope and optimism and pessimism and things like that become online and are potentially aided by brain development.
But of course there are other key developmental processes, including puberty in particular, and of course puberty is a process that activates brain changes but also activates physical changes and activates social changes. So, you know, as the child moves through the phases of puberty and enters into this world where it’s not just about sexual developmental, although that’s obviously key, but it also brings them into the kind of adult, more adult world of complex relationships. Certainly sexual romantic relationships, but also more hierarchical and complex social world.
So that’s happening as well. You know, and obviously there are transitions in terms of schooling that occur. You know the environment changes. There are many, many changes that occur in social relationships, peer relationships, and there are transitions that are happening in the family which is really important because the family relationship between the parents and the child in particular are being transformed during this time.
So, you know, really there are changes occurring on so many fronts and all of them create both opportunities for healthy development and growth, but also some vulnerabilities which can in some individuals result in greater risk for mental health problems.
Interviewer: We’ve mentioned depression and substance use. What are the types of mental health problems that commonly emerge during or after that transition from childhood to adolescence?
Professor Nick Allen: Yeah, so depression and substance use are two key ones. Other ones that often emerge at that time are eating disorders and some forms of anxiety disorders become more frequent, particularly the ones that have an emphasis on worry and cognitive processes, as opposed to those that are more related to fear and phobias. So the fear and phobia disorders often emerge during childhood. Whereas, you know, once again, in line with what I was saying about as the adolescence cognitive capacities are increasing and particularly for these capacities to project into the future or to imagine different worlds and to represent abstract concepts then phenomena like worry which is associated with generalised anxiety disorder also potentiates potentially in those contexts.
Interviewer: It sounds like a lot of it is around relational, sort of, introspected relating to other people.
Professor Nick Allen: Absolutely, yeah. I mean, you know, as you may well know there are many people from an evolutionary point of view who feel that it was our need to deal with each other and our social relationships that actually represented one of the most complex cognitive challenges that may have driven the evolution of our cognition. So it may well be that this kind of social cognition that the adolescent is moving into is in fact fundamental to the reason that we have the kind of brain that we do have.
Interviewer: What factors typically put a young person at greater risk of developing mental health problems in adolescence?
Professor Nick Allen: There are many. As we know all mental health problems are multiply determined in terms of varying risk factors. So there are a range. You know, the one that I like to start with, because I think it’s so fundamental, is the experience of stress and maladaptive environments and that, of course, can occur during adolescence, during the onset of adolescence but also there can be effects of stress and maladaptive environments earlier in life that can start to… Where the effects start to emerge during adolescence.
So stressful environments are a key one. Obviously there are a range of biological processes that can increase risk. So genetic processes, processes associated with brain development, processes associated with hormonal development, which could include puberty. So in fact we know that particularly amongst girls there’s a strong line of evidence that the timing and pace of puberty can have an influence on risk for mental health problems during adolescence. That family environments absolutely strong evidence there for them to be associated with risks. So family environments that are characterised by interactions that are conflictual and characterised by an absence of positive interactions definitely associated with greater risk.
There are peer processes. So the kinds of peers that one associate with, they can be related to stress in peer processes and, of course, there’s a particular kind of stress associated with romantic and sexual relationships. So we know that a bad breakup from a romantic relationship is a very powerful precipitant of mental health problems during adolescence, but they can also, interestingly, be some positive relationships, peer relationships that the adolescent considers positive that can also have negative effects.
So, for example, there’s a phenomena called co-rumination which is where two young people who are experiencing mental health difficulties spend a lot of time talking to each other or interacting over the Internet about their negative feelings and their sense of hopelessness and ruminating together. So the irony there is that very often the young person will identify that relationship as a very important and positive relationship with someone who understands me well, but may also be associated with some risk if that ruminative process that occurs between the two individuals increases the risk for them.
Interviewer: From your own research, Nick, what can you say about the impact that adverse childhood experiences have on a young person’s emotional functioning and also on the biological mechanisms that underpin that?
Professor Nick Allen: Yeah, so we’ve done a number of studies where we’ve looked at earlier life stress and how it’s impacting this process of transition to adolescence. We found that there’s no question that early experiences of stress, trauma, abuse, neglect, etc. have a negative effect on people’s development biologically, interpersonally and of course increased risk for mental health problems, but there’s also some good news here in the sense that it does seem like adolescents, and particularly this transition period into early adolescence, offers a chance for some reparative effects at that point.
So, for example, I can give you one example. There was a study that we did where we looked at brain development across adolescents and the influence of socio-economic deprivation during early life on brain development, and we found as many people have, that young people who had experienced that socio-economic deprivation during early life had a different pattern of brain development, but the really fascinating thing was that we found in that same study that if you had a really positive and healthy family environment then the effect of early socio-economic deprivation on brain development was essentially nullified.
So, you know, there is this idea that there are, even though early life stress can have this negative effect, there are still opportunities to right the ship, particularly if the environment during the adolescent period is good. Both in terms of the family environment, the peer environment, the health care environment, etc. So this really shows us that going back to one of your original questions, the great importance of focusing on adolescents because in many ways it’s a second chance to undo, if you like, some of the difficult experiences that may have occurred earlier in life.
Interviewer: Which risk factors are modifiable and is there a window in terms of when interventions will be most effective?
Professor Nick Allen: Yeah, that’s a great question. It’s a question that we think about all the time in terms of there are many risk factors. You know, if you’re looking at brain development or genetic factors there’s often not a clear pathway to an intervention based on those. They can certainly be used potentially to identify people who are at risk, but when we’re designing interventions we want to know about modifiable risk factors, and of course there are many.
One that we have focused on in our work is sleep, because we know that it’s an early warning sign for mental health difficulties. It’s also something that is changing developmentally during this period. You know, and whenever something is changing and there is what we call developmental plasticity so we think that there’s an opportunity for intervention to have a greater impact when that developmental change is occurring, and it’s also modifiable.
There are methods by which you can change or improve someone’s sleep patterns. We’ve done some studies on not only the relationship of sleep to risk, but also intervention studies looking at whether we can improve sleep, which we can and many other people have shown that as well, but also that this can also improve mental health in young people. So sleep is one example, but it’s just one amongst many.
There are lots of social processes, as I mentioned before, that can be intervened in. The family environment. Parenting can be studied and there’s an intervention opportunity there as well, both for prevention and for treatment. Peer processes are something that can be modified and also some of the cognitive and emotional processes can be affected by psychotherapy with the individual, particularly cognitive behavioural therapies.
Although I might say with earlier adolescence there is a tendency to find that the behavioural interventions that emphasise behaviour change can be much more effective earlier in life than the ones that emphasise cognitive change.
Interviewer: And you’ve talked about early adolescence. Is that the key in terms of that window? Does it have to be early or can intervention still be helpful in say people that are 17?
Professor Nick Allen: Absolutely. I mean, intervention can be and is very important at any phase of life. So I don’t… but I think the trick is to understand at each phase of life what are the unique developmental opportunities for intervention at that particular phase. Which are the processes that are both developing and therefore open to change and influence, but also that are determining someone’s risk for mental health problems? So an analogy here might be reading recovery programmes.
You know, there’s an idea that if a child is struggling with learning to read that there is a kind of window of opportunity, a developmental window where a reading recovery programme will be most effective in helping the individual, but that doesn’t mean that reading programmes cannot be helpful right across the lifespan, and it’s a little bit the same with the intervention studies we’re talking about here. We think, you know, when we look at early adolescence we see that there are some particular opportunities there, but there are also unique opportunities in later adolescence. For example, the emergence of sexual and romantic relationships and its influence on mental health is something that’s probably more particular to mid to late adolescence than it is to early adolescence in general, although there’s lots of variability.
So processes that are focusing on that probably are well targeted to those, to that mid to later adolescence group. Whereas if you look at family processes there’s probably a particular opportunity in the transition from childhood to adolescence because that is a time when the family is really recalibrating and having to learn new ways to interact with each other now that the adolescent is going through the kinds of changes that they’re experiencing.
Interviewer: Nick, it’s very clear from what you said that your aim is not just to shed light on the underlying causes of mental health problems, but to inform developmentally targeted approaches to prevention and intervention. You’ve mentioned some of your research on sleep, parent and teen sexual romantic relationships. Can you share some more details about some of these studies and any findings that you could share?
Professor Nick Allen: I’ve already mentioned some of the work that we’ve done on sleep where we’ve… and that’s probably the work in terms of the intervention work that we’ve done that’s most developed. Certainly we’ve found that sleep is a risk factor for mental health problems across adolescents that sleep is modifiable and that when you improve sleep you can also improve mental health symptoms at the same time.
So that’s a really important line of research and one that we plan to continue, and as I said many others have contributed to that as well. I think in terms of family environments, you know, we’ve done extensive studies on families as environments is a risk factor for mental health problems, and particularly we’ve done a lot of studies on how family environments interact with other aspects of risk, such as brain development, such as early life stress, to either ameliorate or potentiate the risk that’s associated with those other factors.
So that’s one of the reasons we have an interest in families because, going back to your previous point, that is a modifiable risk factor. So it is interacting with something that’s not so easily modifiable, like processes of brain development, puberty, immunology, etc. Then it gives us something that we can intervene in which could modify those other processes and therefore reduce risk. You know, and our findings in family environments really come down to the fact that it’s not only the rights of positive and conflictual behaviour that occur within the family, but also the specific context in which they occur.
So what I mean by that is it’s pretty easy to be nice to your kid when you are having a fun time and you’re doing something that everybody enjoys. What we find is that the particular context in which the capacity to be warm and supportive and positive towards your child really makes a difference is when you’re disagreeing about something. So in other words, if you can disagree or discuss something that you have a conflict over but do so in a way that is positive, supportive and optimistic then that tends to be a very, in our research, tends to be a very important preventative factor for mental health problems.
By the same token if you flip the switch one of the areas where conflict is most damaging is when people slip into conflict in situations where they have the opportunity for a positive interaction. For example, let’s say the family has decided that they’re going to go out for dinner and share a meal together and rather than capitalising on that positive experience and enjoying it, the family instead falls into an argument about where they’re going to go.
That’s a very simple example, but my point, my broader point is that it’s not just about being nice all the time and never being nasty. It’s about really applying the skills to be positive, optimistic, supportive and caring in the situation when it’s most challenging to do so, which is when you’re disagreeing about something, and it’s also learning to avoid falling into conflict when you have these opportunities for positive interactions.
So in terms of the parenting intervention work that we’re developing that’s really an important focus. We’re teaching parents not just to change these patterns of behaviour, but to understand which particular interactional contexts are going to be most powerful in terms of helping the family function better and ultimately preventing their child from experiencing a mental health difficulty.
Interviewer: Can you say any more about how you go about translating findings of the sort you’ve described into practice to better support young people to cope with that fragile transition from childhood through to adolescence?
Professor Nick Allen: Yeah, so the approach we’ve taken is because we are often trying to find novel or new approaches to the problem. So this is not to say that the approaches that we have now aren’t important and useful. They are, but we’re trying to add to the options that people have. The arrows they have in their quiver, if you like, for these kinds of tasks. So the way we have approached it is that we start with longitudinal prospective studies to try and understand what are the risk factors that predict the onset of mental health problems during adolescence?
How early can we detect them with reliability, and then we go on to ask the question that you asked before which is which of those are modifiable and do we have methods for modifying them? So that’s how we sort of think it through and then once we have targeted a particular risk factor like that, then we try to build an intervention, and in many cases there are already intervention methods available that we can build on, but if not then we start our own, and then we work through that process of intervention, development where you start with [inaudible 22:47] and individual case studies. You try to refine the methods over time and then, of course, one ultimately wants to build towards properly powered, randomised controlled trials so that you can really answer the question of whether this is helping, but you don’t want to jump straight into that.
You really want to go through this more interactive treatment development process so that you know that you’re building an intervention that’s feasible and acceptable, but also that actually moves the target that you want to move. Changes the behaviour that you’re focusing on.
Interviewer: Nick, you are the Director of the Centre for Digital Mental Health which explores digital ways of tracking and analysing behaviour to detect mental health needs and it also provides personalised interventions. How does this aspect all work?
Professor Nick Allen: Yeah, so this is something that I really pivoted to in my research probably about five or six years ago, and it really was…It’s a continuation of all of the issues that we’ve been talking about. It was looking for methods of intervention that target modifiable behaviours that are developmentally specific and, you know, when you look at adolescents one of the things that’s obviously very salient these days is that they start to use smartphones and that these devices become absolutely central to their social life and their functioning and in a way that often drives parents a bit crazy.
So we felt that that provided a unique opportunity to modify behaviour in healthy ways. Many people have been concerned about the negative effects of devices on mental health, and we’ve published on that issue too, but really we’re more particularly focused on what are the opportunities presented by these technologies for mental health intervention and particularly, you know, things that are scalable where you can deliver them to lots of people simultaneously and that are highly accessible.
You know, you’re already where the adolescent is. You know, in a context where they’re already there. So we’ve been working particularly on a method called mobile sensing and what that means is that we try to understand the patterns of use, the ways people are using the phone by collecting those data and we use those data to turn them into meaningful behavioural signals so we can look at things like sleep, for example. We can quantify that just from patterns of phone use.
We can look at physical activity. We can look at patterns of language used and look for cognitive features and interpersonal behaviour, you know, and so on, and there’s lots of ways you can get these data from the phone. Obviously with someone’s full awareness and permission, and then turn them into signals that can be fed back to the person to give them an idea of how these patterns of behaviour affecting their mental health.
So, you know, for example, rather than someone having to wear a wrist wearable and do a lot of logging of their sleep behaviour, you can look at patterns of phone use and you can use that to feed back to the person.
What is the relationship of this phone use to your mental health, to you as an individual, and therefore that becomes then a point of leverage for intervention where if we can say, listen, in your data we see that when you get less sleep you feel worse. That’s a relationship. That’s not just general, not just true in general, but it’s true for you specifically. So, therefore, we’ve now got a really good idea that if we can try to improve your sleep health then let’s work out and see if that actually helps your mood better.
And of course we could do the same thing with patterns of physical activity that are measured by the phone. Patterns of social activity. How often you’re contacting people and even patterns of phone use, like saying when you spend more time on social media maybe you don’t feel so good. So maybe that’s something that you want to want to look at changing. So this is really the project that we’re working on.
We’re trying to find ways to use these methods to give people individualised and personalised feedback on what patterns of behaviour influence their mood and then use that to drive an intervention, which then helps them to change the things that are really specifically relevant to them.
Interviewer: Are the interventions also, kind of, personalised digital tools so they can…?
Professor Nick Allen: Yeah. So the approach that we’re using is a combination of some material being presented on the phone alone and then some of it being embedded within a treatment relationship with a practitioner. So one of the great challenges that digital mental health interventions have is what’s called user engagement. So to put it concretely, people often don’t use these interventions for very long. They often drop out very quickly from their usage. So one of the great challenges is how do you build interventions that are more sticky and that people will continue to use and hopefully get greater benefit from, and one of the approaches to that and the one that we’re emphasising right now in our work is, is there a way to, if you like, digitally enhance the treatment process so that you are enabling the practitioner to not only have insight into their client’s behaviour, but also to be able to build lots of different touch points that the practitioner and the client have together that are not just limited to the office consultation.
So you can use methods like, well, obviously, you know, with the Covid pandemic, tele-health has become a huge aspect of health care generally and mental health in particular, but we can also use the so-called asynchronous methods of contact. You know, such as like texting and so forth to provide the patient with more continuous support for their therapy plan. That’s the kind of transformation that I think we need in health care and that these tools really give us the possibility for.
Interviewer: Nick, what other research areas are coming up for you?
Professor Nick Allen: Well, I’ve got to say, a lot of my research is on the digital mental health area. So we have a couple of studies where we’re evaluating the use of these digital tools for detection of mental health difficulties. In particular we have a couple of studies that are focused on suicide risk. Looking at young people who are at risk for suicide and seeing if we can detect periods of higher risk from the patterns of phone behaviour and the idea then once again is that they are times for intervention.
So we want to ultimately build towards what we call a just in time model of intervention. A model where the intervention comes to you at the time where it’s going to be most effective and most useful. So definitely that area of suicide prediction and prevention it’s a big focus and also studies looking at depression. Looking at risk for relapse and recurrence and looking at the digital tools there.
Then finally, yeah, the area that I talked a little bit about before which is designing digital therapeutics that young people will actually find engaging and that they will use, but that are still based on strong evidence and evidence based principles.
Interviewer: Is there anything else in the pipeline that you’d like to mention?
Professor Nick Allen: There’s always a lot in the pipeline, but one never knows which of them are going to get done, because there’s a lot to do. So I think the topics that I mentioned just before probably are the ones that we’re most confident of moving forward and so forth, but we’re interested in a lot of different ideas. There’s a very nascent idea we’ve been discussing about using virtual reality to teach social skills that are relevant to mental health difficulties. How to deal with difficult interpersonal situations and so forth.
You know, this process of teaching social skills therapeutically is one that is really hard to do in the traditional consultation format, you know, that most clinicians use. So the idea of using tools that can create virtual social environments, give people the opportunity to practice and fail and practice again and get feedback and therefore become more skilful is a really interesting one as well, but as I say that’s a fairly nascent idea and one that we’re working up at the moment is a possibility.
Interviewer: Finally, Nick, what is your takeaway message for those listening to our conversation?
Professor Nick Allen: Well, I think it’s that, you know, that this period of transition from childhood to adolescence is a time of enormous excitement, possibility, optimism, but it’s also a time when there is significant vulnerabilities emerging at the same time. So that’s why it’s such an important time to think about the environments in which our young people are growing up, and that includes family environments, peer environments, cultural environments, the kinds of institutions that they interact with. You know, play scenes, sporting clubs.
There’s a lot of levels to this period, but the general point is that investment in those things and investment in creating positive environments for young people when they’re growing up through this period and through all periods really is something that’s really going to pay off in a very concrete way in terms of improved mental health in those young people. That improve trajectories in their life and, of course, will influence the next generation because the adolescents of today are the parents of the near future and their own children will be influenced by the health and wellbeing of their parents just as we all have been.
Interviewer: Nick, thank you so much. More details on Professor Nick Allen please visit the ACAHM website www.acahm.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 overview and do share with friends and colleagues.