In this ‘RESHAPE Study’ series episode, Professor Tamsin Ford and Lauren Cross explore the lockdown experiences of young people and parents, as well as discuss reintegration back into pre-pandemic routines.
The ‘RESHAPE Study’ series is a new mini-in conversation series that will explore the RESHAPE study and the impact of its findings for parents, teachers, policymakers, and mental health professionals.
Discussion points include:
- How the contradictory findings of existing literature on the experiences of young people’s mental health during COVID shaped the planning of the study.
- The RESHAPE study design, how participants were selected, and the unexpected challenges.
- The importance of structure and routine, as well as access to social and familial connections.
- Engagement versus efficiency with regards to learning during the pandemic and the role of schooling.
- Help-seeking and self-problem solving and the importance of matching what we provide to the needs of the individual person.
- Navigating reintegration and the importance of communication and compassion.
RESHAPE or ‘REflecting on the impactS of covid-19 on cHildren And young People in England: exploring experiences of lockdown, service access and education’ is a large study looking at how life changed for children, young people, and parents during the lockdown and how this may have affected them. This is a follow-on study from the National Study of Health and Wellbeing: Children and Young people and is a joint effort between the University of Exeter, the University of Cambridge, King’s College London and the NHS.
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Lauren is a PhD student funded by the NIHR School of Public Health Research and is supervised by Dr. Esther van Sluijs. Lauren’s PhD will explore who engages in school based prevention research and seeks to identify opportunities for more inclusive research and intervention practices.
Before starting her PhD, Lauren worked as qualified teacher in London and the East of England. She completed a BSc in Psychology at the University of Bath and an Mphil in Educational Research at the University of Cambridge. After graduating, Lauren worked as a research assistant at the Institute of Psychology, Psychiatry and Neuroscience (King’s College London) and the Child and Adolescent Resilience and Mental Health (ChARM) research group at the University of Cambridge. Within these roles Lauren worked on various research projects exploring school based mental health outcomes and experiences. In addition, Lauren has contributed to research surrounding the impact of Covid-19 associated restrictions, including national lockdowns and school closures, on children and young people. (Bio and image from MRC Epidemiology Unit)
Tamsin Ford is Professor of Child and Adolescent Psychiatry at the University of Cambridge. She researches the organisation, delivery, and effectiveness of services and interventions for children and young people’s mental health. Her research covers the full range of psychopathology and agencies, practitioners and interventions that relate to the mental health of children and young people. Every interaction with a child presents an opportunity to intervene to improve their developmental trajectory. Her work has direct relevance to policy, commissioning and practice.
Tamsin completed her postgraduate training in psychiatry on the Royal London Hospital Training rotation and then the Bethlem and Maudsley Hospitals, after which, she completed her PhD at the Institute of Psychiatry, Kings College London. She moved to Exeter in 2007, where she established a group of researchers whose work focuses on the effectiveness of services and interventions to support mental health and well-being of children and young people. In October 2019 she moved to the University of Cambridge.
Tamsin has been a member of ACAMH since 1996. She was an Editor for ACAMH’s journal CAMH for six years, stepping down as lead editor in June 2014. She has been a board member for ACAMH since 2011, and vice-chair since September 2020.
Other resources
- RESHAPE Study: Key Takeaways on Eating Disorders with Professor Tamsin Ford and Clara Faria
Transcript
[00:00:01.319] Clara Faria: Hello, welcome to the RESHAPE study series for the Association of Child and Adolescent Mental Health, or ACAMH for short. This is a new mini-In Conversation series that will explore the RESHAPE study and the impact of its findings for parents, Teachers, policymakers, and mental health professionals. I’m Clara Faria, an ACAMH Young Person Ambassador, and today, I have the pleasure of interviewing Professor Tamsin Ford, Professor of Child and Adolescent Psychiatry at the University of Cambridge, and Lauren Cross, a PhD Candidate at the MRC Epidemiology Unit, also in the University of Cambridge.
RESHAPE, or “Reflecting on the Impacts of COVID-19 on Children and Young People,” is a large study, looking at how life changed for children, young people and parents in England during the lockdown, and how this may have affected them. This is a follow-up study from the National Survey of Mental Health and Wellbeing of Children and Young People, or MHCYP for short, and is a joint effort between the University of Exeter, the University of Cambridge, King’s College London, and the NHS. In this episode, we will focus on young people and parents’ lockdown experiences during COVID, and their reintegration back into pre-pandemic routines.
If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and share with friends and colleagues. Welcome, Lauren and Tamsin, thank you so much for being here today. Can you each start with an introduction, giving a short overview of what you do?
[00:01:42.909] Lauren Cross: So, I’m Lauren Cross. I come from a teaching background and formerly worked as a Research Assistant on the RESHAPE study. I am currently undertaking a PhD, and this is exploring, “Participation Experiences in School-based Health Prevention Research.”
[00:02:00.329] Professor Tamsin Ford: And my name is Tamsin Ford. I initially trained in the NHS to be a Child and Adolescent Psychiatrist, and then, having completed that training, went back to school and did my own PhD, and became an Epidemiologist. And so, my research, and my research group, focus on how we optimise interventions and services to support children’s mental health.
[00:02:23.250] Clara Faria: Thank you so much. There have been some studies looking at the impact of lockdowns in children and young people’s mental health, with different findings. Some suggested restrictive measures were responsible for worsening young people’s mental health, while others found that, for certain groups, lockdown was associated with improved mental health. How did you make sense of these findings, when planning the study you conducted, or RESHAPE?
[00:02:46.510] Professor Tamsin Ford: So, I have been involved all the way through my academic career with the National Survey Series. These have been commissioned by the Department of Health, and were to address the problem for government of how many children out there have an impairing psychiatric disorder, or a mental health condition, that needs treating.
The first was in 1999, there was one in 2004, and then a big gap ‘til 2017. And, in fact, myself and a colleague, Tamsin Newlove-Delgado, who I think you can see in other podcasts in this series, were pushing the Department of Health to follow-up the 2017 sample, and Tamsin got some funding and a fellowship to do this, and we were just organising this when the pandemic started in 2020. And it made such sense to pivot what we were doing away from the initial plan, but it needed more funding, towards a follow-up of children’s mental health in the pandemic, because of the fact that, okay, it was three years before, but we did have a well-described probability sample, rather than a convenience sample.
And, actually, at the time we were planning the study, so it was funded by the Medical Research Council, and it was deliberately a little bit vague, that we would do a couple of questionnaires, and that we would do deep dives into the detail of peoples’ experience, we could do a couple with each of the surveys that we did. And we didn’t specify what we were going to do with those, because we wanted to be able to respond to what the policy problem was.
However, we decided very quickly from early reports that lockdown experience seemed to vary, and, therefore, it seemed a very important thing to learn more about, partly because different samples, different ways of getting data, that the initial data, was so very varied. So, it seemed like this was a really good sample, where we knew a lot about their background, where we could make sure, as far as possible, we got a range of people, from a range of areas, with a range of experiences, to make sure that we reflected across all the different pandemic lockdowns that were happening. Because I think the take home message is just how varied it was for families. As I think people said at the time, we might all have been weathering the same storm, but we were not by any means in the same boat, to try and get through it.
[00:05:14.660] Clara Faria: Can you tell us a bit about this RESHAPE study design, and how you selected the young people that were going to take part under the specific lockdown experience study?
[00:05:24.419] Professor Tamsin Ford: So we thought it really interesting to explore the variation that we saw in our very first follow-up survey, where we asked people a question about, “How was lockdown for you?” And then there were five points people could answer from, from “very much worse,” to, “very much better.” And, yes, quite a lot of people said that lockdown made their life worse, or much worse. However, there was a sizeable chunk of people, even those who were struggling with their mental health, who said lockdown had made their life better.
And that seemed really important to explore in a qualitative fashion, so in conversations with people. So, this was one of the first studies that we did, that question was asked in 2020, anyone who had said in that survey that they were happy to respond to further calls for research, and who wasn’t in a different study, we were asking about service use, where it was more important to get everybody who’d accessed services, and so that slightly limited us, was eligible.
And then we took what’s called a purposive sample. We tried, very hard, to make sure that we had the whole range of experience from “much worse” to “much better” represented. We wanted to make sure that we had young people, but we also had, had parents talking about younger children. So, the parents were talking about children between the ages of five and 18, and the young people were secondary school age up into emerging adulthood, into their early 20s.
And there was a bit of a delay; it took almost a year to have the contact details from NHS Digital. In a way, that enhanced the study, because it meant we’d been through more than one lockdown and could ask about reintegration, which turned out to be really important later on. And we targeted people who are less represented in research, particularly those of low socioeconomic status, to try and make sure that we really didn’t just get the usual suspects speaking to us.
[00:07:37.030] Clara Faria: One of the strengths of the study, in my opinion, is that your research team is so diverse. We have you, Tamsin, that is an Epidemiologist, we have Tamsin Newlove, you mentioned before, who brings in a public health perspective. And, Lauren, you mentioned your background of education, as you were a former Teacher, how did you draw from that experience when planning the study questions and investigating lockdown experiences in young people?
[00:08:00.629] Lauren Cross: Yeah, we also had, I would say, even wider strengths in our team, in terms of, we have people who were providing a caregiving role during the pandemic. We had those who had been a student and had experienced educational disruption, so we really did have quite a wide perspective of experiences to draw upon.
And we took quite a discursive approach to developing things like our topic guide, also reflecting on, sort of, initial themes as they had emerged. And I think that richness of experience and different perspectives, so, how I would see things as a Teacher and what I would have done, had I been in that situation, versus the parent on the other side, were sometimes very different. So, I think having those conversations were really useful, alongside doing some public involvement work, to, kind of, get a flare of what was going on, in that time.
[00:08:56.130] Clara Faria: That’s really interesting. And the idea of doing a qualitative study to better understand young people’s diverse range of experiences is, indeed, brilliant. Regarding the timing of the study, when were the interviews conducted? And were there any unexpected challenges you encountered? You just mentioned the PPI work you did, how was conducting that PPI work during the pandemic, Lauren?
[00:09:19.970] Lauren Cross: So, the study itself was conducted in terms of the data collection period, over four months, so this was between November 2021 and March 2022. If you think back, this was a time when, although many public health measures remained, for example, we were still wearing masks, and there was some concern over a novel variant of COVID-19, but life was largely returning to normal, or, at least, a version of normal, during this phase.
And in terms of challenges encountered, I think needing to be flexible with scheduling, with many of the interviews being conducted in evenings and weekends, to fit with participants’ preferences and schedules, was a logistical challenge. But as with the PPI that you mentioned, all interviews and, sort of, public involvement had to be conducted over the phone, or online. Which meant it was harder, or took a little bit longer maybe, to build rapport, which is such a valuable element within qualitative research, having that, sort of, give and take, and that relationship, especially when you’re tapping into peoples’ lives and experiences, and particularly with young people who are perhaps less familiar or comfortable with an interview setting.
And I remember, at the time, it was one of the things we discussed within our team meetings, and one of our co-authors, Alex Hartley, who was a student who had experienced educational disruption, he was our resident, sort of, young person, said something which I think is really insightful, that, for him, and young people, interviews and the word “interviews” feels like a scary thing. It’s something you do for job opportunities or, sort of, universities, and you feel like there’s a right or wrong answer, and a pressure to do well.
So, maybe there is something interesting about the framing of the methods that we use that’s important to participant experiences, but maybe that’s my PhD coming into the, sort of, reflection of my previous experiences as a Research Assistant there.
[00:11:37.790] Clara Faria: I love that you pulled a bit from your current PhD work, and I’m also really curious to know more about that. Because it’s interesting that you mentioned what Alex said about interviews being scary, because as a young person, I found them scary too, and definitely had – it has a connotation of something more formal, and building that rapport with participants online must have been a challenge indeed.
After you conducted the interviews and you did your analysis, what were the key conclusions and what would you say are the study main findings? And did anything come up in the conversations that you were not expecting?
[00:12:17.990] Professor Tamsin Ford: There were three major themes came out: learning experiences, emotions and coping, and then decompression and discovery. I think we did find what the preliminary research was showing us, and we sampled in order to try and have access to the breadth of experience, that actually the experience was very variable. I’d have worried if we hadn’t found that.
I think what we were surprised about, because we were doing a separate education-based study, was the emphasis that came through from the participants on education, as a kind of major, major focus, of worries, of access, of just the importance of school and education to these young people, and to the parents and their children. And, you know, access to engaging learning environments was obviously key, but participants also emphasised the importance of social and familial connections, which we had expected. There’s some fabulous work from Helen Minnis and others in Glasgow, demonstrating it over the first few months, where they studied some families and then they went back.
But where there were adequate resources, and where people could work from home, and they had access to equipment and somewhere quiet to work, actually people were really valuing this time together. Whereas the families where that wasn’t the case, maybe they didn’t have Wi-Fi, maybe there were problems with mental health in one or more members, or substance misuse, sometimes violence, that things very rapidly began to get into a vicious circle. So, we were expecting to get a range, and we were expecting social and family connections to be important.
I think what I hadn’t expected, but, again, others were beginning to report it, was also the importance of structure and routine. And that’s an important learning point, because that is something that could be a public health message, that schools and public health messages and advice and support for parents could be about the importance of trying to get a new routine going, in order that people have a rhythm to their time, it is important to us as human beings. And that people are sleeping adequately and eating and exercising.
I will stop there. Lauren, is there anything you think I’ve missed, or anything you’d like to amplify?
[00:14:46.089] Lauren Cross: So, one thing which I would like to pick up on, or just really stood out for me, as a former Teacher, is the experiences surrounding learning in lockdown, and particularly surrounding engagement versus efficiency. So, lots of participants were reporting it was actually way quicker, they could get through all of their school day’s work within the morning and then do other things. But, at the same time, they felt uninspired, and the word “chore” was used when describing those learning experiences.
So, I think that’s really interesting as a Teacher, in terms of thinking about the role of schooling and how we learn, and is it just, sort of, taking in knowledge, in which case this is more efficient? But if you’re talking about inspiring passions in a subject, then it’s not necessarily the most effective method, and you do need that, sort of, engagement and interaction and discussion around topics. So, that, for me, as a former Teacher, was very interesting.
But other things to pick out on, I think, are surrounding help seeking. Some things are things that unfortunately we classically have come to expect in terms of provision. So knowing where to access support isn’t always clear, and then when you do get down the pathway of accessing supports, particularly around mental health and wellbeing, it can be reported to be impersonal, or the services themselves are overwhelmed.
But I also found it interesting that some young people were reporting a preference to self-problem solve. And I think we don’t necessarily have services which are set up to facilitate self-problem solving, Tamsin, maybe you’re a better person to come in on this. But it’s interesting, in terms of there seems to be, on one hand, services being overwhelmed and people not being able to access them, but, on the other hand, people saying they’d rather self-problem solve, and we don’t have services set up in that way.
[00:16:51.899] Professor Tamsin Ford: I think it’s a very astute observation, you know, it’s really interesting to hear that. So, from other studies, for example, the IMPaCT trial, the NIHR funded trial of different psychological therapies for depression in young people, a vast number of young people had one or two sessions and then didn’t come anymore. And, actually, they were followed for up to 18 months and were doing fine. So, dropping out of treatment actually was a rational decision for them and it’s like, “Thanks, that’s all I needed.”
And I do think that we try and give everyone a Rolls-Royce service, when, in fact, some people, all they want and need is a couple of steers and a bit of support about how to disentangle a particular situation or predicament that they’re in. They don’t want weeks and weeks of therapy. So, I think we need to get better at matching what we provide to the needs and the desires of the individual person, and not everybody needs 12 weeks of CBT. Some people maybe just need an hour long conversation to have the time and space to think with someone about what is the problem and what they might do about it, and then would welcome the space to go away and try and sort it out for themselves.
[00:18:06.360] Clara Faria: It’s so interesting that both of you mentioned that and that some young people reported that they wanted more self-directed help. Because it just reminded me of the work of a Researcher here in the UK, Maria Loades, she just gave a lecture in ChARM very recently, and she’s doing lots of work around single session interventions for young people, which is exactly this case. I don’t know if you want to comment more on that, Tamsin?
[00:18:32.799] Professor Tamsin Ford: She’s looking at this, kind of, single session approach. And, you know, I think, at the moment, the system is overwhelmed, it’s hard to get the intensity going for those that do need weeks as opposed to more than one or two sessions. And, actually, we might do a lot better by many more young people if we offered less in the first instance, and that might actually free up capacity for those with more complicated and difficult problems, who need that Rolls-Royce treatment.
You know, I think we need to really think very hard about how we organise and deliver mental health services in this country. Because, you know, where waiting lists exceed a year, or more, that is a dreadful situation for young people, it’s a dreadful situation for those caring for them, whether they’re practitioners or their family, and young people pay a very heavy developmental price, potentially, if they’re not functioning for, say, a whole academic year. So, what you want is a system that can offer something quick and simple that, for many people, might be sufficient. So, yes, I’m really interested to see the outcome of Maria Loades’ current work; can’t wait for her to get through her trial.
[00:19:45.310] Clara Faria: And going back to RESHAPE’s findings, one of the key areas you identified in your analysis is navigating reintegration, and you even commented about the importance of routine as one of the topics that came up. Do you have any particular insights from those interviews, or factors that came up, that helped explain a successful reintegration for young people? Maybe something that we can convey as a public health message to parents and carers.
[00:20:10.440] Lauren Cross: Yeah, I think to educators as well. I think communication and compassion are two words which come into mind, and particularly in terms of reintegration into educational settings, but, also, social spaces. Experiences really did vary, but there were some amazing examples of educational settings doing these two Cs really well. Sharing videos of the environment, walking through one-way systems, introducing staff members, and explaining what, and why, which is important, things might look different, ahead of time, before, sort of, young people got there and as things were evolving. I think that’s a really good example of good practice that we saw in our interviews.
And then on the compassion side, I think allowing an adjustment period, perhaps with a phased return, so you can slowly build up interactions and, sort of, going back to school, for example, would be really valuable, so it’s not everything happening at once. Some of our participants described this, sort of, period where all of those milestones of growing up, whether it was just, like, going to gigs, or it was driving lessons, or, sort of, flirting with girls or boys, all of these things, and then you sort of get put back into a situation where this is happening all at one time, when it would normally be in a spread-out period, that was quite intense.
And I think employing discretion and kindness surrounding how rules and restrictions were enforced, I think was coming out as being particularly important. And that’s particularly in the context when rules were new, or were constantly changing, and, let’s face it, it happened a lot, so it was a constantly, sort of, dynamic period. And it was very confusing, so having a little bit of leeway, I think, when that was happening was really important.
And, finally, I would reflect from doing these interviews, that the temptation sometimes was to prioritise academic content catchup. So taking the time to really reflect and process experiences, doing some skill development work, and creating a safe space to say, “I’m not okay,” could really make a difference when it comes to integrating back into these spaces.
[00:22:28.179] Clara Faria: Thank you, Lauren. And still on the study’s findings, other areas you identified as key were emotions and coping. I’m curious about which factors were identified by the young people and the parents as helpful for increasing the ability to cope. Did anything surprise you, like, the interviews with the parents were really different from the interviews with the young people?
[00:22:54.960] Professor Tamsin Ford: I’ll start, but, again, I’d really welcome Lauren’s view on this. Again, the variedness of peoples’ experience, and I think those who coped well in lockdown sometimes didn’t find it so easy to really reintegrate. And the other way round, there were some who really struggled during lockdown who then were, like, chomping at the bit to be back and found that bit really easy. So, we shouldn’t think that there was just one experience that was either negative or positive, each individual’s experience varied.
And, I guess, going back to an earlier question, this is why the studies initially, that were taken at different times from different samples, were coming up with such widely differing findings, the fact was that all of that was going on for different people at different times. I think the fact that some people really found it a valuable time for reflection and self-discovery and the, kind of, being out of the pressure of everyday life, was something I hadn’t expected to find reported by young people.
I think, also, what we need to bear in mind is – and, you know, some comments really summed it up, that actually children missed out on a lot of developmentally important experiences that you don’t get when you’re just with your family. So, there’s a quote, which I won’t be able to say verbatim, but essentially, mother who had a child who was – would have been in the survey who was primary school age, but also had a preschool child, who’d missed out on nursery, on mother and toddler groups, just had much less contact with other children, was saying, “He’s less confident.” You know, “Yes, he’s back, he’s in school now, and he didn’t miss any schooling, but, actually, he’s less confident in social situations than his sibling is.”
And I think, also, in the teenage years, those young people who were early on in their secondary school career, or perhaps transitioning into that environment, missed a couple of years of slowly developing skills at how you socialise in a much bigger – you know, the social demands of a secondary school, compared to a primary school, are hugely different. And normally, steps are taken to ease year sevens or the first year into it, because people recognise it’s such a step. But there are a group of kids who went essentially straight from the top end of primary school into the middle of their secondary school career, with all the hormonal changes that have gone on and, suddenly, they’re faced with this environment. I’m not surprised some of them found it really hard to reintegrate, and I’m also not surprised some of them were, like, “I need people.” Lauren, I don’t know if you have anything you would like to add?
[00:25:41.080] Lauren Cross: Yeah, I think there are lots of really interesting comments about people being two years on, and the person you were at the start to the person you were at the end was sometimes really different. And reconciling that in terms of whether it was school friends, your, sort of, school identity, university, transitions to different places, I think that was a really powerful message and something I hadn’t considered to be coming up.
The other thing that I feel young people missed out on, and this tracks maybe towards the upper end of high school and then into universities, as well, it’s not just social skills, but preparation and preparedness to take exams. So, lots goes into that phases, and I think now people have, sort of, missed that GCSE experience, or that ‘A’ level experience, and they’re now, sort of, the stage on removed, and having to do that.
And, also, lots of people were reporting career development stuff, as well. So, whether that was work experience, getting a part-time job, sort of doing inset stuff with your university or school, that’s another factor that I thought was interesting that young people were saying, “We’ve really missed this opportunity to prepare us for our next stage of life.”
[00:27:07.250] Clara Faria: When looking at the study main findings, what do you think are the main implications for meeting children and young people’s needs, in the present and in the future? Do you have any recommendations for a future intervention, or key takeaway messages?
[00:27:23.429] Lauren Cross: So, in terms of if there were to be future lockdowns or public health restrictions or social measures of this kind, I think the, sort of, key message, and the most important one, is that schools should be the last to close and first to open, and educational settings. Because they really do provide a very important role, not just only academically, but I think in terms of support and protection of our most vulnerable children and young people. And for times when closures are necessary, we should think very carefully about implementing small group care with trained and trusted adults, and particularly working very closely with vulnerable families.
I would also advise that families and educators try to encourage a sense of routine and social connection in ways that are possible. They might not be perfect, but having some systems in place can be really valuable, in terms of helping young people get into those positive cycles.
However, I also think there are insights from this research which are important, regardless of whether we are experiencing a pandemic or social restrictions or otherwise. And I think that is just surrounding the sheer variability of experience, we’ve said it a lot, but in terms of inequalities, access to resources, help seeking, support available, I think it’s really important to just reiterate the point that children and young people in this country have very different day-to-day experiences and very different levels of access to support.
Arguably, lots of these things were exacerbated by the pandemic, but they weren’t created by it, and they certainly haven’t gone away because these restrictions have lifted. In fact, if you reflect on our current socioeconomic climate, arguably, they’ve likely gotten worse. So, our study revealed huge differences in those ways that people were able to live their lives, and the resources they have access to. So, I know it’s not novel, but I think it is really important to highlight that more work is needed in this area and greater intervention.
[00:30:12.790] Clara Faria: Thank you so much, Lauren and Tamsin, I think with that answer, actually we could all understand the importance of RESHAPE study and how your findings are going to help inform future intervention and public policy. Well, thank you so much once again for your time and for recording this podcast today.
And if you want to know more details on Professor Tamsin Ford and Lauren Cross’s work, please visit the ChARM and ACAMH website, www.acamh.org, and also follow us on Twitter for more updates on the RESHAPE study series, @acamh. ACAMH is spelt A-C-A-M-H. Do keep an eye out for other podcasts in the RESHAPE study series, including episodes on service access, eating disorders and special education needs and disability. And don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with your friends and colleagues.
