Evidence Synthesis Studies, and Autonomic Dysregulation and Self-injurious Thoughts and Behaviour

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In this Papers Podcast, Dr. Alessio Bellato discusses his JCPP Advances Special Issue Editorial ‘Evidence-based child and adolescent mental health care: The role of high-quality and transparently reported evidence synthesis studies’ (https://doi.org/10.1002/jcv2.12197).

Alessio also co-authored a Research Review paper in the Special Issue entitled ‘Autonomic dysregulation and self-injurious thoughts and behaviours in children and young people: A systematic review and meta-analysis’ (https://doi.org/10.1002/jcv2.12148), which will also be discussed.

There is an overview of the paper, methodology, key findings, and implications for practice.

Discussion points include:

  • Definition of evidence-based synthesis studies.
  • How they undertook qualitive analysis of the papers.
  • The good practice recommendations.
  • Implications of the research review for clinicians, teachers, and parents/carers.
  • Implications of the research review from a research perspective.

To find out more about the 2023 JCPP Advances Special Issue ‘Evidence-based Synthesis Studies for Child and Adolescent Mental Health Conditions’, do check out our fantastic landing page of resources from the Special Issue.

In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP)The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.

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Dr. Alessio Bellato
Dr. Alessio Bellato

Dr. Alessio Bellato is a Lecturer in Child and Adolescent Mental Health at the School of Psychology at the University of Southampton in the UK. He previously worked as a child clinical psychologist in Italy before embarking on his academic career in the UK and Malaysia. He is also a Joint Editor at JCPP Advances.

At present, Alessio’s research is focused on exploring whether specific indicators of arousal regulation, such as heart rate variability, can be utilised as diagnostic markers for emotional dysregulation and internalising symptoms. He also investigates their potential in monitoring intervention outcomes in conditions like ADHD and other neurodevelopmental disorders.


[00:00:00.299] Mark Tebbs: Hello, and welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, I’m a Freelance Consultant. Today, I’m really pleased to be talking to Dr. Alessio Bellato, who is the co-author of the editorial, the JCPP Advances Special Issue, entitled, “Evidence-Based Child and Adolescent Mental Health Care: The Role of High Quality and Transparently Reported Evidence Synthesis Studies.” Alessio also authored a paper in the Special Issue and we’re going to be discussing both publications. So, welcome, really lovely to be speaking to you.

[00:00:43.550] Dr. Alessio Bellato: Hello, Mark, hello, everybody. Thanks very much for having me today.

[00:00:46.890] Mark Tebbs: Great stuff. So, we’ll start by talking about the editorial. Could you start by introducing yourself?

[00:00:53.170] Dr. Alessio Bellato: Yes, my name is Alessio Bellato. I’m a Lecturer in Child and Adolescent Mental Health at the University of Southampton in the UK. I started working on this editorial when I was at the University of Nottingham Malaysia. And so, I would like to thank, first, Henrik Larsson, who is Editor-in-Chief of JCPP Advances, who involved me in this project and asked me to contribute to the editorial. So, I collaborated with him and then – and there were other people on this editorial. We had Ioana Alina Cristea from the University of Padova in Italy. We had Cinzia Del Giovane from Reggio Emilia and Modena, Italy, and then, we had Seena Fazel from University of Oxford, Guilherme Polanczyk from Brazil, the University of São Paulo, and lastly, Marco Solmi, who is in Canada at the moment.

[00:01:51.500] Mark Tebbs: Thank you. It’d be really useful if you could define some of the terms you use. So, particularly, I’m thinking “evidence-based synthesis studies,” and if you could pick out some of the highlights, that’d be great.

[00:02:01.000] Dr. Alessio Bellato: Okay, so, yeah, this is a new experience for me. It is my first editorial ever, so again, I’m very thankful to our Editor-in-Chief, Prof. Henrik Larsson, for giving me the opportunity to work on this. So, when we talk about “evidence synthesis studies,” we are, basically, referring to different types of studies, like systematic reviews, all meta-analysis or umbrella reviews. So, this Special Issue, I think it was, basically, design and created already in early or late 2021. So, basically, there was a call for papers and then, authors could submit their ideas, that were reviewed by the Editors and then, they could submit their papers, basically.

They were looking for a specific type of study, such as systematic reviews, which are, basically, you know, summaries of the literature, but done in a very rigorous and very systematic ways. So, very informative for both clinical practice and research. Or meta-analysis, so, meta-analysis is a bit of an advancement of systematic review, where a very specific type of statistical analysis, is done to, again, summarise, pool all the data about a certain research question, certain topic.

So, the idea is that, you know, we want to provide an updated overview of the literature on a certain topic, and that’s actually what has been done in this Special Issue. So, in this editorial, we, basically, we summarised the 13 evidence synthesis studies that were included, but we also did something more than I think that, you know, we are talking about in a few moments.

[00:03:31.260] Mark Tebbs: Yeah, so, it would be really good if you could tell us how you did that qualitative analysis of the papers.

[00:03:37.630] Dr. Alessio Bellato: It was a, kind of, an experiment. So, when we were discussing with the Editor-in-Chief, you know, about how to discuss these papers, we say, “Okay, let’s do an experiment. Let’s try to appraise the quality of these publications,” and not just to see if they were good. We knew that they were, you know, good publication because they underwent a very rigorous peer review process and Editors looked at that. But what we wanted to do is really, to try to identify what were then, the, kind of, similarities and differences between the different studies, and also, write down some recommendations, some guidelines, for authors that in the future, you know, they may want to publish with JCPP Advances.

So, what we did, we used a specific tool, which is called AMSTAR tool. This is, basically, a series of question about each of the publication, and specifically in relation to the manuscripts, so the articles, so, basically, how things were reported in the paper. Like, you know, for example, did the authors pre-register their study and publish the protocol before conducting it? So, basically, when you use this tool, you answer the question with a yes, with a no or with a, “I’m unsure about it,” and then, at the end, you can really see, you know, what are the similarities, again and the differences and between the different papers.

So, I did the same for each of the 13 studies and what we found, basically, it was, again, that the quality of the papers that were accepted and then published in the Special Issue was very, very high, actually. And the studies were more or less consistent in reporting the research questions transparently. They all included a protocol where, basically, they pre-registered their research question before conducting the study, which is very important, actually. There were just some differences in, for example, reporting who did what during the systematic review process, and we know this is very important, especially nowadays. You know, we have this rise in the use of artificial intelligence tools, even for research, and we know that when you do a systematic review, basically, you screen all the papers that you find. And we know that nowadays, specific tools, which are based on AI, have been created to support Researchers in doing that.

So, what we think is important, you know, from now on, is this should be acknowledged, basically. So, if you use a specific AI tool – and plus, it’s important, actually, now, to do this independently. So, usually, you have at least two Researchers working on the same papers at the same time, ‘cause you want again, to be very vigorous and then, you cross-check, you know, what they have done. So, it’s important to report these very consistently in the papers.

[00:06:09.759] Mark Tebbs: That’s really interesting. What were the good practice recommendations that came out from the work?

[00:06:15.849] Dr. Alessio Bellato: Yeah, this is another very important point, and something that we discussed with our current Editor-in-Chief of JCPP Advances, Prof. Erik Larsson. So, what we thought, you know, we thought it would be – have been good to provide authors who may be interested, again, in publishing with this journal, but also peer reviewers, who may not be fully familiar with this technique, with a series of recommendation, a series of good practices, that we encourage them to follow from now on, when again, they are preparing a manuscript to be submitted to JCPP Advances or, you know, when they are reviewing one, for example.

So, obviously, I’m not going to talk about it fully, so I suggest, you know, our listeners to have a look at the editorial. It’s quite short, hopefully quite easy to read, so have a look at that. But I think it’s important to highlight what I think the main recommendation is, which is, basically, to be transparent in reporting the main information about the study that you want to publish. What were the original research questions and the hypothesis? How was the screening conducted? How was the study conducted? And also, what level of quality, you know, the studies included in a systematic review had.

And another important recommendation, because for those of you who do not know JCPP Advances, this is a journal that is entirely based on open science. So it’s very important to report if you want to publish a systematic review or a meta-analysis, for it to provide, you know, as much as possible, your codes, your analysis and if possible, also your data and a clear description of how you analyse your data. So that, you know, you can keep the study very open, and readers can fully understand what you have done, and I think this is a very important recommendation that I have.

[00:08:00.520] Mark Tebbs: Yeah, I agree. I think it’s a really important editorial. Can we turn to your paper? You’re the co-author for the paper and it was called the “Autonomic Dysregulation and Self-Injurious Thoughts and Behaviours in Children and Young People: A Systematic Review of Meta-Analysis.” Could you introduce the people that you worked with?

[00:08:19.830] Dr. Alessio Bellato: Yes, this was a very interesting and real collaboration that involved Researchers at different levels of their career, working in Malaysia, working in the UK, and working in Brazil. So, I work with Dr. Giorgia Michelini from Queen Mary University of London and Dr. Elizabeth Shephard, who is based at the Universidade de São Paulo in Brazil. They helped me, basically, manage the project, and then, we also had Dr. Margherita Malanchini from Queen Mary University of London, who brought her expertise in child and adolescent mental health, and it would also be important to thank all the other co-authors who helped with the systematic review. We have Muskaan Aleeza Admani, Camila Deak, Luis Carlos Farhat, Maria Carolina Fontana Antunes de Oliveira and Rebecca Vasconcelos.

[00:09:09.130] Mark Tebbs: Thank you. Could you just start by giving us a brief overview of the paper?

[00:09:13.680] Dr. Alessio Bellato: This was a, I think, an important paper, also, for me, because it was a real collaboration, and so, we had, basically, Researchers working from Malaysia, where I was based at the time when I was working on this, people working in the UK and people working in Brazil. So, it was quite a large collaboration and I’m very happy about the fact that it was published in JCPP Advances.

So, what we did in this paper was, basically, summarising the existing literature and also conducting a meta-analysis to understand if children and young people who experience suicidal thoughts or self-harm, they also show difficulties in regulating specific bodily mechanism, such as, for example, you know, calming down when they experience a negative emotion. So, that was the main goal of this paper, which was, at the end, a systematic review and meta-analysis.

[00:10:02.269] Mark Tebbs: So, could you describe those, kind of, original research aims?

[00:10:06.779] Dr. Alessio Bellato: We know that suicidal thoughts and self-harming behaviours are, unfortunately, very common in children and young people. What we do not fully know and fully understand nowadays is why some children and young people actually experience these and why many others do not. So, one theory that is quite popular in the literature is that suicidal thoughts and self-harm could arise from other mental health difficulties that are associated with difficulties in arousal regulation. So, let me explain what I mean with the word ‘arousal’.

So, arousal refers, basically, to the level of activation of our body at a certain time, and we know that arousal changes based on the context, based on the situation, and based on the time of the day, as well. For example, now, you know, it’s after lunch, so people may be, you know, a bit tired, you know, and I’m sure that even your level of arousal, your level of activation, is slightly lower than, for example, let’s say, 10:00am this morning. And similarly, you know, think about when you get angry, when something, you know, bad happens in your life, our body tends to activate, you know, and tends to become more aroused, we call it, you know, basically, to be prepared to face the situation and cope with it.

So, what we do as humans is, basically, regulate arousal. So, if we are too bored, too tired, or we are too overexcited, too activated, too angry, for example, we, kind of, try to restore the level of arousal to a level that, you know, we are comfortable with, you know, something that makes us feel good, basically. So, the idea is that some children and young people, but also adults, you know, who experience suicidal thoughts and self-harm, may actually engage in these behaviours because they may experience some difficulties, involuntarily regulate arousal.

And arousal is something that we can measure, for example, by looking at heart rate and changes in heart rate based on the situation. We have some evidence, for example, you know, that people who self-harm report feeling better and more relaxed immediately after self-harming. So, it could be that this is really a strategy, you know, for them to improve their wellbeing, you know, at least centrally. And we know that many studies actually looked at these associations, so to try to understand, again, if there is an association between arousal regulation, self-harm, and suicidal thoughts.

So, what we wanted to do, and this is our primary research goal of this paper, was, again, to summarise the literature on the topic, to try to reach, again, a conclusion, is there a strong evidence in favour of this hypothesis? Or maybe we don’t really, you know, know yet what’s going on. So, this is actually what we did.

[00:12:42.149] Mark Tebbs: So, could you tell us how you did it? Could you tell us about your methodology?

[00:12:46.430] Dr. Alessio Bellato: Yes. So, this is, obviously, a general discussion about how a systematic review and a meta-analysis is usually conducted. So, basically, what you do, again, is set up your research question, which is what I’ve just talked about, and then, you develop what we call a search strategy. So, a series of words that you need, you know, to search for papers that are relevant to your research question. It’s like going to the library and ask the Librarian, say, “Hey, I would like a book on vegan meals. You know, I want to prepare a vegan meal and I don’t know how to do it. Can you suggest me a book for that?” And, obviously, and they will probably search for them with these key terms.

That’s what you do at the beginning. So, you, basically, identify specific keywords and then, you search in online databases. You download all the papers. So, basically, at the beginning of the study, we had 5,000 – more than 5,000 articles that we screen one-by-one. So, we, you know, at least two people, actually, looked at the title and the abstract of each paper and determined if they thought that the paper was eligible for inclusion. And then, after you have identified all the potentially relevant papers, basically, you look at the full text. So, you know, you go online, you go to the Journal page or through the library, you get the full text, read the full paper to determine, actually, the eligibility.

And at that point, you have to try to have a look at bigger picture, you know, if I take all – and we had, basically, 20 articles that, at the end, were relevant to answer our research question. If I consider all of this together, what are these papers, what are these articles telling me? And then, you can also use meta-analysis, which is, again, a statistical method where you look at the numbers, look at the results and try to pool them altogether to have, basically, a larger sample. You try again to understand, you know, what is the conclusion about your research question? Are most of the papers in favour of your hypothesis or against, or is there a mix?

And this a very interesting process, which takes some time, so it’s important to have Researchers who are already somehow expert in conducting systematic reviews, or people who want to learn, which is usually what I have. I have students, you know, who want to learn and, you know, with appropriate supervision, they can learn about it, and so, it’s a nice skill to have as a Researcher.

[00:15:00.490] Mark Tebbs: Yeah, great description, too. What did you find? What were the key findings from that process?

[00:15:06.209] Dr. Alessio Bellato: So, the good news is that the findings were in line with our hypothesis. So, what we found is that children and young people – so, we summarised these 20 papers altogether, so this finding does not count from one or two paper. It’s, basically, you know, taking all the papers, the 20 papers, in consideration, and we found that children and young people displaying self-injurious thoughts and behaviours, indeed, show difficulties in regulating some bodily mechanism, specifically heart rate.

So, what we found, we found a specific index of arousal dysregulation, specifically lower heart rate variability, which is thought to reflect, you know, reduced ability to, basically, regulate cardiac activity, and we found this in children and young people experiencing suicidal ideation and self-harming, basically.

[00:15:52.820] Mark Tebbs: Okay. So, let’s turn to the implications of that. Tell us what that means, maybe from a clinical perspective, first of all.

[00:16:00.899] Dr. Alessio Bellato: Yeah. So, again, as I said before, we know that self-harming and suicidal thoughts are very common in children and young people. We have about one out of four children and young people, according to the last statistics, experiencing either a suicidal ideation or self-harming. So, in order to appropriately support them, it’s important to identify them, first of all, especially because as I said before, many of these children also experience other kind of mental health difficulties. So, some of them may not be able, you know, to communicate properly that they are struggling, for example.

So, the idea, you know, with this type of paper, with this line of research, is try to identify some, kind of, markers of, in this case, suicidal ideation, suicidal thoughts, and self-harming behaviours. We are not there yet, so we cannot use, for example, heart rate variability or heart rate to identify those who are more at risk, for example, of developing suicidal ideation.  But what we can do, and this is actually why it’s important, we can work towards understanding if heart rate variability can be used in clinical practice as an objective marker of mental health and wellbeing.

For example, to see, okay, if I try, you know, Intervention A or this specific management support strategy, that’s a heart rate variability change. Because if heart rate variability is a, kind of, a marker of mental health, mental wellbeing, maybe we would be able to understand, you know, more efficiently and more accurately what intervention works best for that specific child, that specific young person, for example.

[00:17:39.060] Mark Tebbs: Thank you. I’m just thinking about, you know, we’ve got a lot of, like, parents and carers and Teachers who listen at the moment, are there any implications or messages for them at the moment?

[00:17:50.030] Dr. Alessio Bellato: This is a message that I don’t think comes only from this specific paper, but from different papers, from the whole literature that we have on the topic of, for example, suicidal ideation, self-harm, but also, emotional dysregulation. So, if we look at the literature, parents, carers and Teachers, you know, they can somehow pay particular attention to those children and young people who are, somehow, you know, more irritable than others, they may show rapid changes in mood.

Maybe, you know, especially when they are young, they seem to struggle more in self-regulating, in calming down when they receive bad news, you know, when they could not play, you know, with their favourite toy, for example, or when they experience negative emotions. ‘Cause, in some cases, these are actually the children who may be experiencing mental health difficulties and may cope with this with some strategies that are not really helpful for them, such as, for example, self-harm.

So, to these parents, to these Teachers, if you’re worried that a child or a young person that you know, you know, has suicidal thoughts or engages in self-harm or they show emotional dysregulation, sometimes it’s just important, maybe, to offer to listen to them, you know, give them space, find a way that they are comfortable to express their feelings. And obviously, if possible, I think this is a general recommendation, suggest them to consult a professional that knows how to best support them.

[00:19:14.960] Mark Tebbs: Yeah, brilliant, thank you. So, we’re coming towards the end of the podcast. I’m just wondering whether you could tell us whether there are any implications, from a research perspective, from your work?

[00:19:25.230] Dr. Alessio Bellato: Yeah, so again, this is very important, because again, all the literature is now suggesting that, you know, we may be able to support children and young people who struggle. We really need to find interventions that are effective, but we also know that if we have one intervention that is effective for one child, it doesn’t necessarily mean that the same intervention works the same for another child.

So, what we have to do as Researchers is first, try to understand how the interventions that we commonly use in clinical practice, for example, you know, psychotherapy or medication, how do they affect our ability to regulate our bodily functions, such as, you know, heart rate? Because if we identify the link, then we may be able to understand more how these interventions actually affect mental health, mental wellbeing and also, how they are affected by the presence of, for example, a more complex profile. Just think about a child with attention-deficit/hyperactivity disorder who also show emotional dysregulation.

So, this is something that I’m planning to do in the future, so try to understand, again, how interventions that we currently use in clinics in the UK, but also more globally, how do they affect heart rate variability? So, if anybody who’s listening, you know, is interested in collaborating with me in the future, please be in touch. It’ll be great to work together.

[00:20:45.010] Mark Tebbs: Great stuff. Could we just finish up with a final take home message for our listeners?

[00:20:50.770] Dr. Alessio Bellato: Yeah, I mean, we are doing a podcast and from what I know, I don’t know much, but I know the podcasts are aimed at making our research, our work as Researchers, somehow more accessible and more clear to the general public. And I think this is a general recommendation that I also have for authors who submit and publish systematic reviews and meta-analysis. It’s something that we talked in – about in the editorial. You know, we know that many policymakers, Politicians, but also Clinicians and healthcare professionals, they use this type of study, they use systematic reviews and meta-analysis, to guide their own practice, but also to make important decisions for the whole society.

So, considering that, you know, the paper that I published is a systematic review and a meta-analysis and the editorial is on systematic review and meta-analysis, I think it’s important to highlight and stress, you know, again, about the importance that we write our papers or our systematic reviews by, for example, including a lay summary so that everybody can understand what the paper is about, what the study’s about. Or a short overview of the main findings, at least, you know, so that, again, everybody can understand what we did, why we did it, and how what we found is important.

[00:22:02.070] Mark Tebbs: Brilliant. Thank you, that’s a really important leaving message, so thank you so much for your time. It’s been a really interesting podcast. For more details on Dr. Alessio Bellato, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, and let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.

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