Transdiagnostic Profiles of Behaviour and Communication: Academic and Socioemotional Functioning and Neural White Matter Organisation

In this Papers Podcast, Dr. Silvana Mareva discusses her JCPP paper ‘Transdiagnostic profiles of behaviour and communication relate to academic and socioemotional functioning and neural white matter organisation’ (https://doi.org/10.1111/jcpp.13685). Silvana is the first author of the paper.

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

Discussion points include:

• An insight into CALM (the Centre for Attention, Learning, and Memory), including its aims and transdiagnostic approach.
• Co-morbidity as one of the main challenges to the current diagnostic system.
• The sub-groups identified through grouping children with similar behavioural profiles, irrespective of their diagnostic status.
• The importance of focusing on neural white matter organisation.
• Implications for child and adolescent mental health professionals and those working in education.

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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Silvana is a Postdoctoral Research Associate at the Centre for Attention, Learning, and Memory (https://calm.mrc-cbu.cam.ac.uk/). Her work focuses on studying neurodevelopmental difficulties transdiagnostically aiming to understand how and why children may struggle at school and how to best support the wellbeing of neurodivergent young people. (Bio from Cambridge Neuroscience)

Other resources

• Featured paper ‘Transdiagnostic profiles of behaviour and communication relate to academic and socioemotional functioning and neural white matter organisation’, (2022). Silvana Mareva, Danyal Akarca, The CALM Team, Joni Holmes

Transcript

[00:00:01.420] Jo Carlowe: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a Freelance Journalist with a specialism in psychology. 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, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances.

Today I’m interviewing Dr. Silvana Mareva, Research Associate at the Medical Research Council Cognition and Brain Sciences Unit at the University of Cambridge and a member of the Management Committee at the Centre for Attention, Learning and Memory, known as CALM. Silvana is the first author of the JCPP paper, “Transdiagnostic Profiles of Behaviour and Communication Relate to Academic and Socioemotional Functioning and Neural White Matter Organisation.” This paper will be the focus of today’s podcast.

If you’re a fan of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues.

Silvana, thank you for joining me. Can you start with an introduction about who you are and what you do?

[00:01:19.900] Dr. Silvana Mareva: Hi, Jo, many thanks for having me. It’s a real pleasure to be speaking to you today. So, very briefly about myself. I’m a Developmental Psychologist who focuses on studying neurodevelopment and child and adolescent mental health, most probably.

[00:01:34.520] Jo Carlowe: So, we’re going to look at your JCPP paper today, but before we do that, Silvana, can you tell us a little about CALM? We have focused on it in some past podcasts, but it would be great to get a reminder of CALM’s aims and its transdiagnostic approach.

[00:01:50.369] Dr. Silvana Mareva: CALM stands for Centre for Attention, Learning and Memory and it’s a research clinic that first opened its doors back in 2014 at the Cognition and Brain Sciences Unit of the University of Cambridge. And at the time it was established, it was quite unique in its approach to studying neurodevelopment, because one of the defining features of the centre is our participant recruitment strategy.

So, what we did is that we simply asked health and educational professionals to refer children who they consider to be struggling in the areas of attention, learning and memory, irrespective of whether they fit diagnostic categories or not. And this meant we really saw a very diverse group of children and young people, one that has rarely been represented in research before, meaning that some of the children we saw had a single diagnosis, some had multiple, but most didn’t really fit any specific kind of diagnostic rubrics.

And this is, of course, quite different to the typical recruitment strategy that is used in this field, which is to focus on a particular diagnostic group and then, kind of, contrast their profile to the profile of serving a neurotypical group or another diagnostic group. So, this, kind of, unique approach allowed us to build what we call a transdiagnostic cohort study, where we were aiming to look at neurodevelopment, most probably looking across diagnostic boundaries, but also integrating across the behavioural, cognitive, neural and genetic level. And I should also mention here that we also, kind of, recruited what we call a comparison group of children. So, these are children that are recruited from exactly the same schools that all the children who were being referred to us were attending, but this group was simply not referred to us by practitioners.

My personal involvement of the project has been since 2017, when I first started my PhD and since then, I finished my PhD working on this project and then, I stayed on as a Postdoctoral Associate, as well, and of course, a lot of things happened in this time. We have certainly been very busy, and we have seen about 1,000 children now between 2014 and last year, 2022, which is when we finished data collection.

[00:04:06.290] Jo Carlowe: Thank you very much. Now, in the paper, you describe comorbidity as one of the main challenges to the current diagnostic system. Can you elaborate on this?

[00:04:16.729] Dr. Silvana Mareva: Of course. So, we do, indeed, often talk about comorbidity as one of the main challenges to diagnostic systems and what I mean here is the fact that it’s actually fairly rare for a diagnosis to occur in isolation. So, for example, the overlap between ADHD and dyspraxia is currently estimated to be around 50%. We know that about – that a third of individuals diagnosed with autism also meet the criteria for ADHD. We know that about a quarter of autistic individuals experience diagnostic level of anxiety. So, it’s really the sort of thing that it’s not very surprising, when you think about it from a developmental science point of view, ‘cause we know that this, kind of, early emerging developmental nature of difficulties often means that a child who experiences difficulties in one area, such as motor skills, is more likely to later on, also experience challenges in other domains, such as social or cognitive functioning, let’s say.

And I really want to be careful here and say that this is always probabilistic, rather than deterministic, as we know that individual trajectories are so, so variable and can be shaped by multiple factors, including factors in the child’s environment. And, also, I think, relatedly to this comorbidity challenge, it’s this other challenge that is often discussed around what we call heterogeneity. So, in the context of diagnostic taxonomies, this is the fact that there is immense diversity within diagnostic boundaries, meaning that two individuals with the same diagnostic label actually can often have quite different experiences and quite different presentations, sometimes a very contrasting types of needs. So, that’s the two challenges that we often, kind of, cite as a main limitation to diagnostic taxonomies.

[00:06:09.360] Jo Carlowe: That was super helpful. Let’s get into some of the detail of the paper itself. So, this is “Transdiagnostic Profiles of Behaviour and Communication Relate to Academic and Socioemotional Functioning and Neural White Matter Organisation.” Can you give us an overview of the paper to set the scene?

[00:06:26.420] Dr. Silvana Mareva: This paper is actually part of my PhD thesis and in this specific project, I looked at the CAMH cohort and I specifically focused on a parent ratings, executive functions, social communication and language. And I chose to focus on these areas because they’re considered hallmark symptoms of different neurodevelopmental conditions. So, executive functions are often considered a core difficulty in ADHD. Social communication is classed as a diagnostic symptom for autism and language difficulties are really the hallmark of developmental language disorder.

But we actually know that these areas of difficulties commonly co-occur both within, as well as across, diagnostic boundaries. So, in this project, I, kind of, aim to look at our cohort, asking this question, “In this very mixed group, can we identify robust subgroups of children with similar profiles of strengths and difficulties across these areas?” And then, wondering, would these groupings tell us anything about the types of profiles that children have, both emotionally and academically? And also wondering, would these groupings correspond to diagnostic taxonomies? Would they, in any way, relate to different parts of children’s brains and how they’re related? Something that we call neural white matter organisation.

[00:07:48.259] Jo Carlowe: Can you tell us a little about the methodology that you use for the study?

[00:07:52.712] Dr. Silvana Mareva: So, in this case, we used the method called a community dissection and this method is based on graph theory, so it’s very similar to cluster analysis, in many ways, and it allows us to explore the data to identify data-driven groups of children or clusters of children who share similar profiles across a range of domains. And the way that this is achieved is very simply, taking a pair of children and then, estimating how similar their profiles are across measures of interest. And visually, this can be represented as a network, where each child is represented as adults and the similarity across profiles is represented by lines connecting those dots, where thicker lines represent, kind of, the stronger resemblance across profiles.

And then, once we map all the children and their resemblance to one another, then we use an algorithm and that identifies region of this network, where adults tend to be more strongly linked to one another, relative to their links with the rest of the network. And then, these regions of the network then become our subgroups, or clusters of children who share more similarities among one another.

[00:08:58.620] Jo Carlowe: Great, that was really clear. Thank you. So, as you’ve just described, in this study you identified groups of children with similar behavioural profiles, irrespected of – irrespective of their diagnostic status. What subgroups were identified, then, using this approach?

[00:09:12.790] Dr. Silvana Mareva: We saw that the groups that we identified using this method didn’t really closely align with other children’s diagnoses that were reported by the people who were referring them to the centre. So, that means that children with diagnoses like autism and ADHD were actually represented in all three different groups that we identified using this method, and these were three groups that actually had very different profiles. But this diagnostics label did not always tell us what the child’s profiles of strengths and difficulties was, but then, what did the groups tell us, then?

Well, we saw that one of the groups that we identified was a group of children who really had most pronounced difficulties in the language area. So, they struggled with things like the use of grammar, for example. Then, there was another group of children whose more substantial area of difficulties was executive skills. So struggling with things like remembering instructions and paying attention, planning a complex task, that type of thing, and the final group that mostly struggled with social communication, but also with emotion regulation.

And then, interestingly, when we compare these groups that were characterised by these profiles of strengths and difficulties, do a comparison group of children, the one that I mentioned earlier, then we saw that relative to these comparison children, all of these groups of children struggled with school learning. So these were, like, tests of maths and reading, as well as with mental health, in this case, assessed using the Strengths and Difficulties Questionnaire. So, kind of, suggesting to us that, at least in this cohort, there were these three different developmental pathways to academic and mental health difficulties, one via, kind of, executive function type of difficulties, another via language, and a final one by social communication and emotion regulation type of difficulties.

[00:11:02.170] Jo Carlowe: My understanding is that you compared behaviour across the subgroups and also differences in brain structure and there was a particular focus on neural white matter organisation. Can you explain, for the layperson, why was it important to focus on white matter?

[00:11:17.280] Dr. Silvana Mareva: Neural white matter is often said to be a communication highway of our brains. So, we focused on neural white matter because its maturation enables efficient communication between different parts of the brain. So, in simple terms, white matter helps different parts of the brain work together and it supports our ability to think, to learn and to perform complex tasks. And without going into too much detail here, I’m just going to quickly say that what we observed was that relative to our comparison group of children, most of the differences we saw in neural white matter were actually common to all of these three groups with different profiles of strengths and difficulties.

So, in other words, we found that our groups had altered neural white matter connections in many of the same areas. We also found relatively fewer group unique patterns of deviation relative to this comparison sample and these group unique differences actually partially corresponded to the known neural correlates, and the group’s primary area of difficulties, kind of, adding to an existing evidence base of what others have also observed. This idea that our brain co – organisation really corresponds to functional skills and not so much to diagnostic labels.

[00:12:32.470] Jo Carlowe: You’ve already highlighted quite a few findings, but what else is important to mention?

[00:12:38.149] Dr. Silvana Mareva: Yeah, another thing I’d say is that while this study wasn’t really designed to explicitly test or falsify a given T-rate, defining that children with the same diagnosis were represented in all of our data-driven groups challenges some of our dominant theories that assume that a single mechanistic so-called deficit can explain the profile of a particular diagnostic group. Instead, what I’d say is that our results are a lot more consistent with accounts that emphasise the possibility that multiple causal pathways can lead to the same type of difficulties. As we saw, despite substantial differences in children’s strengths and difficulties, such as relatively more pronounced difficulties with language or executive function or social communication, all of our groups struggled with math and reading and mental health, relative to this non-referred group of peers who are attending the same schools.

[00:13:34.140] Jo Carlowe: So, what are the implications of this for CAMH professionals and for those working in education?

[00:13:41.700] Dr. Silvana Mareva: I guess, in practice, this means that a diagnosis of a neurodevelopmental condition may not always directly lead to a specific support fund and it seems that a one size fits all approach may not be very effective, or indeed, needed for everyone with the same diagnosis. And I think that a child’s diagnosis may not always be very informative in terms of what their relative strengths and weaknesses might be. So I’d say we are seeing more and more evidence that the importance to consider the individual and their specific profile, rather than focusing solely on addressing their diagnosis.

[00:14:21.000] Jo Carlowe: And in terms of diagnosis, what are the implications of your findings with regards to current diagnostic approaches? Are there some recommendations that emerge from your research?

[00:14:31.060] Dr. Silvana Mareva: Well, I guess, despite this kind of widespread influence of diagnostic systems, what I think this study, as well as many others, have shown, is there seems to be this mismatch between a diagnosis and actual strengths and difficulties of individuals. So, then, I think here, we’re starting to see the sense of wonder of then, to what extents are these, kind of, diagnostic approaches and taxonomies slowing our research progress? And I think perhaps we’re starting to talk about the need to think more advanced diagnostically and to relax our reliance on diagnostic categories to shape research.

But this, of course, is not always very simple and there are a number of questions that really merit very careful consideration before, kind of, embarking on this, kind of, widespread adoption of this transdiagnostic approach. Because I’d say that the influence of a lot of these kind of diagnostic approaches is so far-reaching currently and they define our funding calls. We have conferences, we have journals that are really, kind of, dedicated to publishing research on autism or ADHD or dyslexia. And in this country, we often have, like, specific services for individuals with ADHD or for autistic individuals.

So, in other words, I mean, diagnostic categories were, for decades, providing us with the organisational basis, not only for research, but also for healthcare, educational, legal system. So, while we may want to move away from using these labels to organise our research, they do play a very important function in society, such as providing self-knowledge, sense of identity and community to so many. It’s really challenging to, kind of, understand what the needed steps here are, because in the context of overwhelmed and our overstretched services, diagnosis and diagnostic thresholds can become this, kind of, very convenient, although undeniably very questionable, threshold for making decisions about who can access some type of support or service, and we’re seeing a lot of alternatives emerge.

I think many of us see the neurodiversity movement as a, kind of like, a framework that moves us away a little bit from diagnosis, because it, kind of, proposes a use of an umbrella term and in contrast to the current, kind of like, diagnostic approach. It is not so bound on the categorisation and, kind of, the deficits, but it’s somewhat more holistic in its approach.

[00:17:00.620] Jo Carlowe: Hmmm, it’s really fascinating that you – that idea that there is some risk to shaking things up.

[00:17:05.770] Dr. Silvana Mareva: Yeah.

[00:17:06.770] Jo Carlowe: Let’s return to the paper. Is there anything else in the paper that you would like to highlight?

[00:17:10.170] Dr. Silvana Mareva: I think very, very important to say here, I don’t want to forget to mention this, is CALM is a team effort. We have a huge team of Researchers who have made this cohort possible, and we’ve been so, so fortunate to have had brilliant support from many practitioners as well, as well from hundreds of families. So, I want to make sure to say a huge thanks to all of them. And I also want to make sure to acknowledge my brilliant PhD Supervisor, Professor Joni Holmes, who is the Head of the CALM study, as well as Professor Sue Gathercole and Professor Duncan Astle, who have been instrumental in shaping the CALM study, and on a more personal level, have been truly inspiring mentors to me.

[00:17:53.120] Jo Carlowe: Are you planning any follow-up research or is there anything else in the pipeline that you would like to share with us?

[00:17:58.870] Dr. Silvana Mareva: I guess, like I was just, kind of, mentioning, I’m very passionate about thinking about how we can encourage healthcare and education systems to relax current emphasis on diagnosis, how to start to consider how we can embedded this more needs-led or transdiagnostic approach. I, in fact, know that there is a lot of interest around this in the NHS and there is a lot of, kind of, appetite for innovation, but – and like I already mentioned, I think there is a need to systematically consider both, kind of, the evidence, as well as the lived experience, as well as the wider implications to, sort of, get this right. So, I’m currently planning some work in this direction, which I’m, kind of, very excited about, so that’s one thing in the pipeline.

Another thing I want to mention, which it, kind of, has to do with the CALM study more broadly, is that we recently finished data collection for our longitudinal follow-up. That means that we saw about half of the cohort again five years later. So, we are very excited to be starting to consider questions around longitudinal changes, stability, which are very important things and things that we get asked about very often. It’s very early days. We don’t have any results, really, to share yet, but definitely watch this space.

And finally, I just want to flag that we have now made all the data from our baseline, so this is the first time that we saw the children and young people, available to other Researchers by a managed open access portal. So, if Researchers are interested in answering their own research questions using our cohort, they can go to our website and apply to access the dataset, submit an application and provided that the clients use the data in a responsible manner that, kind of, meets our ethical guidelines and consideration, and they’ll receive access to it and they’ll be able to have a look at the data themselves.

[00:19:47.640] Jo Carlowe: Great. Can you just remind us of the website address?

[00:19:50.540] Dr. Silvana Mareva: If you just Google Centre for Attention, Learning and Memory, I think you’ll find the – our website.

[00:19:55.620] Jo Carlowe: Finally, what is your take home message for our listeners?

[00:19:59.650] Dr. Silvana Mareva: Well, from me, I say that the take home message is around the limitations of diagnostic heuristics and siloed ways of thinking and the need to think more holistically when it comes to neurodevelopment. I also personally think and hope that our findings are adding to an evidence base that, kind of, speaks to the need to transform our approach so that we can respond to families’ needs quicker and that we can consider the child as a whole person, rather than just one condition at a time.

I do think that focusing on this kind of strengths and difficulties type of approach is something that can save time and resources and can provide a more effective way to support children and families. I do acknowledge that it’s not a trivial undertaking and we need to think very carefully about how we can support neurodevelopmental services to get this right and to really make sure that we are making the impacts we want to be making.

[00:20:55.280] Jo Carlowe: Thank you ever so much. For more details on Dr. Silvana Mareva, please visit the ACAMH website, www.acamh.org and Twitter @acamh. ACAMH is spelt A-C-A-M-H. 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 friends and colleagues.